Howard James Essay _2_

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					James Howard



                        And the winner is ….. Dermatology!

British Association of Dermatologists – Undergraduate essay prize

University contrasts with high school in that the most popular subject is not necessarily the one

involving the least work. Students enjoy a course if they come out of it feeling confident and

genuinely interested about the subject. Regarding subjects in medical schools, students will look

fondly back on a which they entered ignorant, and came out feeling they could actually treat a

patient. Lectures about pathophysiology of disease and slides demonstrating lesions are useful,

but they will not engage students, and they will certainly not make the dermatology course stand

above its peers.


Why Dermatology?


In medical school we learn dermatology because it’s important, not only for the future

dermatologists amongst us, or for the large proportion of medical students who will go on to

general practice, but because dermatological symptoms rear their heads in all forms of medicine.

One might argue that a five day module in dermatology is a disproportionately small amount of

time for teaching about diseases which consume 2% of the NHS budget and affect one third of

individuals. Still, not many of the specialities get the option of five days of focused teaching.


Teaching the Students – Deep versus Superficial Learning


When thinking about what we need to teach students, we must ask ourselves ‘what are the roles

of the dermatologist?’ Obviously, the budding dermatologist must be able to recognise and

diagnose conditions, but they must also be able to investigate patients, and manage them

accordingly; a doctor may well recognise the characteristic rash of dermatitis herpetiformis, but

one must appreciate the importance in testing anti-endomysial antibodies, and treatment through

pharmacological (e.g. dapsone) and behavioural (e.g. diet control) means.



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So how do we teach the students? Lectures are an option, though five days of dermatology

lectures are unlikely to win the hearts and minds of the students attending them, nor the poor

dermatologists who have to present the same topics every week to successive groups.

Furthermore, most of what the students see in a lecture they can likely find for themselves in a

textbook. Teaching through clinics is likely to be more popular with staff and students, for most

students find patient-centred learning more interesting and memorable. They can observe the

processes of decision-making, and can contribute their own thoughts; there are few things as

satisfying for a medical student as making a difficult diagnosis.


In educational theory, learning from clinics might be referred to as ‘deep learning’, whereby

experiences (e.g. of patients in clinic) are linked to concepts and principles the student already

knows, and the resulting long-term retention of facts can be used to solve novel problems.

Lectures, however, resemble ‘surface learning’, the memorisation of isolated facts, which is

harder to put into context and remember1. A study investigating medical student learning style

found that final year students in exhibited a deeper approach to learning than the

undergraduates, who typically receive more didactic teaching2.


The disadvantage with teaching through clinics, however, is a lack of structure. Whilst variety is

the spice of life and keeps things interesting for the experienced dermatologist, a medical student

can be left feeling disorientated and confused after an eclectic clinic, and may find it hard to

consolidate their learning. “Was it the psoriasis patient or the acne patient using topical retinoids?”


Dermatology lends itself quite well to structured teaching; open a dermatology textbook and one

will find the contents page has logic to it – it may start with psoriasis and dermatitis, two very

common diseases which are similar in many respects, and complement each other during study.

Another section may refer to infectious diseases, and another to benign and malignant tumours.

If one were to break down the core curriculum which one might wish to teach the medical

students into fifths, it might look like the following:


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    1. Psoriasis, eczema, and acne

    2. Benign and malignant tumours

    3. Infections and infestations

    4. Systemic disease and other genetic disorders

    5. Blistering disorders and drug reactions


This compartmentalisation of topics really does help the medical student with their learning – it

not only guides them in their reading, but helps them organise their thoughts, too – a patient

with dry, erythematous and excoriated lesions could well have dermatitis, but also psoriasis –

they can both look quite similar, are both are thought to be due to T-cell dysfunction, so what

shall I check for? The organised student may then look for distinguishing features, such as the

distribution or the presence of nail signs.


                          Dermatology Logbook - Contents

    1.         Signs and symptoms – dermatological nomenclature


    2.         List of dermatological conditions


    3.         Important conditions (worksheets)


    4.         Clinical skills portfolio


    5.         Dermatological emergencies


    6.         Case presentation




But how do we actually get the student to tackle these topics? Whilst presenting students with a

bulk of literature might not prove popular, providing just a skeleton of the topic and asking them

to investigate a few key points will prevent them getting overwhelmed. Students would be given


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a log book (see above) prior to the attachment containing summary sheets on the key topics,

such as the example sheet for psoriasis (see below). Whilst such sheets would not be sufficient

for the students to revise for finals, they would provide a basic framework for the conditions

students are likely to see in clinic. By asking the students to complete the brief sheets on

psoriasis, eczema, and acne for their first clinic, one can ensure that the students at least know

the basics of some of the more common conditions they are likely to encounter. Through

structured and modular learning, the student gains a sense of achievement through completing a

topic, and the confidence to investigate the material in more depth afterwards.


