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    Empirical-studies.doc.doc Empirical-studies.doc.doc Document Transcript

    • Empirical studies with a focus on dermatology training issues This reference list is intended to be illustrative not exhaustive. For a list of search terms used please refer to the bottom of this document. • Alam, M. 1998, "Mergers, separations, and transformations of dermatology residency training programs: a resident's perspective", Arch.Dermatol., vol. 134, no. 9, p. 1158. • Alam, M. 2001, "Dermatologic surgery training during residency: room for improvement", Dermatol.Surg., vol. 27, no. 5, pp. 508-509. • Benelli, C., Roscetti, E., & Dal Pozzo, V. 2001, "Reproducibility of the clinical criteria (ABCDE rule) and dermatoscopic features (7FFM) for the diagnosis of malignant melanoma", Eur.J Dermatol., vol. 11, no. 3, pp. 234-239. Abstract: Dermatoscopy improves the sensitivity and the specificity in the diagnosis of melanoma. Although the reproducibility of dermatoscopic features has been the subject of research, no study up to now has compared the reproducibility of dermatoscopic features to the reproducibility of the clinical criteria of the ABCDE rule. For this reason we decided to examine the reproducibility of the clinical ABCDE rule and of our diagnostic dermatoscopic method 7FFM, as well as of the individual criteria of both. A total of 73 dermatologists attended three dermatoscopic courses and examined a set of clinical and dermatoscopic slides of 50 pigmented skin tumors. Agreement % and K value for a kappa statistical analysis have been calculated to evaluate inter-rater reliability. The clinical and the dermatoscopic methods showed similar values of concordance: clinical score 2 mean agreement = 68%, mean K = 0.44; clinical score 3 mean agreement = 73%, mean K = 0.61; 7FFM mean agreement = 83%, mean K = 0.64. The clinical criteria A, B, and C and the dermatoscopic features of our method presented similar values of concordance as well: clinical criteria mean K range 0.35-0.25, dermatoscopic features mean K range 0.62-0.25. The dermatoscopic features of our method 7FFM show a good reproducibility after a short training program, similar to the reproducibility of the clinical criteria of the ABCDE rule for the diagnosis of melanoma • Bishop, J. A., Bradburn, M., Bergman, W., Osterlind, A., Pinney, E., Rosdahl, I., Scerri, L., Weichenthal, M., Mant, D., Breitbart, E. W., Karlsson, P., & Altman, D. G. 2000, "Teaching non-specialist health care professionals how to identify the atypical mole syndrome phenotype: a multinational study", Br.J Dermatol., vol. 142, no. 2, pp. 331-337. Abstract: The atypical mole syndrome (AMS) phenotype is the strongest known risk factor for cutaneous melanoma but recognition of the phenotype has been claimed to be problematic and to require specialist assessment. This study determined the ability of previously unskilled doctors and nurses in five countries to recognize the phenotype after brief training. The system used was the AMS scoring system. This incorporates melanocytic naevus counts, clinical atypia of naevi and distribution of naevi. The agreement in scoring between the dermatologist and trained personnel was determined in 986 patients; overall agreement in diagnosis was 94.5% (kappa 0.70, P
    • < 0.0001). The kappa scores in different countries ranged from 0.65 to 0.77 for individual naevus characteristics, indicative of good agreement. Accurate diagnosis of the atypical mole syndrome phenotype is possible by non-specialists. This has implications for collaborative studies of naevi, for screening and for both primary and secondary prevention of melanoma • Bittorf, A. & Diepgen, T. L. 1996, "Teaching resources for dermatology on the WWW--quiz system and dynamic lecture scripts using a HTTP-database demon", Proc.AMIA.Annu.Fall.Symp, vol. 46-50, p. -50. Abstract: The World Wide Web (WWW) is becoming the major way of acquiring information in all scientific disciplines as well as in business. It is very well suitable for fast distribution and exchange of up to date teaching resources. However, to date most teaching applications on the Web do not use its full power by integrating interactive components. We have set up a computer based training (CBT) framework for Dermatology, which consists of dynamic lecture scripts, case reports, an atlas and a quiz system. All these components heavily rely on an underlying image database that permits the creation of dynamic documents. We used a demon process that keeps the database open and can be accessed using HTTP to achieve better performance and avoid the overhead involved by starting CGI-processes. The result of our evaluation was very encouraging • Bittorf, A., Bauer, J., Simon, M., & Diepgen, T. L. 1997, "Web-based training modules in dermatology", MD Comput., vol. 14, no. 5, pp. 371-6,381. Abstract: With the goal of using the full power of the World Wide Web for computer-based education, we developed an interactive system for training in dermatology with a database of several thousand color images. The system consists of lecture scripts, case reports with recorded sound, an online atlas, and a quiz system--all relying on the underlying image database. The images used have been reviewed and rated by a senior dermatologist. At