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Advancing the Science and Art of Teaching Dermatology
Abstracts Presented at the 10th Winter Meeting of the Dermatology Teachers Exchange Group, March 12, 2000, San Francisco, Calif
Introduction by Ponciano D. Cruz, Jr, MD
Arch Dermatol. 2001;137:808-811.
INTRODUCTION
The Dermatology Teachers Exchange Group (DTEG) convenes biannually in late winter (February or March), concurrent with the annual meeting of the American Academy of Dermatology, and in the fall, concurrent with the meeting of the Association of Professors of Dermatology. At the DTEG meeting that was held March 12, 2000, in San Francisco, Calif, 9 abstracts were presented on residency selection, residency training, medical student education, primary physician education, and utility of dermatologic care. The DTEG meeting that was held September 8, 2000, featured a workshop on competency-based training of residents.
The DTEG is led by a steering committee whose members are as follows: Ponciano D. Cruz, Jr, MD; John E. Olerud, MD; Robert T. Brodell, MD; Janet A. Fairley, MD; Steven E. Wolverton, MD; William D. James, MD; Gregory J. Raugi, MD; and Antoinette F. Hood, MD. Since its inception, the DTEG has been supported by annual grants from Pharmacia-Upjohn, Kalamazoo, Mich. The abstracts presented herein are given in alphabetical order based on the surname of the first author.
ABSTRACT 1
IMPLEMENTING BASIC INFORMATICS IN A RESIDENCY TRAINING PROGRAM
Ashish C. Bhatia, Bryan R. Davis, Robert T. Brodell, Rouald D. Crock; Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio, and Department of Internal Medicine, Northeastern Ohio University College of Medicine, Rootstown
Industry and education are turning toward technology to assist in the timely dissemination and collection of the information necessary for the efficient day-to-day functioning of institutions and the individuals within the organization. Networks, whether institutional (LAN, WAN, etc) or global (Internet), are ideal for such tasks and may be used in our residency programs to share information, including schedules, conference information, handouts, reading lists, and memos.
To address this need, an informatics system was developed using Now Up-to-Date (Power On Software Inc, Minneapolis, Minn). It automatically generates and updates a Web-based residency calendar and attending/resident clinic schedules to a remote Web server. Subsequently, other features, such as lecture and conference schedules, have been added. Residents' call schedules with pager numbers are also published on a private area of the Web server and are used to produce up-to-date call schedules for secretaries and telephone operators.
There are several benefits of this system. Residents and faculty may check their schedules from any computer with Internet access. Community-based faculty members have instant access to conferences and lectures offered at the medical center and can join the hospital faculty and residents. The program director and staff are able to update schedules and calendars frequently and rapidly. Finally, there is a marked decrease in the amount of paper waste generated in the production of these documents and their updates.
The initial system was designed to allow fast, easy updates, with minimal training of administrative staff. It also served as "first step" for the staff, residents, and faculty to acclimate to a paperless system. Concepts for enhancement of this system include the dissemination of other printed materials (handouts, reading lists, etc) and the addition of educational seminar modules with rich graphics. Data collection features are being developed using FileMaker Pro, a Web-enabled, cross-platform database. The features in progress include (1) pretest and posttest materials and evaluations; (2) a Web-based resident procedure log system; and (3) a feedback form to improve usability of the informatics system.
ABSTRACT 2
CATALOG OF UTILITIES IN DERMATOLOGY
S. C. Chen, A. M. Bayoumi, B. Brown, S. Soon, K. Aftergut, P. Cruz, S. Austin, C. McCall, M. K. Goldstein; Stanford University, Stanford, Calif (Drs Chen, Brown, and Goldstein); University of Toronto, Toronto (Dr Bayoumi), and McMaster University, Hamilton (Dr Soon), Ontario; University of Texas at Southwestern, Dallas (Drs Aftergut and Cruz); and Emory University, Atlanta, Ga (Drs Austin and McCall)
Utilities are one way to measure quality of life; they quantify the strength of a patient's preference for a health outcome. As such, utilities are key in cost-effectiveness analyses where mortality is minimal, but they are not widely available for dermatology. We elicited utilities for a variety of dermatoses and explored whether patient perception and reaction could explain utility scores. We also explored whether utilities cluster near 1.0 (range, 0-1.0), as skin problems are often considered minor health states.