Ideally during or after each clinic, the doctor would quickly go over the day’s topic with the

student. This may just involve going over the sheet they’ve completed, with a few questions,

such as asking the student how they might treat the teenager presenting with acne and what

questions they would ask the teenage girl wishing to commence isotretinoin treatment. The idea

is not to ‘grill’ the student; indeed, most students enjoy the chance to show they’ve done some

work on a topic, and find one-on-one teaching a very useful way to consolidate their learning.

Through these small vivas, one can reinforce the structured approach to the sessions, even if that

particular clinic was lacking in relevant patients.




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                                              PSORIASIS

Psoriasis is a chronic inflammatory disease that affects mainly the skin. It is thought to be an auto-
immune disease, with increased __ - cell activity observed in affected tissue.

Subtypes

       ___________________________ - ‘Classical’ psoriasis, multiple plaques, large or small, with
        scaling, over the trunk and limbs. The extensor aspects, scalp and nails are commonly
        involved.

       ___________________________ - From the latin for ‘drop’, widespread small plaques over
        the trunk and limbs, typically appearing in adolescents following streptococcal infection.
        Usually resolves, but may recur or progress to other forms of psoriasis.

       ___________________________ - Numerous sterile pustules appear on the palms and soles.
        Erythema develops, with brown discolouration and scaling. Often precipitated by oral
        steroid use.

       ___________________________ - A rarer variant typically seen in young children. Brisk
        inflammation occurs, with pustules appearing at the nails and fingertips.

       ___________________________ - Erythema focused around the skin folds (axillae, groin,
        natal cleft etc.), in contrast to the typical extensor distribution. Little or no scaling. May be
        confused with fungal infections.

       ___________________________ - Life-threatening, confluent erythema. Scaling is often
        absent. Patients usually feel very unwell, with significant heat and water loss from the
        hyperaemic skin.


Psoriasis shows the ___________________________ phenomenon, where plaques arise at sites of
injury.

Nail   signs  include   ___________________________,                 ___________________________,
___________________________.

Treatments may be local or systemic:                 Psoriatic arthropathy affect __ % of sufferers,
                                                     and there are 5 typical subtypes.
1. ___________________________                       1. ___________________________
2. ___________________________                       2. ___________________________
3. ___________________________                       3. ___________________________
4. ___________________________                       4. ___________________________
5. ___________________________                       5. ___________________________




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However, AM and PM clinics Monday-Friday may well wear a little thin. How might one occupy

the remaining teaching slots, assuming each student attends five clinics? Ideally, there would be

an introductory lecture to dermatology; dermatological nomenclature is one of the most

important tools of the trade – without the power of description one will embarrass oneself in the

exam, but also as a junior doctor when communicating with your seniors, or writing in patients’

notes. Frequently a medical student is asked to describe a lesion in clinic, and their mind races

with terms like pustules, cysts, nodules etc. A lecture explaining the differences between a papule

and a nodule, an erosion and an ulcer, would prove invaluable, and would preferably be given at

the start of the week, to help prepare the student for the clinics ahead of them.


Computer Aided learning


Dermatology is a very visual subject, and lends itself very well to computer aided learning (CAL).

CAL has many benefits – it allows one to present the student with a large image library, which

would be impractical to add to the student logbooks. Furthermore, it allows the students work

through case studies progressively, only seeing the answer for the question once they’ve had a

‘stab’ at it. Finally, it allows the students to follow hyperlinks to other resources, where they may

learn more about the conditions covered. Indeed, a 12 year meta-analysis by the U.S.

Department of Education found that students using CAL performed better on average than

those who only engaged in face-to-face learning3.


CAL modules may cover a picture quiz, where students have to describe a series of lesions and

propose differentials, or they may cover individual cases of patients, with questions on history

taking, examination, investigation, and management.




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Dermatology in Primary Care


As well as the students’ individual timetables (see last page) and summary sheets, the logbook

would contain a list of conditions that they should hope to have seen in clinic. However, it

would also contain a list of conditions that are unlikely to have been referred beyond primary

care; a week of hospital dermatology will not provide the student with much experience of either

acute dermatoses, or those conditions which are rarely referred beyond the GP (e.g. measles, scarlet

fever, molluscum contagiosum, penicillin cross-reactivity in glandular fever). Students can find dermatology in

primary care quite difficult – a very different set of conditions rear their heads, and the GPs are

regularly asked to decide if a mole is suspicious or not – quite a daunting task for an F2 in

general practise, who has done little if any dermatology since medical school. These problems are

not helped by the fact that students get relatively little structured teaching in the primary care

setting. It would therefore be useful for the students to receive a lecture in ‘dermatology in

primary care’. This lecture can tackle conditions such as molluscum and pityriasis rosea, but also

the use of dermoscopy in examining moles for referral to secondary care.