present, they are described with a hierarchical key system that permits searching for images by their content. We have evaluated our statistics on access and the results of an open user survey based on an adaptive questionnaire. The responses to 200 questionnaires completed in a two- month study period are encouraging. The online resources are being used not only for training in dermatology but also for continuing education and reference • Chen, F. M. 2001, "Dermatology referrals in an academic family medicine clinic", South.Med J, vol. 94, no. 5, pp. 475-477. Abstract: BACKGROUND: Variations in referral rates among primary care physicians have implications for cost and quality of care, as well as primary care training. Dermatology referral rates of residents and faculty from an academic family medicine clinic are described. METHODS: Using a computerized referral tracking system, all dermatology referrals from January to March 1999 were retrospectively reviewed. Referral rates were calculated for individual providers, rates of uncompleted referrals were calculated, and reasons for referral were examined. RESULTS: Residents and faculty made 102 dermatology referrals during the study period. Although no significant differences occurred in referral rates between residents and faculty, significant variation occurred among individual providers. Junior residents had more uncompleted referrals (83%) than senior residents (29%) 2
    • and faculty. Common skin conditions accounted for most referrals. CONCLUSIONS: Wide variation exists in dermatology referral rates among family medicine residents and faculty. Moreover, many referral appointments are not kept. Family medicine training curricula should include formal education on the referral process • Ersser, S., Newton, J., Taylor, H., Van Onselen, J., & Kaur, V. 1998, A Descriptive and Evaluative Study of a Dermatology Nursing Service, Oxford Centre for Research and Development, Oxford Brookes University. • Feldman, S., Coates, M., Fleischer, A., Mellen, B., & Williford, P. 2001, "Comparing the Diagnostic Accuracy of Dermatologists and Nondermatologists", Archives of Dermatology, vol. 137, no. 12. • Feldman, S. R., Fleischer, A. B., & McConnell, R. C. 1998, "Most common dermatologic problems identified by internists, 1990-1994", Arch.Intern.Med, vol. 158, no. 7, pp. 726-730. Abstract: BACKGROUND: Internists in all settings see many patients with skin conditions. Thus, their education in dermatology is important. Information on which areas of dermatology are most commonly seen in internal medicine practices is necessary for designing effective educational programs on skin disease. OBJECTIVE: To determine what types of dermatologic problems internists most commonly diagnose. METHODS: National Ambulatory Medical Care Survey data from 1990 to 1994 were analyzed for dermatologic diagnoses. Physicians specializing in internal medicine and all its subspecialties were compared with dermatologists and with other physicians. RESULTS: The most common skin disorders diagnosed by internists were dermatitis (15.8% of all diagnoses) and bacterial skin infections (14.0% of all diagnoses). Combined, bacterial, fungal, and viral infections included 28.3% of the most common dermatologic diagnoses made by internists. The top 10 most common diagnoses accounted for 57.9% of all skin-related diagnoses and the top 20 most common diagnoses accounted for 72.8%. Internists were more likely to see patients for bacterial skin infections, herpes infection, exanthem, urticaria, and insect bites while dermatologists more commonly saw patients for actinic and seborrheic keratoses, warts, benign and malignant skin tumors, and psoriasis. CONCLUSIONS: The most common dermatologic diseases diagnosed by internists differ considerably from those diagnosed by dermatologists. Because dermatologists do much of the dermatology teaching of internal medicine residents, it is important to recognize these differences to place emphasis on the proper areas of study. Some common or serious skin conditions not often diagnosed by internists such as psoriasis and melanoma also deserve attention in internal medicine training programs • Fleischer, A. B., Feldman, S. R., & McConnell, R. C. 1997, "The most common dermatologic problems identified by family physicians, 1990-1994", Fam.Med, vol. 29, no. 9, pp. 648-652. Abstract: BACKGROUND AND OBJECTIVES: Because all family physicians see numerous patients with dermatologic complaints, their education in skin disorders is important. Data are needed to help program directors know which areas of dermatology deserve the most time and emphasis. This study determined what types 3