We recruited 250 dermatology subjects from Stanford (Palo Alto, Calif), Grady (Atlanta, Ga), and Parkland (Dallas, Tex) Hospitals. We elicited utilities using the time trade-off technique and derived scores for symptoms, emotion, and function using the Validated Functional Status Questionnaire, Skindex. We classified disease according to location and whether it was in an exposed area.
We cataloged utilities for 62 dermatoses and demonstrated a wide range in utilities (0.64 to 1.00). The location of the skin problem (mean utility for body, 0.94; face, 0.96; genitals, 0.74; limbs, 0.97; and trunk, 0.97), especially those in the genital area, significantly affected utility (P<.001). Exposure to potential viewers (yes, 0.96; no, 0.91) did not significantly affect utility, but the ratings of symptoms, function, and emotions did (P<.001).
Our study is the first catalog of utilities for diverse dermatoses. Concerns for clustering of dermatology utilities are unfounded. Since our catalog consists of data elicited directly from individuals, it is a better source for utility estimates than is extrapolation from nondermatologic diseases. Researchers can use these values to conduct meaningful cost-effectiveness analyses for dermatology.
ABSTRACT 3
RESIDENCY SELECTION: THE SOUTHWESTERN EXPERIENCE
Ponciano D. Cruz, Jr, MD; Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
Having directed the dermatology residency program at the University of Texas Southwestern Medical Center, Dallas, for at least a decade, I share our perspective on residency selection as a reference point for comparing and contrasting other programs' experiences and as a starting point to for analyzing selection techniques with respect to outcome. At its very essence, our program has 2 goals: to train excellent clinicians and to produce leaders in dermatology. Over time, our selection process has favored national (rather than regional) recruitment; a 6:1 ratio between the respective numbers of invited interviewees and of match positions (3-5 match positions per year); a single set of 2-day interviews; a focus on past behavior (in lieu of hypothetical situations) as predictors of future behavior; evaluation of distinct (rather than global) domains; standardized (as opposed to relative) scoring; and an emphasis on the second (more than on the first) program goal. Because we are committed to a democratic process, each faculty member who participates in interviews (residents as well as the chief resident) has an equal opportunity to influence the match ranking. This ranking is based on 2 sets of frameworks generated for 4 domains (first set, character and comfort level; second set, scholarship and leadership) that are graded independently by evaluators. During a dedicated meeting, each applicant is discussed and her or his ranking is refined by consensus. Because of the increasingly large number of highly qualified applicants competing for a very small number of positions, winnowing candidates has become a humbling, laborious, and difficult task. It is also a critical process: the first lap in an annual relay in which we hand the baton to the next generation. As such, residency selection is a responsibility worthy of our valued time, analytic appraisal, and improved effort.
ABSTRACT 4
ANALYSIS OF MEDICAL STUDENT EXPERIENCE WITH PATIENTS AND PROCEDURES DURING A CLINICAL DERMATOLOGY ELECTIVE
Karla S. Draft, Evan R. Farmer, MD, Antoinette F. Hood, MD; Department of Dermatology, Indiana University School of Medicine, Indianapolis
Two of the goals of medical education are the acquisition of knowledge and the acquisition of experience in a supervised environment. We measure the acquisition of knowledge via pretraining and posttraining tests. We need to develop tools to measure the experience of our students with regard to the patient population, specific diseases, severity of disease, various forms of treatment, and procedures.
Our objective was to document and analyze the clinical experience of medical students during their dermatology elective. All fourth-year medical students on the dermatology elective from July 1999 through January 2000 used a self-report log of patients and procedures. The data collected were the clinic site, number of patients, diseases, age of patients, degree of student involvement, and procedures performed.
Twenty-five students participated in the study in 6 clinic sites. A total of 3007 patients were seen by the students, with an average of 120 patients per student per month (range, 31-235 patients; median, 98 patients). Each student performed the initial examination on an average of 56 patients per month (range, 12-126 patients; median, 56 patients) and was primarily an observer of 46 patients per month (range, 10-96 patients; median, 37 patients). Each student performed an average of 1.8 procedures per month (range, 0-8 procedures; median, 0). The logbooks appeared to be variably completed.
