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    1 Comment for this article
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    The need for a standardized and evidenced based guide to the total body skin examination
    Kathleen P. McGuinn and Jeffrey J. Miller, MD | Department of Dermatology, Penn State Hershey, Milton S. Hershey Medical Center, Hershey, PA, USA
    TO THE EDITORRecently, Garg and colleagues surveyed 800 medical students to assess their confidence, intent, and performance of a skin cancer screening exam. We commend the authors for identifying curricula which promotes the integrated skin exam as part of routine physical examinations by physicians in all specialties.1 A deficiency of total body skin exams (TBSE) has been hypothesized to be an important deterrent to early melanoma detection efforts. In addition, the U.S. Preventive Services Task Force maintains that there is insufficient evidence to recommend a TBSE for skin cancer screening.2 We propose a need for the development of a standardized and evidence based TBSE. The Skin Cancer Research to Provide Evidence for Effectiveness of Screening (SCREEN) trial in Germany underscores the importance of a standardized skin exam. In this trial, physicians of various specialties were certified to perform a TBSE by watching an eight hour instructional video. Diagnosis of melanoma increased during the trial, and the rate of melanoma mortality declined over a ten year period in the region this study was performed.3 This trial demonstrated the feasibility and positive impact of implementing a large-scale, standardized, skin cancer screening intervention. To the best of our knowledge, there are no studies which attempt to determine a comprehensive, systematic and evidence based approach to the TBSE. One study suggested that lighting which is comparable to natural light is ideal for the TBSE.4 We plan to collaborate with engineers in order to develop a standardized flow to the TBSE, accounting for patient and examiner positioning and exam table lighting. Similar to the cardiac physical exam (the steps of which most of us remember), the approach to the TBSE should be taught to students and clinicians in a standardized method that is timely and reliable. Only then can our specialty more reliably demonstrate its utility and value.REFERENCES1. Garg A, Wang J, Reddy SB, et al. Curricular Factors Associated With Medical Students' Practice of the Skin Cancer Examination: An Educational Enhancement Initiative by the Integrated Skin Exam Consortium. JAMA Dermatol. 2014.2. Force USPST. Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150(3):188-193.3. Katalinic A, Waldmann A, Weinstock MA, et al. Does skin cancer screening save lives?: an observational study comparing trends in melanoma mortality in regions with and without screening. Cancer. 2012;118(21):5395-5402.4. Coltart I, Lewis G, Taylor D, Burge S. Let there be light! Lighting levels for dermatological examination. Br J Dermatol. 2006;154(4):781-783.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    August 2014

    Curricular Factors Associated With Medical Students’ Practice of the Skin Cancer Examination: An Educational Enhancement Initiative by the Integrated Skin Exam Consortium

    Author Affiliations
    • 1Department of Dermatology, Hofstra North Shore Long Island Jewish School of Medicine, Hempstead, New York
    • 2Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
    • 3Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
    • 4Department of Dermatology, University of Texas Southwestern Medical School at Dallas
    • 5Division of Dermatology, University of Massachusetts Medical School, Worcester
    • 6Department of Dermatology, Stony Brook University School of Medicine, Stony Brook, New York
    • 7Department of Dermatology, University of Utah School of Medicine, Salt Lake City
    • 8Department of Dermatology, University of Connecticut School of Medicine, Farmington
    • 9Department of Dermatology, Brown Alpert Medical School, Providence, Rhode Island
    • 10Department of Dermatology, Ohio State University College of Medicine, Columbus
    • 11Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts
    JAMA Dermatol. 2014;150(8):850-855. doi:10.1001/jamadermatol.2013.8723
    Abstract

    Importance  As medical school curricula become progressively integrated, a need exists to optimize education related to the skin cancer examination (SCE) for melanoma, a relevant competency gap that influences secondary prevention efforts.

    Objectives  To identify curricular factors associated with medical students’ confidence, intent, and performance regarding the SCE.

    Design, Setting, and Participants  Survey-based cross-sectional study from the Integrated Skin Exam Consortium at accredited US medical schools among a volunteer sample of second-year students representing 8 geographically varied public and private institutions. Students were administered a questionnaire to assess characteristics, curricular exposures, and educational and practical experiences related to skin cancer, as well as knowledge of melanoma risk and a detection method.

    Main Outcomes and Measures  Primary outcomes were confidence in performing the SCE, intent to perform an integrated skin examination, and actual performance of the SCE.

    Results  Physical diagnosis session and clinical encounter were most predictive of confidence in performance of the SCE (odds ratios [ORs], 15.35 and 11.48, respectively). Other curricular factors associated with confidence included instruction time of at least 60 minutes on skin cancer (OR, 6.35), lecture on the SCE (OR, 7.54), knowledge of melanoma risk (OR, 3.71), and at least 1 opportunity to observe the SCE (OR, 2.70). Physical diagnosis session and at least 4 opportunities to observe the SCE were most predictive of intent to perform an integrated skin examination (ORs, 4.84 and 4.72, respectively). Other curricular factors associated with intent included knowledge of melanoma risk (OR, 1.83), clinical encounter (OR, 2.39), and at least 1 opportunity to observe the SCE (OR, 1.95). Clinical encounter, physical diagnosis session, and at least 1 opportunity to observe the SCE were most predictive of performance of the SCE (ORs, 21.67, 15.48, and 9.92, respectively). Other curricular factors associated with performance included instruction time of at least 60 minutes on skin cancer (OR, 2.42) and lecture on the SCE (OR, 5.04).

    Conclusions and Relevance  To augment the practice of the SCE among medical students, course directors may design an integrated curriculum that includes at least 60 minutes of instruction related to melanoma and the SCE, a description of the integrated skin examination as part of the physical diagnosis course, and education on high-risk demographic groups and anatomic sites specific to men and women and on the ABCDEs of melanoma, and at least 1 opportunity to observe the SCE.

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