    • of skin problems family physicians most commonly diagnose. METHODS: Study researchers analyzed National Ambulatory Medical Care Survey data from 1990 to 1994 for dermatologic diagnoses. We then compared physicians specializing in family practice and its related fields (general practice, family practice sports medicine, and family practice geriatrics) with dermatologists and other physicians. RESULTS: The most common skin disorders diagnosed by family physicians were dermatitis (16.4% of all diagnoses), pyoderma (13.7%), wart (8%), tinea infection (5.4%), and epidermoid cyst (5.1%). The top 10 most common diagnoses accounted for 65% of all skin-related diagnoses, and the top 20 most common diagnoses accounted for 81.8%. Family physicians more commonly saw patients for infectious processes, infestations, and insect bites, while dermatologists were more likely to see patients for psoriasis, alopecia, and rosacea. CONCLUSIONS: Skin disorders diagnosed by family physicians differ considerably from those diagnosed by dermatologists. Because dermatologists do much of the dermatology teaching of family practice residents, it is important to recognize these dissimilarities to place emphasis on the proper areas of study. Some common or serious conditions, such as psoriasis and melanoma, are not often diagnosed by family physicians and also deserve attention in family practice training programs • Geller, A. C., Prout, M., Sun, T., Lew, R. A., Culbert, A. L., & Koh, H. K. 1999, "Medical students' knowledge, attitudes, skills, and practices of cancer prevention and detection", J Cancer Educ., vol. 14, no. 2, pp. 72-77. Abstract: BACKGROUND: Surveys of U.S. physicians show deficiencies in cancer detection and counseling skills. Thus, there is a compelling need to provide skills teaching during medical school for cancers with preventable mortality and for counseling techniques for smoking prevention and cessation. METHODS: In advance of the integration of initiatives for cancer education into the medical school curriculum, the authors conducted a baseline survey of students' knowledge, attitudes, skills, practices, observation, and training (KASPOT) related to cancer education. Eighty-one percent of Boston University School of Medicine students (n = 499) completed surveys. RESULTS: The students reported higher levels of KASPOT for breast and cervical cancers, compared with skin cancer examination or tobacco use cessation or prevention counseling. More than half of third- and fourth-year students reported that too little emphasis was given to cancer control education. CONCLUSIONS: It appears that students' practice and skills for detection of the most common cancer (skin cancer), and for cancers with the greatest mortality (tobacco-related cancers) are deficient. Revisions in medical students' curricula should seek to address these shortcomings • Gerbert, B., Maurer, T., Berger, T., Pantilat, S., McPhee, S. J., Wolff, M., Bronstone, A., & Caspers, N. 1996, "Primary care physicians as gatekeepers in managed care. Primary care physicians' and dermatologists' skills at secondary prevention of skin cancer", Arch.Dermatol., vol. 132, no. 9, pp. 1030-1038. Abstract: BACKGROUND AND DESIGN: This study determines (1) the readiness of primary care physicians (PCPs) to triage optimally lesions suspicious for skin cancer, (2) the difference in their abilities from those of dermatologists, and (3) whether accurate diagnosis after viewing slide images transfers to accurate diagnosis after viewing lesions on patients. Seventy-one primary care residents and 15 4
    • dermatologists and resident dermatologists diagnosed and selected a treatment/diagnostic plan for skin lesions suspicious for cancer. The lesions were shown on slides, computer images, and patients. Participants' performance was compared with biopsy results of all lesions. RESULTS: Dermatologists' scores were almost double those of primary care residents, and primary care residents' performance was positively associated with previous experience in dermatology. Primary care residents failed 50% of the time to diagnose correctly nonmelanoma skin cancer and malignant melanomas, and 33% of the time they failed to recommend biopsies for cancerous lesions. Primary care residents failed to diagnose malignant melanomas 40% of the time; dermatologists failed to do so 26% of the time. Both groups performed better using slide images compared with patients. CONCLUSIONS: Primary care residents may not be ready to assume a gatekeeper role for lesions suspicious for skin cancer. Because of the seriousness of missed diagnoses, especially of malignant melanomas, we need to improve the triage skills of PCPs. Future studies should evaluate whether primary care training allows sufficient time for PCPs to learn the necessary skills. Until we can show that PCPs are prepared to triage optimally, managed care plans should reduce the threshold for referrals to dermatologists of potential skin cancers • Harlow, E. D. & Burton, J. L. 1996, "What do general practitioners want from a dermatology department?", Br.J Dermatol., vol. 134, no. 2, pp. 313-318. Abstract: Four hundred and fifty-six practitioners (GPs) in Avon were asked what they required from their department of dermatology, and what improvements to the present service they could suggest. Most GPs preferred to manage the majority of dermatological problems themselves, with support from the department where necessary. They referred to a hospital department because they lacked the necessary expertise, but would prefer to receive training, advice and support in managing their patients rather than surrender long-term care to a specialist department. Despite this expressed willingness to shoulder more of the dermatological burden, only 31% of the GPs had received any postgraduate training in dermatology. In fact 57% said they had little interest in the subject and had not attended any form of dermatology teaching since qualifying. GPs would also like more guidance in the form of regularly updated guidelines and protocols, and easy access to dermatologists for telephone advice at regular fixed times. Some also felt that consultants should aim to provide diagnosis, investigation, and management guidelines for referred patients after a single visit. These findings should prompt a re-appraisal of the relative roles of GP and dermatologist, and emphasize the need for vocational training and continuing medical education in dermatology for all GPs • Kernick, D., Powell, R., Reinhold, D., Sawkins, J., & Warin, A. 2000, "A cost consequence study of teh impact of a dermatology trained practice nurse on the quality of life of primary care patients with asthma", NHS Centre for Reviews and Dissemination. 5
