Dermatology in the Undergraduate Medical Curriculum

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					Dermatology in the Undergraduate Medical Curriculum

Curriculum Design
The recommendations of the General Medical Council (GMC) in “Tomorrow’s Doctors” provide
the framework that UK medical schools use to design curricula 1,2. The GMC recommended that
all schools should define “a core curriculum encompassing the essential and skills and the
appropriate attitudes to be acquired at the time of graduation”.

Core Curriculum
   • Common to all students
   • Limited to essential and important knowledge, skills and attitudes
   • Essential competencies must be mastered for safe practice
   • Rest of “important” core requires a high standard of mastery
   • Promotes learning with understanding, not rote learning
   • Encompasses application of knowledge and skills to solving clinical problems
   • Prepares students for continued learning
   • Built on in subsequent education

Core curricula in UK medical schools are supplemented by student-selected components
including special study modules (SSMs) and electives, that occupy between 25% and 33% the
curriculum. Students may have opportunities to undertake projects or research in areas such as
biological or clinical sciences, medical humanities, public health or health care management.

Student-Selected Components (SSCS)
   • Provide choice and extend the range of subjects available
   • Develop research skills
   • Promote in-depth study
   • Introduce potential career paths
   • Develop self-directed learning skills
   • Should challenge students and reward excellence

Dermatology in the Curriculum
The dermatology that is mastered by undergraduates will underpin postgraduate education in
Foundation courses, medicine and general practice 3. In 1999 the British Association of
University Teachers of Dermatology (BAUTOD), after consulting a small group of consultant
dermatologists, produced recommendations on the content of the undergraduate dermatology
curriculum 4. These recommendations have been refined using a modified Delphi technique. A
multidisciplinary panel that included dermatologists, medical specialists, surgeons, tutors in basic

sciences, general practitioners, dermatology nurses, pharmacists and junior doctors ranked the
importance of 145 dermatological learning outcomes. The recommendations for the
dermatological content of the core curriculum on this website are based upon the results of this
study, which was presented at the Annual Meeting of the British Association of Dermatologists in
July 2005 5. This core should be supplemented by dermatological SSCs, in which students chose
to study dermatological topics in depth.

Learning and Teaching
Dermatological learning and teaching may occur in a variety of clinical placements, including
general practice, and may be integrated into the course at different stages. Vertical integration
will introduce students to dermatological problems and relevant skin biology from year one
onwards while horizontal integration breaks down artificial barriers between courses and
specialities within an academic year. In addition to studying the fundamentals of skin biology and
dermatology, all students should have direct clinical contact with dermatological patients. A
minimum of 10 half-day sessions and preferably more, should be available for this clinical
experience. The organization of learning and teaching will depend on local facilities but the
learning outcomes at each stage of the course should be clear to students, teachers and

Students should learn to direct their own learning. They must have access to suitable learning
resources including course material (that may be available on an electronic learning site),
dermatology texts, pictures of skin diseases and computer technology.

Learning and teaching may involve:

•   Formal lectures. Schools have reduced the number of lectures, replacing them with
    interactive forms of teaching and learning, often problem-based.
•   Problem-based learning. Dermatological cases may be used to bridge the gap between basic
    sciences and clinical practice. Scenarios generally put together by a team of writers, may be
    dermatological. The case is handled by a small group of students, who discuss the problem,
    define the knowledge required to solve the problem, share amongst themselves the tasks to
    seek the relevant answers or information needed, and come together one to two weeks later to
    resolve the problem. Each group is supervised by a facilitator who may or may not have
    expertise in the area under discussion. The facilitator’s role is not to provide answers, but to
    guide learning so that the group achieves the desired outcomes.
•   Early clinical contact. Patients with skin diseases may be used to illustrate biological
    concepts (immunology, structure and function, physiology, genetics), to introduce subjects
    such as communication skills and medical ethics and to illustrate the difficulties inherent in
    living with or managing a chronic disease with accompanying impairment, handicap or
•   Community experience. General practice attachments take an increasing proportion of time in
    most curricula. Undergraduates have an opportunity to learn from patients with a spectrum of
    dermatological problems, which is slightly different from those encountered in a hospital
    setting. Some dermatological courses are integrated into courses in primary care.
•   Clinical experience. On-the-job teaching requires planning and preparation as well as time for
    feedback and reflection, but successful clinical teachers will have learned to teach in short

    “bites”, making the most of teaching opportunities in the clinic and balancing the conflicting
    demands of patients, students and junior staff.
•   Case studies, learning portfolios and logbooks. Students may be required to record cases
    seen or keep a reflective record. A proportion of cases might have a dermatological flavour.
•   Computer-assisted learning. Web-based resources may be used to supplement learning.
    Telemedicine and computer technology facilitate distance learning when students are
    working in different sites. Students may also use web-based resources for personal learning,
    to prepare for teaching, to investigate problems encountered during clinical attachments or for

Dermatologists should play their full part as examiners in medical schools, this includes writing
questions and contributing cases for clinical examinations. Analysis of student experiences has
shown that an “intended” core curriculum is not sufficient to ensure that students are proficient in
basic skills such as describing skin lesions. If skills are deemed essential, they must be both
taught and assessed. The method and timing of assessment influence learning, but students should
not be over – assessed 8.

