Medical Student Detection of Melanoma: Clinical Skills

The mortality from melanoma, currently the sixth most common malignant neoplasm in men and women, increases after age 50 years and can be expected to increase as the US population ages.¹ Sixteen percent of melanomas are discovered by physicians, and 76% of those are detected by primary care physicians.^2,3 Given that 41.8% of US annual physician visits are to a family practitioner or internist, there is an opportunity for primary care physicians to perform opportunistic screening for melanoma.⁴

Among non-Hispanic whites, early detection of melanoma has enhanced survival from 68% in the early 1970s to 92% in recent years. However, Hispanic and black patients have benefited less from early detection.⁵ The 5-year relative survival rate for black patients has changed from 67% in the 1974-1976 period to 78% in the 1995-2001 period (P > .05).⁶ In Florida, the proportion of distant-stage melanoma diagnosed among Hispanics and blacks remained stable from 1990 to 2004 compared with a steady decrease in the percentage of melanoma cases diagnosed at distant stage among non-Hispanic whites.⁷

Lower rates of physician surveillance, possibly due to reduced awareness of melanoma presentation in darker-pigmented individuals, is one potential cause of melanoma diagnosis disparity. To determine the performance of opportunistic screening and awareness of melanoma in light- and dark-skinned individuals, we examined the ability of second-year medical students to detect an incidental melanoma moulage applied to a non-Hispanic white and a black patient, each with a dermatologic disease.

Prior to this study, Northwestern University Feinberg School of Medicine second-year medical students near the completion of their preclinical year were required to attend a 1-hour lecture on melanoma and nonmelanoma skin cancer detection. E-mails were sent to the class the week following this lecture to recruit medical students to voluntarily participate in an elective dermatology experience.

Groups of 3 to 5 students gathered around the examination table to listen to the case presentation by a dermatologist, who pointed out clinical features of the disease, and the students examined 9 patients who demonstrated dermatologic conditions such as psoriasis or severe atopic dermatitis. A non-Hispanic white patient with skin phototype II and a black patient with skin phototype V, both with dermatologic conditions on their lower extremities, wore a prosthesis (moulage) simulating melanoma at the dorsal web space of the first and second toe (Figure 1 and Figure 2). The remaining 7 patients did not have nevi clinically suggestive of melanoma.

Students completed a survey about their age, sex, clinical experiences in dermatology, and interest in becoming a dermatologist. They later responded to the following questions: “Did you notice any additional/other lesion(s) on any patient?” “If yes, tell us on which patient(s) you saw an additional/other lesion.” In groups identifying the moulage, dermatology faculty recorded whether melanoma was included in the differential diagnoses offered by students.

We used χ² statistics and t tests for between-group comparisons.

Among the 58 voluntary participants in a class of 140 students, 48 of them had prior dermatology experience (83%) consisting of didactic sessions (n = 18, 38%), didactics and small group (n = 22, 46%), observing a dermatologist for a half-day clinical session (n = 5, 8%), or didactics, small group, and observing a dermatologist (n = 3, 6%). Thirteen students classified themselves as future dermatology residents (22%), 9 as primary care (16%), and the remaining students were undecided.

Nine students noticed the “melanoma” lesion (16%). There was no significant difference due to patient race in noticing the lesion: 4 students noticed it on the black patient and 5 students on the non-Hispanic white patient. Students interested in dermatology were more likely to notice the melanoma (P = .04). Students identifying the lesion were more likely to offer melanoma as a possible diagnosis in the non-Hispanic white patient than they were in the black patient (P = .03).

While more medical students in this study identified the incidental melanoma (16%, n = 9) than the 1 student in 285 in our group's prior similar study (0.35%),^8,9 students were less likely to offer melanoma as a diagnosis when the lesion was noticed on the black patient. In 1993 and 1994, Robinson and McGaghie⁹ assessed senior medical students' ability to identify a clinically suspect lesion applied to the neck below the ear of a standardized patient being seen for “headache.”

A possible explanation for the students' increased ability to detect the lesion in the current study is the proximity of their melanoma-detection lecture to the application of these clinical skills, which occurred 1 week after the lecture. In the earlier study, the patient with a clinically suspect lesion was seen 2 years after the students' skin cancer detection lecture. However, the medical students had 2 years of experience in clinical clerkships and selectives. Our current study was conducted 1 week after a lecture on skin cancer detection. The clinical context may also explain the difference in detection rates. The prior study used standardized patients with chief complaints unrelated to dermatology, while the current study used patients being seen with dermatologic conditions. Thus, the current students were cued to perform visual inspection, and the moulage was applied to the body surface on view.

Many of the students who were interested in becoming dermatologists sought clinical experiences with dermatologists, which may have increased their confidence in recognizing the lesion. Medical students commonly have less than 10 hours of exposure to dermatology over 4 years of medical school and do not feel comfortable performing skin cancer screening.¹⁰ In a survey of 659 US graduating medical students, 23% had never observed a skin cancer examination, and 43% had never examined a patient for skin cancer.¹¹ The homogeneous study sample of our study with overrepresentation of those interested in dermatology limits the generalizability of conclusions drawn from this study.

With increasing melanoma incidence and no apparent decrease in melanoma mortality, it is essential for physicians to promptly recognize it in patients from all ethnic groups, initiate culturally appropriate discussion of the possible diagnosis with the patient, and provide appropriate triaging of persons with suspect lesions. As nearly two-thirds of patients with melanoma visited a US physician in the year before diagnosis, primary care physicians are ideally positioned to perform opportunistic screening, counseling, and triage.¹² Teaching melanoma screening to medical students and reinforcing the skills with primary care residents is an essential part of professional education.

Correspondence: Dr Robinson, Department of Dermatology, Northwestern University Feinberg School of Medicine, 132 E Delaware Pl, #5806, Chicago, IL 60611 (june-robinson@northwestern.edu).

Accepted for Publication: April 5, 2010.

Author Contributions:Study concept and design: Robinson, Lio, Hernandez, Wickless, and McGaghie. Acquisition of data: Robinson, Lio, Kim, and Lee. Analysis and interpretation of data: Robinson, Kim, and Chang. Drafting of the manuscript: Robinson, Hernandez, and Kim. Critical revision of the manuscript for important intellectual content: Lio, Lee, Wickless, McGaghie, and Chang. Statistical analysis: Lee and Chang. Obtained funding: Lio. Administrative, technical, and material support: Robinson, Lio, Hernandez, Kim, Wickless, and McGaghie. Study supervision: Robinson.

Financial Disclosure: None reported.

Funding/Support: This research was supported in part by a grant from the Association of Professors of Dermatology (Dr Lio), the Jacob R. Suker, MD, Professorship in Medical Education at Northwestern University (Dr McGaghie), and by grant UL 1 RR025741 from the National Center for Research Resources, National Institutes of Health (Dr McGaghie).

Role of the Sponsors: The sponsors had no role in the preparation, review, or approval of the manuscript.

Disclaimer: Dr Robinson is editor of the Archives and was not involved in the editorial evaluation or editorial decision to accept this work for publication.

Previous Presentation: Portions of the work were presented as a poster at the American Academy of Dermatology Annual Meeting; March 5-8, 2010; Miami, Florida.