Moore MM, Geller AC, Zhang Z, Hayes BB, Bergstrom K, Graves JE, Kim A, Martinez J, Shahabi L, Miller DR, Gilchrest BA. Skin Cancer Examination Teaching in US Medical Education. Arch Dermatol. 2006;142(4):439-444. doi:10.1001/archderm.142.4.439
Copyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2006
To determine physician preparation for performing the skin cancer examination (SCE).
We evaluated medical students' observation, training, and practice of the SCE; hours spent in a dermatology clinic; and self-reported skill level for the SCE by a self-administered survey.
Graduating students at 7 US medical schools during the 2002-2003 academic year.
Main Outcome Measures
Percentages of students reporting SCE skill observation, training, and practice.
Of 934 students, 659 (70.6%) completed surveys. Twenty-three percent of students had never observed an SCE, 26.7% had never been trained to perform an SCE, and 43.4% had never examined a patient for skin cancer. Only 28.2% rated themselves as somewhat or very skilled in the SCE. This rate dropped to 19.7% among 553 students who had not completed a dermatology elective. Compared with students without training, students who had been trained at least once in the SCE were 7 times more likely to rate themselves as being somewhat or very skilled in the SCE. Sixty-nine percent of students agreed that insufficient emphasis in their medical training was placed on learning about the SCE.
This survey documents the need for more consistent training of medical students in SCE. Even brief curricular additions would augment students' perceived skill levels and improve practice patterns and competencies of future physicians. More frequent and improved SCEs might result in earlier detection of melanoma and nonmelanoma skin cancers by nondermatologists, with significant public health benefits.
It was predicted that more than 1 million cases of nonmelanoma skin cancer and more than 59 000 cases of melanoma would be diagnosed in 2005 in the United States.1 The incidence of melanoma and nonmelanoma skin cancers is increasing, and melanoma mortality is the sixth leading cause of death from cancer.2 Early detection of melanoma may result in improved outcomes, as primary tumor thickness is the strongest predictor of prognosis and guides therapy.3 Screening in the form of a total body skin examination is noninvasive, requires no special equipment, and is reasonably cost-effective compared with other conventional cancer screening strategies.4 Although there is a lack of direct evidence and consensus regarding the utility of routine screening examinations by primary care physicians of patients who are not at high risk for skin cancer,5 early detection of skin cancer is critical in reducing morbidity and mortality from these malignant neoplasms.6
Despite this, skin cancer primary and secondary prevention practices are performed less frequently than other preventive practices, such as breast examinations, Papanicolaou tests, pelvic examinations, and rectal examinations.7 Most patients, including those in high-risk groups, do not receive skin examinations as part of routine primary care.8 In addition to the lack of consistency on guidelines for skin cancer screening, physician attitudes toward skin cancer screening and prevention, as well as a lack of training, knowledge, and clinical skills in the examination, have been identified as barriers in clinical practice.7 Because most patients with skin lesions are seen by nondermatologists,9 all primary care physicians should have basic clinical skills in the diagnosis and evaluation of suspicious skin lesions, and acquiring such competencies should be part of standard curricula at all medical schools.
Training of medical students in the skin cancer examination (SCE) is an important antecedent to physician practice. A panel convened by the American Academy of Dermatology and the Centers for Disease Control and Prevention recommended inclusion of skin cancer education in the medical school curriculum on the basis that, at a minimum, all graduates of medical schools and nursing schools should learn to provide sun protection counseling for children and their families and to perform a skilled SCE in adults.6 The panel recommended that a core set of knowledge and practice skills be identified and proposed that the educational strategies could vary from didactic teaching to practical instruction. However, the panel urged that the current status of skin cancer education in medical schools be assessed before development of a specific curriculum.
To our knowledge, our study is the first to assess the state of SCE training of students at a cross-section of US medical schools and to offer curricular development guidance in this area. A previous study10 of SCE teaching was completed at Boston University School of Medicine in 1996 and 1997. The present study expands on that study and surveyed graduating medical students from the class of 2003 at 7 US medical schools.
We surveyed fourth-year students at Harvard Medical School, Boston, Mass; Boston University School of Medicine; Stanford University School of Medicine, Stanford, Calif; Virginia Commonwealth University School of Medicine, Richmond; The University of Texas Southwestern Medical School, Dallas; Mayo Medical School, Rochester, Minn; and University of Michigan Medical School, Ann Arbor. These medical schools are geographically varied, include public and private institutions, and had graduating class sizes ranging from 43 to 190 students. To administer the surveys, we recruited a fourth-year student at each school to serve as an on-site volunteer coordinator.