    • • Kilkenny, M., Yeatman, J., Stewart, K., & Marks, R. 1997, "Role of pharmacies and general practitioners in the management of dermatological conditions", INT.J PHARM.PRACT., vol. 5, no. 1, pp. 11-15. Abstract: Interviewers in the three community pharmacies in Maryborough, Central Victoria, Australia, collected data over four weeks from 830 people obtaining 1011 skin related products. At the same time, the general practitioners in the area recorded all patients seen with skin related conditions, the management they required and the diseases for which they were treated. Over 70 per cent of the products obtained were non-prescription items, the sources of recommendation for these being pharmacy staff (39 per cent), family (27 per cent), medical practitioner (19 per cent) and other sources (15 per cent). Purchasers of one-third of the OTC products had already sought advice at some stage from their medical practitioner; 57 per cent of these products were subsequently bought on advice from sources other than their medical practitioner. For 34 per cent of the OTC purchases the consumers had described their symptoms to pharmacy staff, and in one third of these the consumer had at some stage seen a medical practitioner about the condition. Of those who described symptoms within the pharmacy, 55 per cent were seen only by a pharmacy assistant, the remainder being seen at some stage by the pharmacist. More consumers with inflammatory skin diseases purchased an OTC product from a pharmacy than visited their GP. All people with suspected neoplasms consulted a GP rather than a pharmacist. Education programmes are required to ensure that pharmacists have adequate knowledge of the conditions for which OTC skin products are available. Public education is required to ensure that consumers who seek advice for skin disease in the pharmacy do so from the person in that environment who is appropriately qualified to give it • Kirsner, R. S. & Federman, D. G. 1996, "Lack of correlation between internists' ability in dermatology and their patterns of treating patients with skin disease", Arch.Dermatol., vol. 132, no. 9, pp. 1043-1046. Abstract: BACKGROUND AND DESIGN: We determine whether a subset of internists exist who are better at diagnosing skin disease and therefore select themselves to treat the majority of patients with dermatologic disorders. A survey was conducted in which internists reported their self-perception regarding their abilities in dermatology, the amount of dermatology training they had received, and the percentage of patients they encounter with and treat for skin diseases. This was correlated with results from an objective photographic (Kodachrome) examination assessing their diagnostic abilities in dermatology. The setting was university and private practices in Miami, Fla, and New Haven, Conn. The participants were general internists, medical subspecialists, and medical residents. After completing a self- administered questionnaire, each physician then participated in an examination where they were shown 20 color photographs of common skin disorders. We correlate the relationship between the survey variables and the results of the photographic examination. RESULTS: Eighty-four internists diagnosed 50.5% of the diseases correctly. Internists perceive themselves as mediocre in dermatology (2.6, on a scale of 1-5, 5 being the best), which correlated with their poor performance on the photographic evaluation (P = .04). Internists reported having limited education or training in dermatology (> 85% having < 1 month of training in or after medical school). There was a trend toward a correlation between the amount of training 6
    • internists received and their ability in dermatology (P = .07). Notably , there was no correlation between internists' ability in dermatology and the percentage of patients they encounter with and treat for skin disease. CONCLUSIONS: Internists receive limited training and have resultant poor performance in diagnosing skin disease. Internists are aware of their limited ability in dermatology as demonstrated by their mediocre self-perceived ability. Notably, no correlation was found between internists' abilities in dermatology and the percentage of patients they encounter and treat for skin disease. Therefore, we did not demonstrate a subset of internists, superior at dermatology, who treat the majority of patients with skin disease. This suggests patients with skin disease may be better served by dermatologists • Lorenzoni, L., Da Cas, R., & Aparo, U. L. 