There was a wide range of experience by the students on our dermatology elective. We plan to use these data to develop the framework for our clinical elective, including the minimal numbers of patients and procedures that constitute an adequate experience.
ABSTRACT 5
ANALYSIS OF RESIDENT EXPERIENCE DURING A CLINICAL DERMATOLOGY ROTATION
Holly F.Hahn, MD, Susan M. Perkins, PhD, Evan R. Farmer, MD; Departments of Dermatology and Medicine, Indiana University School of Medicine, Indianapolis
Two of the goals of medical education are the acquisition of knowledge and the acquisition of experience in a supervised environment. We measure the acquisition of knowledge via pretraining and posttraining tests. We need to develop tools to measure the experience of our residents with regard to the patient population, specific diseases, severity of disease, various forms of treatment, and procedures.
As a pilot study, our objective was to document and analyze the clinical experience of residents during a typical clinical rotation. We used the Regenstrief Information System, which is a large electronic database that contains information obtained during each patient encounter and that is linked to a wide variety of laboratory, radiological, and demographic data. We extracted, by resident, preliminary data on the number of patients, specific diseases, severity of disease, and therapy.
The residents, during 1 month, saw a variety of different diseases with a Dermatology Index of Disease Severity range from 1 to 3. Different therapeutic agents were used that could be linked to patients with specific diseases and specific Dermatology Index of Disease Severity scores. Data on residents from other specialties were also captured in the database.
There was a wide range of experience by the residents on our dermatology rotation. We plan to use these data to develop the framework for our rotations, including the minimal number of patients, number of patients with varying severity of disease, experience with various therapeutic modalities, and procedures that constitute an adequate experience.
ABSTRACT 6
OBJECTIVE SCORING PROVIDES FRAMEWORK FOR RESIDENCY SELECTION
W. D. James; Department of Dermatology, University of Pennsylvania, Philadelphia
Residency selection involves merging objective historical achievements with subjective information. Adding structure to the process produces a framework within which the selection committee may arrive at an equitable match list. The committee members score the candidate's record prior to the interview based on objective criteria, such as the medical school record, research publications, awards and honors, advanced degrees, board scores, extracurricular activities, and letters of recommendation. The relative weighting of these data may be tailored to individual program goals. The interviews should assess the candidate's maturity, autonomy, stability, ability to communicate, capacity for leadership, ability to relate, ability to examine issues, academic career potential, and general personality; 75% objective data and 25% subjective data determine the overall score. A preliminary rank list is generated, with outlier scores discussed among committee members. Adjustments made by consensus are reflected in the final match list.
ABSTRACT 7
DERMATOLOGY FOR PRIMARY CARE: DIDACTIC AND INTERACTIVE CONTINUING MEDICAL EDUCATION
Teresa Mann, Roy Colven, Daniel Berg, Douglas Brock, Douglas Schaad, Fredric Wolf; Division of Dermatology, Department of Medicine (Drs Mann, Colven, and Berg), and Department of Medical Education (Drs Broch, Schaad, and Wolf), University of Washington School of Medicine, Seattle
The purpose of our pilot study was to examine the transfer of knowledge following a didactic, large-group continuing medical eduation (CME) course that included interactive, small-group sessions. An 8-hour CME course on dermatology for primary care providers consisted of 10 topics, delivered in 20- to 25-minute didactic presentations, with 3, intervening, 10-minute panel discussions. Also, 3 hours of interactive, case-based, small-group discussion sessions were held in the afternoon to review material presented in the didactic sessions. Participants (n = 106) completed a 20-item, multiple-choice pretest before any didactic sessions. A posttest was administered randomly to 50% of the participants after the large-group didactic sessions and to the other 50% after the interactive, small-group sessions.
Significant gains in knowledge were observed both after large-group didactic sessions alone (premean, 50.9; postmean, 59.9; t44 = 2.70; P<.05), and when those sessions were augmented with small-group discussions (premean, 50.4; postmean, 64.4; t54 = 4.91; P<.001). Using conventional measures of effect size, the size of the effect for knowledge gain was about twice as large with small groups, although the improvement with small groups over large groups did not reach statistical significance.