The student survey was adapted from one used in the prior study10 of SCE education at Boston University School of Medicine. That instrument was modeled after existing instruments that measure students' prevention and detection skills for other chronic diseases. Seven student coordinators in the spring of 2002 reviewed a draft of the survey for content and relevance to the curriculum at their institution. A revised survey was then pilot-tested among graduating students (the class of 2002) at each institution to assess clarity, readability, difficulty, and time required to complete the survey, as well as the potential usefulness of the response data. The survey was finalized in July 2002.
In July 2002, letters of introduction were sent to the deans for medical education and the dermatology department chairpersons at each institution, and coordinators consulted with school administrators to plan school-specific survey distribution strategies. Coordinators also contacted their school's registrar's office and provided us with the total number of graduating students in their class. Survey administration occurred between July 1, 2002, and June 30, 2003. At several institutions, survey distribution took place at a single class meeting; surveys at other institutions were distributed in student mailboxes and via e-mail (mass and personalized solicitations). Incentives were used at several institutions to encourage survey completion, including a lottery for 2 small cash prizes and a contribution to a graduating class fund if the target level of participation was reached.
The institutional review boards at the participating schools reviewed and approved the study. Surveys were collected anonymously.
Students were asked to rate their current skill levels for their performance of the SCE. This was considered the primary outcome for the study. The complete SCE was defined as a careful and thorough examination of the skin for malignant or premalignant lesions. Students were also asked whether they had participated in a dermatology elective and how many hours they had spent in a dermatology clinic under the supervision of a dermatologist or a dermatology resident. They were asked to report the number of times they had observed a physician or been trained by a physician in the complete SCE. Students were also asked about the number of times they had examined a patient for skin cancer. Students were also asked whether they agreed or disagreed with the following statement: “Skin cancer examinations are given too little emphasis in the medical school curriculum.”
Frequency distributions of each of the survey responses were determined. Self-rated skill levels for the SCE were then grouped into unskilled (very unskilled or somewhat unskilled), neither skilled nor unskilled, or skilled (somewhat skilled or very skilled) categories and were examined relative to other survey responses, including hours spent in dermatology clinic, participation in a dermatology elective, and opportunities for observation, training, and practice. The overall number of practice opportunities was also grouped (as 0, 1-5, or ≥6) and cross-tabulated with the other survey responses.
Differences in self-rated skill levels and practice opportunities relative to the other survey responses were tested initially by χ2 test. We subsequently used multivariate regression analysis to test for associations independent of other factors while controlling for age, sex, survey completion period, and clustering effect by medical school. All analyses were performed using SAS statistical software (SAS Institute Inc, Cary, NC).
Of 934 students graduating in the late spring of 2003 from the 7 participating medical schools, 659 (70.6%) completed surveys. Response rates ranged from 63% to 91% at the individual medical schools. The mean ± SD age of respondents was 27.3 ± 3.3 years. Forty-six percent of the respondents were women. Surveys were completed during July through September 2002 (31.7%), October through December 2002 (26.8%), January through March 2003 (13.8%), and April through June 2003 (27.8%). Three percent of all participating students stated that they intended to specialize in dermatology, although this figure ranged from 0% to 11% at the individual medical schools. Primary care practice was intended by 44.5% of all participants; this figure ranged from 30% to 54% at the individual medical schools. Table 1 gives the age, sex, survey completion period, and intended specialty of the participating students.
Table 2 gives the distribution of observation, training, and practice opportunities among respondents, as well as participation in dermatology electives, hours spent in dermatology clinics, perception of school curricular SCE emphasis, and self-rated skill levels. Twenty-three percent of students had never observed a complete examination for skin cancer; this figure ranged from 3% to 39% at the individual medical schools. Twenty-seven percent (range, 13%-44%) had never been trained in the examination. Forty-three percent (range, 24%-59%) of students had never examined a patient for skin cancer. Fifty-seven percent (range, 0%-82%) of all students had spent no time in a dermatology clinic. Only 18.8% (range, 7%-54%) of all respondents had spent 21 or more hours in such a clinical setting.
Sixteen percent (range, 7%-37%) of students reported having participated in a dermatology elective at the time of survey completion (Table 2); of those students who had not participated in a dermatology elective, 16.2% intended to take such an elective before graduation from medical school. Sixty-nine percent (range, 53%-83%) of students agreed that too little emphasis in their medical training was placed on learning about the SCE. Only 28.2% (range, 16%-52%) of students rated their skill level for the SCE as somewhat or very skilled.