2000, "Continuous training as a key to increase the accuracy of administrative data", J Eval.Clin.Pract., vol. 6, no. 4, pp. 371-377. Abstract: The aim of this study was to evaluate the impact of a program of training, education and awareness on the accuracy of the data collected from hospital discharge abstracts. Four random samples of hospital discharge abstracts relating to four different periods were studied. The evaluation of the impact of systematic training and education activities was performed by checking the quality of abstracting information from the medical records. The analysis was carried out at the Istituto Dermopatico dell'Immacolata, a research hospital (335 beds) in Rome, Italy, which specializes in dermatology, plastic and vascular surgery. Error rates in discharge abstracts were subdivided into six categories: selection of the wrong principal diagnosis (type A); low specificity of the principal diagnosis (type B); incomplete reporting of secondary diagnoses (type C); selection of the wrong principal procedure (type D); low specificity of the principal procedure (type E); incomplete reporting of procedures (type F). A specific rate for errors modifying classification in diagnosis related groups (DRG) was then estimated and the effect of re-abstracting on the case- mix index evaluated. Error types A, B, C, E and F dropped from 8.5% to 2%, 15.8 to 4.9, 31.8 to 13.1,4.1 to 0.3 and 22 to 2.6%, respectively. Error type D was 0.7 both in the first (the baseline) and fourth periods of analysis. All differences in error types were statistically significant. In 1999 8.3% of cases were assigned to a different DRG after re-abstracting as compared with 24.3% in the third quarter of 1994, 23.8% in the first quarter of 1995 and 5.5% in September-October 1997. Continuous training and feedback of information to departments have shown to be successful in improving the quality of abstracting information at patient level from the medical record. These positive results were facilitated by the introduction of a prospective payment system to finance inpatient hospital activity. The effort to increase administrative data quality at hospital level facilitates the use of those data sets for internal quality management activities • Murray, S. J. & Raymond, G. P. 1998, "Undergraduate dermatology education in Canada: a survey", J Cutan.Med Surg., vol. 2, no. 4, pp. 220-223. Abstract: BACKGROUND: Two reviews done in the 1980's showed that many Canadian medical schools scheduled relatively little time for dermatological teaching. Many students did not have a real clinical exposure to dermatology. OBJECTIVE: The purpose of this study was to obtain new data to reevaluate the undergraduate training in dermatology in Canada. Methods: A survey was sent to the coordinators of 7
    • undergraduate dermatology of all 16 Canadian medical schools. RESULTS: The survey of medical schools demonstrates the current status of dermatology undergraduate teaching across Canada. Although many improvements have been made in the way dermatology is taught to medical students, many of the problems noticed in the 1980s remain unresolved. CONCLUSION: Because dermatological care in Canada is often rendered by nondermatologists, the dermatologists should emphasize the importance of undergraduate training in their specialty • Oliveria, S., Nehal, K., Christos, P., Sharma, N., Tromberg, J., & Halpern, A. 2001, "Using nurse practitioners for skin cancer screening", American Journal of Preventive Medicine, vol. 21, no. 3, pp. 214-217. • Oliveria, S. A., Nehal, K. S., Christos, P. J., Sharma, N., Tromberg, J. S., & Halpern, A. C. 2001, "Using nurse practitioners for skin cancer screening: a pilot study", Am.J Prev.Med, vol. 21, no. 3, pp. 214-217. Abstract: BACKGROUND: Skin cancer screening has the potential to detect early precancerous lesions and may ultimately be important in reducing melanoma mortality. The purpose of this study was to evaluate the ability of trained nurse practitioners to accurately identify suspicious lesions in a clinical setting. METHODS: We identified five nurse practitioners who had no previous experience in evaluating skin lesions. Each nurse practitioner participated in a training program for skin cancer detection consisting of a workshop, clinical apprenticeship, and didactic lectures. RESULTS: Evaluation of nurse practitioner competency involved three assessments. First, the nurse practitioner's ability to distinguish benign and malignant lesions was assessed using clinical color slides. The sensitivity of all five nurse practitioners to refer benign and malignant lesions for dermatologic follow-up based on the slides was 100%, whereas the specificity ranged from 53% to 100%. Second, each nurse practitioner evaluated approximately 25 different patients along with a single dermatologist. The nurse practitioner's ability to correctly refer patients with suspicious lesions for dermatologic follow-up was determined based on the dermatologist's assessment of need for referral. Results suggested a referral sensitivity and specificity ranging from 67% to 100% and 62% to 100%, respectively. In the final clinical assessment, 30 patients were independently examined by two dermatologists and four nurse practitioners. Using the consensus clinical diagnosis of the