2Department of Medical Education, University of Illinois, Chicago
3Center for Clinical and Translational Science ,University of Illinois, Chicago
During the SP training sessions, a dermatologist (CH) helped coach the SPs on how to answer questions about the clinical history and symptoms of the simulated melanoma. The SP was instructed not to mention the lesion unless the student noticed the moulage. It is only if the student mentions the simulated lesion that the SP would answer specific questions posed by the student. The SPs were to provide the following information if asked by the student: the lesion was noticed approximately 6-8 months prior, the lesion has been growing in size; the patient grew up in Florida with heavy sun exposure, had no prior history of skin cancer, experienced no symptoms of pain or bleeding, and noticed no other changes in any other nevi.
The melanoma moulage case was featured as part of the 12-station Objective Structured Clinical Examination (OSCE) that fourth-year students are required to take. We assessed a total of 357 fourth-year medical students. Students were instructed that everything they observed during the encounter should be considered as part of the patient's presenting clinical findings. Each student had 15 minutes to conduct a focused history and physical examination and 10 minutes to document pertinent history, physical examination findings, differential diagnosis, and work-up plans. Student encounters were video-recorded.
Following the encounter, SPs completed a checklist regarding the history, physical examination, and follow-up recommendations (Table 1). Student clinical notes, SP checklists, and video recordings were all reviewed by two authors (CH and PS) to determine whether the student noticed the melanoma moulage, obtained relevant history, performed a screening physical examination, and correctly counseled the patient regarding further management.
Four previous studies[7-10] have investigated medical student melanoma detection rates using SPs and moulage (Table 3). One of the studies [9] assessed the performance of opportunistic screening in whites and African Americans. Robinson et al. [9] found that 9 of 58 (16%) medical students noticed moulages placed on SPs who presented with dermatologic complaints, with no significant difference in detection due to patient race. Our study design differed in that students assessed SPs during a oneon- one consultation, and SPs presented with chief complaints unrelated to dermatology in order to remove the cue to perform a visual inspection of the skin.
Melanoma SP checklist |
The examinee noticed the melanoma moulage |
History |
The examinee asked me if I have noticed any changes in the lesion |
The examinee asked me if I have experienced any symptoms related to the lesion |
The examinee asked me if I have a family history of skin cancer |
The examinee asked me if I ever had a previous diagnosis of skin cancer |
The examinee asked me about previous sunburns |
The examinee asked me about sunscreen use |
The examinee asked if I had noticed changes in any other moles |
The examinee asked if I performed regular self skin examinations |
Physical Examination |
The examinee noticed the moulage on my hand during the physical examination portion of the encounter |
The examinee examined my feet |
The examinee palpated for axillary lymphadenopathy (must be performed bilaterally) |
Assessment/Plan |
The examinee recommended further follow-up with a dermatologist and/or biopsy |
Our study underscores the fact that much work remains to be done in regards to melanoma education in medical school. In addition to continuing to build on visual melanoma recognition, dermatology curricula need to cover the differences in risk factors and clinical presentations of melanoma in different skin types[11]. For instance, the greatest melanoma risk factors in whites include periods of high intermittent sun exposure and/or large cumulative doses of UV radiation from chronic sun exposure, family or personal history of melanoma and/or non-melanoma skin cancers, large number of common benign nevi, atypical nevi, and history of blistering sunburns[11,12]. Risk factors for African Americans, however, include burn scars, radiation therapy, trauma, albinism, and immunosuppression[12]. Even though less of a significant factor in the development of melanoma in African Americans, UV radiation may still play a role in African American skin[12]. In our study, none of the medical students who had noticed the moulage on African American SPs had inquired about prior sunburn history and only 1 student had asked about sunscreen use. Therefore, it is necessary to educate students not to overlook sun exposure history and sun protection practices even when evaluating African Americans. The importance of examining acral and mucosal regions in African Americans should also be taught as our study found that only 1 medical student evaluating an African American SP had inspected the patient's feet after detecting the moulage on the hand[12].
One limitation of our study was that students assessed either a white or African American SP, which did not allow us to directly evaluate a particular student's skill for both skin types. Other limitations include testing only students attending one medical school and time constraints since this occurred in the context of an OSCE, which may affect the number of students who decide to perform skin examinations and focus only on the wrist pain complaint.
Reports have suggested that secondary prevention efforts, such as skin cancer screenings, are suboptimal in patients of color, with African Americans being screened less frequently than whites[13-20]. One cited reason for the disparity in skin cancer screening is low physician confidence levels in surveillance skills in African Americans[21] and lack of physician education in the risk factors and presentations of skin cancer within this population[3]. Our study highlights the need to continue to develop a more comprehensive melanoma education program even at the medical student level. We demonstrate the potential use of SPs and moulage as an educational tool to reduce educators' dependence on the presentation of melanoma in the outpatient setting at a time when students or residents are present in order to teach or assess their skills. Furthermore, this study begins to hint at educational targets for curricular improvement so that properly trained medical students will graduate with the skills and confidence to provide melanoma screenings for patients of any skin color.
Elements of history, physical examination, and management plan |
Number of students (Black SPs) N = 183 |
Number of students (White SPs) N = 174 |
Noticed nevus |
41 (22%) |
47 (27%) |
Asked if there were any changes in nevus |
38 (21%) |
37 (21%) |
Asked if patient had any symptoms |
31 (17%) |
26 (15%) |
Asked if patient had a family history of skin cancer |
3 (2%) |
7 (4%) |
Asked if patient had personal history of skin cancer |
1 (0.5%) |
2 (1%) |
Asked about sunburn history |
0 (0%) |
7 (4%) |
Asked about sunscreen use |
1 (0.5%) |
2 (1%) |
Asked if patient had noticed changes in any other moles |
7 (4%) |
8 (5%) |
Asked if patient regularly performed self skin examinations |
1 (0.5%) |
0 (0%) |
Examined feet |
1 (0.5%) |
0 (0%) |
Palpated for axillary lymphadenopathy |
1 (0.5%) |
0 (0%) |
Recommended further follow-up |
29 (16%) |
34 (20%) |
Included carpal tunnel on the differential diagnosis |
181 (99%) |
174 (100%) |
Included melanoma on the differential diagnosis |
26 (14%) |
25 (14%) |
Noticed nevus while performing the physical examination |
31 (17%) |
34 (20%) |
Study |
Detection rate (no counseling) provided |
Detection rate (with counseling provided) |
Ethnic differences in detection rate |
Pre-assessment education |
Assessment technique
|
SP chief complaint |
Robinson et al. (1996) [8] |
1/285 (0.35%) |
0/285 (0%) |
N/A |
Skin cancer lecture written exam + photographs |
|
Non-dermatologic |
Robinson et al. (2010) [9] |
9/58 (15.5%) |
N/A |
No significant difference |
Skin cancer lecture |
|
Dermatologic |
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