Clinical Skills


Not all diagnoses, however, can be established on history and examination alone. Skin swabs and

scrapes can play a valuable part in identifying pathologic organisms, and biopsies of excised

lesions may provide important information regarding both staging and diagnosis. Whilst some of

these procedures may be observed in a regular dermatology clinic, or even within primary care, a

timetabled skin surgery clinic would allow students to gain experience regarding excision of more

complex lesions, and appreciate the importance of biopsies with regards to staging melanoma

through depth. As well as through excision, some conditions, such as solar keratoses, can be

managed through cryotherapy.




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The student logbook might contain a list of such procedures, and their indications, but also other

practical skills less directly involved in the diagnosis; students should be aware of how to write a

prescription for emollients and topical steroids, but also complex drugs such a methotrexate; not

only as such prescriptions common, but they are different from typical prescriptions for tablets

and daily medication.


Being ‘safe’


Of course, even if the doctor is unable to diagnose the patient’s rash, they are usually able to

refer the patient on to someone who does. The exceptions, however, are the dermatological

emergencies. Whilst these are rare, they are serious, and whilst the doctor can get away with not

knowing how to treat the specifics of these conditions, they must be able to identify them, and

provide suitable early management. The logbook should contain a list of the more common

dermatological emergencies, along with their causes, symptoms and basic management.

Examples might include eczema herpeticum in an unwell child with a history of dermatitis, or

toxic epidermal necrolysis in the psychiatric patient on lamotrigine, or erythroderma in the

deteriorating psoriasis patient. Emphasis would be placed on recognising the signs of serious

diseases, and basic management of the acutely unwell patient, along with more specific

dermatological measures (IV immunoglobulin, management on burn units etc.)


The End of the Week


The final session of the week would consist of case presentations and a dermatology ‘quiz’. This

session would be a chance for the students to gauge their understanding of dermatology. The

session would start with each student presenting a patient they’ve seen in clinic. The history and

examination would be presented, along with a proposed differential diagnosis and management

plan, and the student would receive constructive feedback from the facilitator of the session. A




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sheet in the students’ logbooks would provide a framework and allow them to keep a copy of

their case presentation for the medical school portfolio.


The ‘quiz’ afterwards would not be a formal test, rather a presentation of clinical histories and

pictures of dermatological signs. Medical students frequently learn about conditions in an

isolated fashion, and find themselves stuck when having to differentiate between them; it’s useful

being asked whether a crusting erythematous lesion on the leg is ringworm or psoriasis, not only

because this is relevant for finals, but it highlights the important distinguishing factors in the

history and examination. The other benefit of having all the students attend the final session of

the week is that it allows them to provide constructive feedback about the course, and raise any

concerns they have, such as any topics they don’t feel comfortable about.


Conclusion


By the end of the week the student will have attended five clinics, a skin surgery session, and will

have received two lectures, regarding dermatological signs and symptoms, and the management

of dermatology in primary care. Furthermore, they will have a log book containing a framework

of conditions, which they themselves have researched, with information on what conditions they

should have seen during their dermatology attachment. This log book would also provide

guidance regarding which investigations and procedures they should have observed, and outline

the presentation and management of the commonest dermatological emergencies. Finally, the

students would have had the chance to complete various CAL modules covered case studies but

also spot diagnoses, which might prove valuable as a teaching aid for finals.


Whilst a week in dermatology is by no means enough time to train the budding skin physician, it

should give medical students a flavour of what it is to be a dermatologist, and make them far

more confident in their abilities to manage some of the most common complaints in medicine.

We must also realise that whilst a logbook may well be effective in ensuring the students




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complete the course with a sufficient understanding of the pathogenesis and management of

dermatological disease, it has its limitations; only through meeting patients and exploring their

concerns and expectations can we really understand the importance of such diseases on our

patients’ lives.


References

    1.   http://www.engsc.ac.uk/er/theory/learning.asp


    2.   Newble DI, Gordon MI. The learning style of medical students. Medical Education (1985; 19: 3-8.)


    3.   Means, B.; Toyama, Y.; Murphy, R.; Bakia, M.; Jones, K. Evaluation of Evidence-Based Practices in

         Online Learning: A Meta-Analysis and Review of Online Learning Studies U.S. Department of

         Education (2009)




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