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Should the Skin Cancer Examination Be Taught in Medical School?
Alan C. Geller, RN, MPH;
Suraj Venna, MD;
Marianne Prout, MD, MPH;
Donald R. Miller, ScD;
Marie-France Demierre, MD;
Howard K. Koh, MD, MPH;
Barbara A. Gilchrest, MD
Arch Dermatol. 2002;138:1201-1203.
ABSTRACT
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Background The fact that thin melanomas are associated with a greater than 95%
survival rate, while later, more deeply invasive melanomas have a 5-year survival
rate of less than 10%, demonstrates the potential personal and public health
impact of early detection. The majority of patients with skin lesions are
seen by nondermatologists who infrequently counsel patients about skin cancer
prevention or perform a complete skin examination as part of routine care.
We documented the antecedents of physician practice by evaluating medical
students' observation, training, performance, and self-reported skill level
for the skin cancer examination and sun protection counseling.
Methods Surveys were administered and completed in classrooms and student workshops
in each of the 4 medical school years during the spring of 1996 and 1997.
We concentrate our analysis on the graduating fourth-year students.
Results Of the 302 fourth-year students enrolled at Boston University School
of Medicine, Boston, Mass, in 1996 and 1997, 223 (74%) completed surveys.
Among fourth-year students, 52% rated themselves as unskilled in skin cancer
examinations. Twenty-eight percent of fourth-year students had never observed
a skin cancer examination, 40% had received no training, and 35% had never
practiced the examination. However, fourth-year students reporting at least
1 opportunity to observe, train, or practice an examination were 3 times as
likely to report themselves as moderately to very skilled as students without
such opportunities.
Conclusion If medical student training rates for the skin cancer examination are
equally low elsewhere, as is likely, the present data suggest that even brief
additions to the current curriculum, integrated into systems teaching, would
augment student exposure and likely boost student skill levels.
INTRODUCTION
SKIN CANCER is the most common malignancy in the United States with
an estimated 1.3 million cases each year.1
Melanoma is the most lethal skin cancer but the diagnosis of thin melanoma
is associated with a greater than 95% five-year survival rate. The majority
of patients with skin lesions are seen by nondermatologists,2
who therefore need to have the clinical skill to recognize early cancer. Acquisition
of basic clinical skills required of most physicians should be part of the
curriculum at all medical schools.
To investigate medical student training for the examination of the skin
for cancer, we surveyed fourth-year medical students at Boston University
School of Medicine, Boston, Mass, to determine the frequency of observation,
training, and practice of the skin cancer examination. These data were correlated
with self-reported skill levels for the skin cancer examination. This survey
immediately followed a national recommendation for inclusion of skin cancer
education in the medical school curriculum.3
METHODS
Since there were no cancer education survey instruments for skin cancer
detection or prevention, the group prepared one, drawing mostly from the medical
literature of instruments that measure a student's prevention and detection
skills for other chronic diseases. A subcommittee developed a survey and,
after individual questions were tested for content, 10 students who completed
the survey as a pilot tested the entire instrument for length and comprehensibility.
Their responses were not included in the final analysis. The final computer-scannable
instrument included 59 questions; a longer summary of the survey was published
elsewhere.4
ADMINISTRATION OF SURVEY
Surveys were administered and completed in classrooms and student workshops
during the spring of 1996 and 1997. Surveys were collected anonymously.
OUTCOME MEASURES
Students were asked to rate their current skill levels for their performance
of skin examinations, including surveying for atypical moles and for counseling
regarding sun protectionpractices. Response choices were very unskilled (1),
somewhat unskilled (2), neither skilled nor unskilled (3), somewhat skilled
(4), and very skilled (5). Students selecting 1, 2, or 3 were categorized
as unskilled.
Students were also asked to report the number of times they had observed
a physician or been trained by a physician in the skin cancer examination
or for counseling patients about sun protection. Students were also asked
about the number of times they had performed a complete skin cancer examination,
examined a patient for atypical moles, or counseled a patient about sun protection.
Students were also asked to recall if they had been taught cancer prevention
in their required lectures, Integrated Problems course, faculty discussions,
or clinical rotations.
STATISTICAL ANALYSIS
Two analyses were performed. First, the self-reported skill levels for
the skin cancer examination for fourth-year students were calculated in the
context of their opportunities for observation, training, and practice. Second,
a  2 analysis was performed to compare
the proportion of fourth-year students reporting themselves as very or somewhat
skilled according to their exposure to cancer prevention education and training.
In addition, the tests were repeated in a multivariate general linear model
including terms for all of the types of education and training to determine
the independent association of each with reported skills in the skin cancer
examination.
RESULTS
Of the 302 students enrolled at Boston University School of Medicine
in the 1996 and 1997 academic years, 223 fourth-year students (74%) completed
surveys, reflecting attendance at the sampled classroom sessions. Forty-one
percent of the respondents were women and the mean age of respondents was
27.5 years (SD, 3.7), virtually identical to the sex and age profiles of the
class overall. There were no significant differences between students completing
the survey in 1995-1996 vs 1996-1997.
SKILL LEVEL, OBSERVATION, TRAINING, AND PRACTICE
Fifty-two percent of fourth-year students reported being unskilled in
the skin cancer examination (Table 1).
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Table 1. Self-reported Skill Levels in Skin Cancer Detection and Counseling
Among 223 Fourth-Year Boston University Medical Students (1995-1996 and 1996-1997)
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Twenty-eight percent of fourth-year students had never observed a skin
cancer examination and an additional 41% had observed only 3 or fewer examinations.