Large-group didactic presentations, both with and without interactive CME sessions, are effective at facilitating short-term knowledge gains. We are examining whether interventions that encourage provider participation may be more effective in longer-term knowledge retention and, more importantly, in changing practice behaviors and ultimately improving patient care.
ABSTRACT 8
VIRTUAL REALITY–BASED SKIN SURGICAL SIMULATION: CREATING FAST FINITE-ELEMENT MODELS FROM MEDICAL IMAGES
Gregory Raugi, Dan Berg, Jeffrey Berkley, Peter Oppenheimer; Division of Dermatology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Human Interface Technology Laboratory, and Department of Mechanical Engineering, University of Washington, Seattle
The goal to develop an interactive, real-time, patient-specific, user-modifiable skin surgical simulator with graphic and haptic feedback has been a formidable challenge. The progress we have previously reported in streamlining the mathematical representation of the viscoelastic properties of skin has made real-time interactivity possible. Despite the mathematical and engineering sophistication of these models, they have lacked the graphical realism necessary to obtain the "immersive" quality required for virtual reality.
Computer reconstructions of human anatomy are in active use in medical education. These reconstructions are not imbued with the mechanical properties of the tissues they represent. We are developing software for creating patient-specific, user-modifiable finite element models from medical images. The steps involved in creating a texture-mapped finite element model are to (1) obtain medical images and texture maps; (2) extract the contours of the structure; (3) generate a 3-dimensional "mesh" from the contours; (4) alter the mesh according to the teaching objectives of the simulation; (5) assign material properties to the mesh, define the boundary nodes, and apply the texture maps to the structure; (6) generate a real-time finite element model; (7) support the tissue models with task-specific tools and training aids. This presentation will demonstrate how we have taken these steps in refining our virtual reality skin surgery application.
ABSTRACT 9
INTERDISCIPLINARY DERMATOLOGY EDUCATION FOR INTERNAL MEDICINE RESIDENTS
S. K. Szabo, M. Charif, K. D.Cooper, G. S.Wood; Departments of Dermatology, Case Western Reserve University, University Hospitals of Cleveland, and Veterans Affairs Medical Center, Cleveland, Ohio
Traditionally, the majority of skin care in the United States has been provided by nondermatologists, and this proportion is increasing. The request for interdisciplinary education at Case Western Reserve University to instruct residents from other specialties has recently increased significantly. We have previously reported our initiatives to restructure dermatology education at the Cleveland medical centers affiliated with Case Western Reserve University (Wood GS, Lynch WS, Davis B, et al. Arch Dermatol. 1996;132:1085-1090). Because of the limited time for dermatology education in internal medicine, our aim was to teach basic dermatologic care and proper referral thresholds. Our program involves 2 main approaches: (1) didactic lectures and (2) dermatology training clinics. The didactic lecture series was designed to cover a core program, including the structure and function of the skin; primary and secondary lesion terminology; basic diagnosis and treatment of 10 important or common skin diseases; and disease prevention and thresholds for referral to dermatology. Ambulatory internal medicine clinics involving dermatology training were established. Originally, dermatology patients were combined with other specialty patients, but this diluted the focus of the training so that now the residents see dermatologic patients exclusively, although each resident attends the clinic only 2 half-days each year. These are low-volume clinics that emphasize resident training rather than clinical service. The clinics are supervised by a dermatology fellow who is responsible for teaching the basics in recognizing and describing skin lesions, in differential diagnosis, and, if the skin problem falls within the core content of the basic training program, in treating the patient in this clinical setting. Initial feedback from medicine residents indicates that there is a demand for more lectures on diagnosis and treatment. Furthermore, there is a substantial interest in the training clinics. In conclusion, there is a widespread need for increased dermatology training for internists/generalists who are already treating more than 50% of skin diseases. We designed a system that should enhance not only the quality of primary care but also the communication between internists and dermatologists.
AUTHOR INFORMATION
Accepted for publication January 25, 2001.
Corresponding author: Ponciano D. Cruz, Jr, MD, Department of Dermatology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9069 (e-mail: pcruz{at}mednet.swmed.edu).
From the Department of Dermatology, University of Texas Southwestern Medical Center, Dallas.
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