dermatologists as the gold standard, the nurse practitioner's sensitivity for detecting significant skin cancer lesions ranged from 50% to 100% and the detection specificity was 99% to 100%. CONCLUSIONS: These preliminary results have important implications for skin cancer screening efforts and suggest that nurse practitioners can be trained to accurately identify and triage suspicious lesions • Plunkett, A., Lau, P., Stewart, K., & Marks, R. 2001, "Skin conditions in the pharmacy: Consumer satisfaction and economic considerations", INT.J PHARM.PRACT., vol. 9, no. 1, pp. 9-14. Abstract: Objective - To evaluate whether consumers were satisfied with advice about skin conditions received from community pharmacists in Victoria, Australia, and to estimate costs and potential savings to the consumer and government associated with managing these conditions in the pharmacy. Methods - In 1997-1998, 8
    • a consumer survey on costs and satisfaction was carried out in Victoria as part of a statewide education programme with community pharmacists. Pharmacists recorded details of dermatological consultations involving over-the-counter (OTC) products, and recruited pharmacy consumers for follow-up by a member of the research team. Results - Consumer consultations were recorded at 126 pharmacies. One hundred and five (58.0 per cent) of the 181 consumers who were subsequently interviewed reported being very satisfied with their consultation. One hundred and thirty-two (73.0 per cent) spent up to 10 minutes consulting the pharmacist and 78 (43.1 per cent) spent between $A5 (£1.95) and $A10 on OTC products. A total of 37 consumers (20.4 per cent) consulted a medical practitioner on the advice of their pharmacist. While most of the 37 consumers spent under $A10 in the pharmacy, if the cost of medical consultation and the subsidised nature of items supplied on medical prescription were taken into account, the costs to the consumer and government would have been greater. The direct costs for a pharmacist consultation on the management of skin conditions were lower than the expected direct costs associated with a general practitioner (GP) consultation. Conclusions - Consumers were satisfied with the advice and treatment they received from the pharmacist on the management of skin conditions. Pharmacists' advice also appeared to be cost- effective for both the consumer and government. Community pharmacists appear to be satisfactory primary providers of advice and treatment for people with minor skin conditions • Richard, M. A., Grob, J. J., Avril, M. F., Delaunay, M., Gouvernet, J., Wolkenstein, P., Souteyrand, P., Dreno, B., Bonerandi, J. J., Dalac, S., Machet, L., Guillaume, J. C., Chevrant-Breton, J., Vilmer, C., Aubin, F., Guillot, B., Beylot-Barry, M., Lok, C., Raison-Peyron, N., & Chemaly, P. 2000, "Delays in diagnosis and melanoma prognosis (II): the role of doctors", Int.J Cancer, vol. 89, no. 3, pp. 280-285. Abstract: A prospective survey was conducted to assess physician responsibility in melanoma prognosis. Consecutive patients with primary melanoma were interviewed and examined using a standardized questionnaire. Main outcome measures were medical components of the delay before tumor resection and tumor thickness. Of 590 melanomas, 29.1% were coincidentally detected by physicians and their tumor depth was lower than in melanomas detected by patients (p < 0.001). Physician sensitivity for melanoma diagnosis was evaluated at 86%. Median time intervals to propose resection and to perform removal of melanoma were short: 0 (mean 103) and 7 (mean 68) days, respectively. Melanomas were managed in an inappropriate way in 14.2% of cases. Location on acral areas and absence of pigmentation were associated with longer medical delays and more frequent inappropriate medical attitudes. Melanomas located on hardly visible areas were less frequently detected by physicians than those on visible areas. Medical delays were shorter, doctor's attitude was more frequently appropriate, and melanoma thickness was lower (p < 0.001) when the patient visited a dermatologist (54.7%) than when he or she visited a general practitioner (33.4%). Our study shows that doctor responsibility accounts for only a small part of the total delay before melanoma removal. However, systematic total examination and better training of doctors, especially about unusual forms of melanoma, could still improve melanoma detection. Copyright 2000 Wiley-Liss, Inc 9
    • • Sanchez-Torres, A. M., Creis, M. J., & Arreaza, P. M. 2001, "Analysis of consultations made to the pharmacist by the users of Ciudad Real pharmacies", PHARM.CARE ESPANA., vol. 3, no. 2, pp. 106-121. Abstract: Objective: To know the type of consultations which pharmacy clients make in the province of Ciudad Real. Methods: A registration sheet of consultations was distributed among the pharmacies of the province of Ciudad Real, so as to note down data for four days, randomly chosen, representing each one of the four seasons (October 1998, January, April and July 1999). The pharmacist recorded diverse data of each spontaneous consultations made by a client of the pharmacy. Results: 1.279 consultations in 30 collaborating pharmacies were registered. 35.7% of the clients were between 30-44 years of age, 25.3% between 45-65 and 74.6% were women. 