The percentage of students rating themselves as somewhat or very skilled in the SCE increased 3-fold (from 9.3% to 27.2%) if students had practiced the examination 1 to 5 times, 7-fold (from 3.5% to 28.0%) if they had been trained 1 to 3 times, and almost 3-fold (from 6.0% to 17.3%) if they had observed the examination 1 to 3 times (Table 3). The percentage rating themselves as skilled in the examination increased almost 2-fold (from 14% to 27%) if they had spent 1 to 5 hours in a dermatology clinic and almost 4-fold (from 20% to 74%) if they had participated in a dermatology elective.
The percentage of students rating themselves as somewhat or very unskilled in the SCE decreased from 77.6% among students with no practice opportunities to 39.4% among those with 1 to 5 practice opportunities (Table 3). The percentage rating themselves as unskilled in the examination decreased from 66.0% among those who had spent no hours in a dermatology clinic to 38.1% among those who had spent 1 to 5 hours in such a setting.
All of the associations observed remained after adjusting for age, sex, survey completion period, and clustering effect by medical school (Table 4). Participation in a dermatology elective, increased hours spent in a dermatology clinic, and increased numbers of observation, training, and practice opportunities were associated with increased self-rated skill levels in the SCE.
Our survey of students at 7 US medical schools found low levels of observation, training, and practice of the complete SCE, with most students rating themselves as unskilled in the examination. Twenty-three percent of graduating students had never observed the SCE, 26.7% had received no training, and 43.4% had never performed the examination. Fifty-seven percent had spent no time in a dermatology clinic. Only 28.2% of students rated themselves as somewhat or very skilled in the examination.
Even small increases in training and practice opportunities, as well as elective exposures and hours spent in a dermatology clinic, were associated with higher self-rated SCE skill levels. In multivariate analyses, increased training and practice opportunities were most predictive of increased skill, while the number of observations was less predictive. Prior investigations demonstrate that medical students can accurately identify melanoma in clinical photographs but do not transfer this knowledge into identification of suspicious lesions during standardized patient examinations.11 This underscores the need for practical hands-on training and practice opportunities. Previous studies have described targeted educational interventions that have improved clinicians' ability to diagnose and plan evaluation strategies for cancerous skin lesions12,13 and that have increased medical students' self-rated skill levels for cancer prevention and detection.10
Teaching of the SCE seems to be suboptimal in the 7 medical schools studied, based on students' self-rated low skill levels. This curricular deficit may result in new physicians graduating without a basic clinical competency and reduces the likelihood that new graduates will include thorough SCEs during routine patient examinations. This is not surprising given the documented poor performance of nondermatologist physicians and trainees in screening for or evaluating skin lesions.14
Our finding that time spent in a dermatology clinic is a predictor of increased skill level suggests that there is a role for dermatologists in teaching and promoting this clinical skill, doubtless complemented by an availability of patients with suspicious or diagnostic lesions. On the basis of our data, even a single session (1-5 hours) spent in a dermatology clinic can dramatically increase student practice opportunities and skill levels. However, exposure to principles of primary and secondary prevention of skin cancer could also be incorporated into other clinical rotations, such as family practice, pediatrics, and general surgery.15
Student response rates were high, ranging from 63% to 91% at the participating medical schools, but we cannot exclude responder bias in shaping our data, and students with particularly positive or negative perceptions of skin cancer training may have been more or less likely to respond to the survey. Self-rated skill serves as a measure of confidence in performing SCEs but it may not be accurate, and we did not obtain objective measures of students' skill levels. Recall of educational exposures may have been influenced by self-perception of skill, and this could have biased our results. Furthermore, it is possible that students may inflate self-rated skill in a medical training environment that encourages rapid but often superficial acquisition of new clinical skills, skills for which mastery may take a lifetime of clinical practice.
Although our survey of 7 US medical schools captures a geographically diverse selection of public and private institutions with different curricular structures and styles, we cannot be certain that our findings are representative of the state of SCE teaching at all US medical schools. However, our study sample was similar to all graduating US medical students in 2003 for age, sex, and intended specialty as confirmed by comparing the characteristics of our study population with the findings of the American Association of Medical Colleges' 2003 Medical School Graduation Questionnaire.16 Therefore, our population was representative of all US medical students with respect to these key demographic variables.