Formative Assessment
Regular formative assessment is a most valuable form of assessment that allows students to
measure their progress. Learning portfolios, logbooks or reflective reports might be discussed
during a formative assessment. Within-course assessments that identify problems when the
students and teachers still have time to address the deficiencies may help students to structure
their learning. Professional behaviour (attendance, organisation skills, ability to take
responsibility for learning) during the attachment might also be discussed in a formative

Summative Assessment
The primary purpose of summative assessment is to determine whether the candidate is
competent. These assessments must strive for the best balance between validity (testing what is
important) and reliability (providing inferences about the student’s competence). To achieve
reliability, assessments must sample as widely as possible from the core competencies. Good
communication between teachers and examiners is essential to ensure that assessments are
aligned with learning and teaching. A blueprint (map or matrix) showing how the assessment is
planned against curricular learning outcomes provides a method for ensuring that assessments
cover or sample the competencies that the course considers to be the most important 8. The aim is
to test a representative sample. Miller’s “pyramid of competence” provides a useful guide to
competencies and how they might be assessed 9. “Knows” (factual knowledge) at the base of the
pyramid is followed by “knows how” (applying knowledge), “shows how” and at the apex
“does”- how the candidate really performs in clinical practice.

Knows and Knows How
Assessments should aim to test application of knowledge, clinical reasoning, problem-solving and
critical appraisal. Tests may include:
     • multiple choice questions (one best answer rather than true/false format)
     • extended matching items
     • structured short answer questions
     • structured oral examinations.

Show How and Does
Skills may be tested in an Objective Structured Clinical Examination (OSCE) with actors or
standardised patients or “on-the-job” using a mini-clinical evaluation exercise (mini-CEX) 10. On-
the-job assessments may have greater validity, but are more difficult to standardise than OSCEs.
Skills that are tested might include:
    • obtaining a history from a patient with psoriasis
    • explaining the diagnosis of psoriasis to a patient
    • counselling a patient about sun protection
    • discussing the management of a child with mild atopic eczema with the mother
    • telling a patient that the histology of a pigmented lesion had confirmed malignant
    • measuring the ABPI
    • writing a prescription for a topical preparation such as an emollient
    • taking a skin swab or skin scrape
    • inserting a cutaneous suture (using a mannequin)

Course Evaluation
Courses should be evaluated. Feedback may be incorporated into a logbook that is handed in at
the end of the course or in forms completed after seminars. Templates for logbooks and
evaluation forms are provided elsewhere on the website. Students should be invited to provide
constructive suggestions for change if they identify problems. Students may be asked to evaluate:
    • Course organization
    • Seminars
    • Clinical experience
    • Quality of teaching in clinics
    • Appropriateness of assessment

Students might also be invited to identify individuals who have been particularly helpful –
positive feedback is a rare commodity. Departments should discuss course evaluations as well as
performance in assessments (the performance of students in assessments reflects the teaching as
well as the ability of students). Students should be informed of the response to their feedback.

1       The General Medical Council Education Committee. Tomorrow's Doctors.
        Recommendations on Undergraduate Medical Education. In. London: General Medical
        Council, 1993.
2       The General Medical Council Education Committee. Tomorrow's Doctors.
        Recommendations on Undergraduate Medical Education. In. London: General Medical
        Council, 2002.
3       Burge SM. Curriculum planning in dermatology. Clin Exp Dermatol 2004; 29: 100-4.
4       BAUTOD. Teaching recommendations for undergraduate dermatology in the UK. In:
        The British Association of Dermatologists, 2000.
5       Clayton R, Burge SM. Defining and validating the dermatogical content of the
        undergraduate medical curriculum (abstract). Br J Dermatol 2005; 153 (suppl.1): 2.

6    Burge SM. Teaching dermatology. Clin Exp Dermatol 2004; 29: 206-10.
7    Burge SM. Learning dermatology. Clin Exp Dermatol 2004; 29: 337-40.
8    Burge SM, Lancaster T. Assessment in undergraduate dermatology. Clin Exp Dermatol
     2004; 29: 441-6.
9    Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;
     65: S63-7.
10   Norcini JJ, Blank LL, Duffy FD et al. The mini-CEX: a method for assessing clinical
     skills. Ann Intern Med 2003; 138: 476-81.


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