59.7% of the consultations were intended for adults. 75.9% of the men made their own consultations compared to 51.9% of women. The women consulted in a higher measure on the family health problems, especially on their children's problems. 48.3% of the consultations proceeded from clients who went to the pharmacy solely to consult. The most frequent motives of consultation were to ask for information on the medicine (32.6%) and to ask for treatment for some symptom in concrete (32.7%). As far as the consultations on medicine 40.6% referred to dosage. The problems most consulted referred to respiratory, dermatological, ear nose and throat, digestive symptoms and different types of pain. Of the clients who expressed the motive for consulting the pharmacist 25.7% mentioned confidence in the service, 21.3% communication difficulties with the physician and 19.3% time-saving. Conclusion: The pharmacy gives a health service, over and above the sale of medicines, to whom not only information of medicines but also treatment or advice for different types of symptoms or pathologies considered as "minor" are requested by the patients. Thus in conclusion the necessity of protocolizing the interventions around the illnesses which with a higher frequency are the reason for consultation: the educational interventions to foment the rational use of drugs, especially with women; a higher collaboration physician-pharmacist and more formation and provision of tools so as to facilitate therapeutic compliance and the detection of interactions and adverse effects • Satimia, F. T., McBride, S. R., & Leppard, B. 1998, "Prevalence of skin disease in rural Tanzania and factors influencing the choice of health care, modern or traditional", Arch.Dermatol., vol. 134, no. 11, pp. 1363-1366. Abstract: OBJECTIVES: To determine the prevalence of skin disease in a rural Tanzanian community and to investigate the health-seeking behavior of this community. DESIGN: The study was in 3 parts: (1) 120 heads of households were interviewed to determine the factors that influence the families' health-seeking behavior; (2) the 800 members of these families were examined for evidence of skin disease; and (3) a focus group discussion was held with influential members of the community to get a broader view of health-seeking behavior. SETTING: A rural village in the southwestern area of Tanzania: Individuals were interviewed and examined in their own homes. RESULTS: A total of 34.7% of 800 villagers had one or more skin diseases, the most common of which were tinea capitis, tinea corporis, scabies, acne, and eczema. Modern and traditional health facilities were equally used, but heads of the households older than 55 years who had never been to school and individuals who were not Christians favored traditional medicine. It was cheaper to 10
    • go to a traditional healer, but modern medicine was thought to be more scientific. CONCLUSIONS: Skin disease was a problem in this village and was perceived to be a problem by both individuals and the community. There is a need to assess the clinical and diagnostic skills of both modern and traditional health practitioners and to instigate a preventive health education program to eradicate the common infections and infestations • Stanganelli, I., Seidenari, S., Serafini, M., Pellacani, G., & Bucchi, L. 1999, "Diagnosis of pigmented skin lesions by epiluminescence microscopy: determinants of accuracy improvement in a nationwide training programme for practical dermatologists", Public Health, vol. 113, no. 5, pp. 237-242. Abstract: BACKGROUND: The poor accuracy of the clinical examination of pigmented skin lesions (PSLs) is a major limitation of secondary prevention strategies for cutaneous melanoma (CMM). In the last few years, the epiluminescence microscopy (ELM) technique has been used increasingly as an adjunct to clinical examination in the dermatology practice. Although the question of training has emerged as a priority, the diffusion, the effects, and the correlates of educational programmes in ELM have seldom been studied. METHODS: Thirty ELM images of PSLs (11 CMMs, 14 melanocytic nevi (MN), and 5 nonmelanocytic lesions (NMLs) each matched with the corresponding clinical or plain photographic image were independently diagnosed before and after a one-day workshop by 83 Italian dermatologists participating in a nationwide educational programme on ELM. The original histology diagnosis was assumed as a gold standard. The overall effect of training on a set of accuracy measures by PSL type was evaluated. The association of the professional sector (public/private), number of years of general experience in dermatology (1-10/>10), average weekly number of PSLs seen (< or =10/11-20/>20), routine use of ELM (no/yes), and area of residence (northern/southern Italy) with the mean number of PSLs correctly diagnosed before and after training was evaluated with the general factorial analysis of variance. The factors associated with improvement between the two tests were evaluated with the analysis of variance for repeated measures. RESULTS: Compared with pretraining data, the average percentage of exact diagnosis increased significantly for all PSLs (CMMs, 72% vs 55%; MN, 68% vs 64%; NMLs, 67% vs 58%; total lesions combined, 69% vs 60%). Baseline as well as final