Because of the logistical difficulties of surveying fourth-year medical students at institutions with different academic schedules and geographically distant clinical sites, surveys were completed at varying points during the 2002-2003 academic year, depending on the schedule and school-specific distribution strategy devised by the student coordinator. Our data may have been influenced by the timing of survey completion, with those students completing the survey closer to graduation reporting more observation, training, and practice opportunities and increased skill in the SCE. This does not seem to be the case on an institutional basis, however, because survey completion period was not an independent predictor of self-rated skill. It is likely that individual curricular differences among medical schools surveyed are more important in shaping student exposure and skill, particularly during the core curriculum of the first 3 years. The fourth-year curriculum at the participating schools primarily consists of elective exposures, in contrast to the required clerkships of the third year (which all students had completed at the time of survey distribution).
Our study revealed significant differences in rates of exposure to and self-perception of skill in the SCE between groups of students at different medical schools, despite an overall low level of exposure and skill. The differences remain after adjusting for clustering effect by medical school. Although some of these differences are accounted for by differences in the proportions of students completing dermatology electives or planning to pursue specialty training in the field, they may also be driven by fundamental differences in curricular structure and content. A 1996 survey of deans of US medical schools, to which 63 (53%) responded, found that a core curriculum in dermatology (mandatory or elective) was provided at just 61% of responding schools.17 A mean of 18 contact hours of dermatology core course instruction was noted per medical student, with 71% of this education occurring during the second year of medical school. However, there was significant curricular variation among institutions.
There was significant variation among the 7 participating medical schools with respect to the intended specialties of their graduates, with 0% to 11% of respondents intending to specialize in dermatology and 30% to 54% of respondents intending to specialize in primary care fields. Clearly, institutions with a higher proportion of students interested in dermatology may have higher rates of exposure to the SCE, as well as more students rating themselves as skilled in the examination. Whether the overrepresentation of students pursuing specialization in dermatology at some schools relative to others is due to differences in core clinical exposures to dermatology or to other factors is unclear. However, basic competency in the principles and practice of SCE screening is desirable for all graduating medical students, regardless of their intended area of specialization.
Our data advance the national skin cancer agenda developed collaboratively by the American Academy of Dermatology and the Centers for Disease Control and Prevention6 and provide a basis for action. Further work should identify a core set of knowledge and practical skills, outline optimal venues for skin cancer education, and allow for evaluation of curricular projects. Ensuring that new physicians graduate from medical school with sufficient training, practice opportunities, and skill in SCE screening may positively shape generalist physician clinical practices and decrease the morbidity and mortality associated with this disease.
Correspondence: Alan C. Geller, MPH, RN, Department of Dermatology, Boston University School of Medicine, 720 Harrison Ave, Doctor's Office Building Room 801A, Boston, MA 02118 (firstname.lastname@example.org).
Financial Disclosure: None.
Previous Presentations: This study was presented in preliminary form at the 2004 meeting of the Americas Chapter of the International Dermato-Epidemiology Association; April 29, 2004; Providence, RI; and as a poster at the 65th Annual Meeting of the Society for Investigative Dermatology; April 28–May 1, 2004; Providence.
Disclaimer: The opinions and interpretations expressed by Mr Zhang are his own and do not necessarily reflect those of the Massachusetts Department of Public Health or any of its agents or governing authorities.
Accepted for Publication: October 28, 2005.
Author Contributions:Study concept and design: Moore, Geller, Zhang, Hayes, Bergstrom, Miller, and Gilchrest. Acquisition of data: Moore, Geller, Zhang, Hayes, Graves, Kim, Martinez, Shahabi, and Miller. Analysis and interpretation of data: Moore, Geller, Miller, and Gilchrest. Drafting of the manuscript: Moore, Geller, and Zhang. Critical revision of the manuscript for important intellectual content: Geller, Zhang, Hayes, Bergstrom, Graves, Kim, Martinez, Shahabi, Miller, and Gilchrest. Statistical analysis: Zhang and Miller. Obtained funding: Moore, Geller, and Gilchrest. Administrative, technical, and material support: Moore, Geller, Hayes, Bergstrom, Graves, Kim, Miller, and Gilchrest. Study supervision: Geller and Gilchrest.
Funding/Support: This study was supported by a Health Services/Quality of Life/Outcome Studies research grant from the American Skin Association, New York City.
Acknowledgment: We thank the American Skin Association for their generous funding of this project, the many medical students who completed surveys, the faculty members and deans at participating schools for their support and cooperation, and James B. Howell, MD, for providing inspiration for this project.