Forty percent had received no training in the skin cancer examination and
an additional 46% had 3 or fewer sessions (Table 2).
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Table 2. Self-reported Observation and Training in Skin Cancer Detection
and Counseling Among 223 Fourth-Year Boston University Medical Students (1995-1996
and 1996-1997)
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Overall, 35% of fourth-year students had never performed a complete
skin examination, and an additional 40% had completed 5 or fewer examinations
(Table 3). Twenty percent of students
had never examined a patient for atypical moles and an additional 47% had
done so only 1 to 5 times.
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Table 3. Self-reported Practical Experience in Skin Cancer Detection
and Counseling Among 223 Fourth-Year Boston University Medical Students (1995-1996
and 1996-1997)
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ASSOCIATIONS OF SKILL WITH OBSERVATION, TRAINING, AND PRACTICE
Fourth-year students who had observed, been trained for, or practiced
a skin cancer examination even once were approximately 3 times more likely
to report being skilled in the skin cancer examination than those without
this experience (Table 4). Those
rating themselves as skilled were more likely than unskilled students to have
observed at least 1 examination (59% vs 21%; P<.001),
been trained at least once (67% vs 18%; P<.001),
and performed at least 1 examination (64% vs 17%; P<.001).
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Table 4. Self-reported Skill Levels in Skin Cancer Examination in Relation
to Education and Training Among 223 Fourth-Year Boston University Medical
Students
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Exposure to cancer-prevention education through lectures, Integrated
Problem courses, faculty discussions, and clinical rotations was also associated
with higher self-reported skill levels (P<.05).
However, this association was not observed in the multivariate model, which
included the terms for observation, training, and practice, implying that
these differences were largely explained by the fact that students in the
teaching programs were also more likely to have observed, been trained in,
or practiced skin cancer examinations.
COMMENT
Our survey of medical students at 1 university found disturbingly low
rates of observation, training, and practice for the skin cancer examination.
Twenty-eight percent of fourth-year students had never observed a skin cancer
examination, 40% had received no training, and 35% had never practiced the
examination. Fourth-year students reporting at least 1 opportunity to observe,
train, or practice an examination were 3 times as likely to report themselves
as moderately to very skilled as students without such opportunities.
Our finding that medical students receive very little training or practice
in the skin cancer examination is consistent with the historically inadequate
performance by nondermatologist physicians and physicians-in-training in screening
or evaluating skin lesions.5-10
Teaching of the examination for skin cancer appears to be minimal in
one medical school; the lack of such teaching almost certainly reduces the
likelihood that newly graduating generalist physicians will include thorough
skin cancer examinations during their routine patient examinations. Our survey
illustrates the need to examine skin cancer education curricula at other medical
schools. The present data suggest that even brief additions to current curricula,
integrated into systems teaching and coupled with faculty development programs,
would augment student exposure and likely boost their interest and skill in
the performance of the examination. Increased effort and awareness by all
physicians should result in earlier detection of both melanoma and nonmelanoma
skin cancer, thus reducing morbidity and mortality.
Student response rates were high, but self-reported data are susceptible
to both underestimation and overestimation of performance. Additionally, these
data are from a single institution; thus, we cannot be certain that our survey
findings are representative of the situation at other American medical schools.
We strongly suspect that the majority of graduating students at Boston University
reporting frequent observations and training took the 1-month dermatology
elective available to about 25% of fourth-year students, but the survey did
not specifically inquire about the impact of this experience on their level
of self-confidence and intended future practices regarding skin cancer screening.
This study follows the creation of a national skin cancer agenda3 developed collaboratively by the American Academy
of Dermatology and the Centers for Disease Control and Prevention, in which
a new curriculum for the teaching of skin cancer prevention and detection
for medical students, nursing students, and allied health professionals was
recommended. Developing a plan to teach the skin cancer examination to future
physicians was recommended on the basis that 1 in 5 Americans will develop
skin cancer over his or her lifetime and 1 in 75 will develop melanoma.11 The majority of lesions are asymptomatic and thus
it is anticipated that performance of complete skin examinations by all examining
physicians will significantly improve detection of lesions in early stages.12 Action on these recommendations is urgently needed.
AUTHOR INFORMATION
Accepted for publication January 24, 2002.
This study was supported by grant R25 CA68463-05 from the National Cancer
Institute, Bethesda, Md.
We thank the Boston University medical students who painstakingly completed
surveys and James B. Howell, MD, for his inspiration for this project.
The opinions and interpretations expressed by Dr Koh are his own and
do not necessarily reflect those of the Massachusetts Department of Public
Health or any of its agents or governing authorities.
Corresponding author and reprints: Alan C. Geller, RN, MPH, Boston
University School of Medicine, 720 Harrison Ave, DOB801A, Boston, MA 02118
(e-mail: ageller{at}bu.edu).
From the Department of Dermatology, Boston University School of Medicine
(Mr Geller and Drs Venna, Miller, Demierre, Koh, and Gilchrest), the Cancer
Prevention and Control Center, Boston University (Mr Geller and Dr Prout),
the Departments of Epidemiology and Biostatistics (Mr Geller and Dr Prout),
and Health Services (Dr Miller), Boston University School of Public Health,
and the Massachusetts Department of Public Health, Commissioner's Office (Dr
Koh), Boston, Mass.
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1. American Cancer Society. American Cancer Society, Cancer Facts and Figures, 2001. Available at: http://www.cancer.org. Accessed October
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Skin Cancer Agenda: American Academy of Dermatology and Centers for Disease
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