accuracy were independent from the professional sector and the years of experience but were greater among those subjects who reported >20 PSLs per week compared with the reference group (< or =10 PSLs). The routine use of ELM was associated with a slight advantage in pretraining accuracy. The area of residence was the strongest determinant of baseline as well as final accuracy. The effect of training was independent from all factors studied with the exception of the area of residence with a 13% increase in the frequency of exact diagnosis in northern Italy (from 66-79%) and 6% in southern Italy (from 55-61%). CONCLUSIONS: Though insufficient in absolute terms, a measurable increase in ELM accuracy can be achieved even with intense training sessions of short duration. Medical education to ELM in southern Italy should be a priority • Webb, J. M., Rye, B., Fox, L., Smith, S. D., & Cash, J. 1996, "State of dermatology training: the residents' perspective", J Am.Acad.Dermatol., vol. 34, no. 6, pp. 1067-1071. 11
    • Abstract: Changes in health care delivery necessitate modification in dermatology training. While the residents at The University of Alabama at Birmingham were planning their 1995-1996 curriculum, several questions regarding the most appropriate allocation of time and resources arose. Interest in other residency curricula prompted the development of a national survey of dermatology residents. Our purpose was to provide comprehensive data regarding the didactic, clinical, surgical, and other aspects of today's U.S. dermatology residency training from the perspective of the residents. It is hoped these data will assist dermatology residency programs with evaluation of their current curricula. A comprehensive 31-question multiplechoice survey was mailed to 631 residents in 70 U.S. dermatology residency programs. Results were tabulated and median values and percentages of responses were obtained. A Wilcoxon rank-sum test, a chi-square analysis, and logistic regression analysis were performed on survey items on the basis of residents' satisfaction with the training program. Two hundred forty-eight responses (39%) were returned with all years of training well represented. Median values and percentages obtained outlined the didactic, clinical, surgical, and other aspects of dermatology residency training. Seventeen percent of residents believed they were not being adequately trained. Satisfaction with training was noted with more didactic faculty involvement, consultations and research, and surgical procedures performed per month. Residents with enriched didactic, clinical, and surgical training experiences are more satisfied with their training programs • Westerhoff, K., McCarthy, W. H., & Menzies, S. W. 2000, "Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy", Br.J Dermatol., vol. 143, no. 5, pp. 1016-1020. Abstract: BACKGROUND: Skin surface microscopy (oil epiluminescence microscopy, dermoscopy, dermatoscopy) has been shown to increase the diagnostic accuracy of melanoma. However, all studies to date have been in an expert setting. OBJECTIVES: To determine whether primary care physicians (PCP) (general practitioners) could improve their melanoma diagnosis using surface microscopy after a short education intervention. METHODS: Seventy-four practising PCP completed a pretest of 50 melanomas and 50 atypical non-melanoma pigmented skin lesions (PSL) containing matched clinical and surface microscopy photographs. PCP were randomized between a surface microscopy education intervention or control group, followed by an identical post-test. RESULTS: Following training there was a significant improvement in the post-test vs. pretest in both clinical melanoma diagnosis (62.7% vs. 54.6%; P = 0.007) and surface microscopy melanoma diagnosis (75.9% vs. 57.8%; P = 0.000007). No difference was found in the control group between the post-test vs. pretest clinical melanoma diagnosis (53.7% vs. 50.6%; P = 0.21) or the surface microscopy melanoma diagnosis (54.8% vs. 52.9%; P = 0.56). Following training there was a significant improvement in the diagnosis of melanoma using surface microscopy vs. clinical diagnosis (75.9% vs. 62.7%; P = 0.000007), which was absent in the control group (54.8% vs. 53.7%; P = 0.59). No significant difference was found in clinical vs. surface microscopy post-test results for non- melanoma PSL in either the intervention group or control group. Improvement in the sensitivity for the diagnosis of melanoma with surface microscopy was seen without a decrease in specificity; this indicated that the effect should occur without increasing 12
    • the number of needless excisions. CONCLUSIONS: All PCP in countries where melanoma leads to significant mortality should be trained in skin surface microscopy. Search Terms Database CINAHL 1994-2001(end) Search terms: Dermatology 2351 records Dermatology, Training and Education 59 records Dermatology and Training 90 records 12 documents were retrieved. Database Medline 1997- 2001 (end) Search terms: Dermatology 33611 records Skin Disease 1095 records Dermatology and Skin Disease 507 records Dermatology, Skin Disease, Training and Education 5 records Dermatology, training and education 91 records Database PUBMED 1982 –2001 (end) Search terms: • Dermatology, skin care, Training and Education 13