Originally published in MedPage Today
by Nancy Walsh, MedPage Today Contributing Writer
Opportunities to learn how to perform skin cancer examinations during medical training are inadequate, a survey of residents found.
More than half (55.3%) of residents said that they had never observed a skin cancer examination, 75.8% said they’d never been taught to perform one, and 57.4% had never practiced doing one, according to Emily Wise, MD, of Boston University School of Medicine, and colleagues.
Only 15.9% described themselves as being skilled at skin cancer examination, the researchers reported in the October Archives of Dermatology.
“Melanoma is the only detectable cancer for which death rates are not decreasing, yet screening rates remain the same,” they wrote.
Previous studies have observed a lack of teaching and practice opportunities for skin cancer examinations during medical school. To see if this gap persisted through residency, Wise and colleagues surveyed 342 residents from four geographically and ethnically diverse programs.
Among the respondents, 50.3% were women and 61.4% were younger than 30.
A total of 40.8% were in their first postgraduate year, 29.9% were in their second, and 29.3% were in their third or fourth years.
Specialties included internal medicine (44%), family medicine (19.3%), pediatrics (19.1%), obstetrics and gynecology (11.7%), and others (5.9%).
More than half had not taken a dermatology elective in medical school (57.5%), and 80% had not done so during their residency.
Less than a third reported routinely examining their patients’ skin, only 18.3% asked about whether any moles had changed appearance, 12.7% inquired about a family history of melanoma, and 10.2% discussed the ABCDs of melanoma (asymmetry, border irregularity, color, diameter).
After adjustment for age, sex, percentage of white patients, and residency location, characteristics associated with residents’ being somewhat or very skilled included:
* Receiving training in skin cancer examination in medical school (OR 3.33, 95% CI 1.49 to 7.41)
* Participating in a dermatology elective during residency (OR 7.02, 95% CI 3.37 to 14.62)
* Spending one or more hours in a dermatology clinic (OR 5.77, 95% CI 2.43 to 13.71)
* Observing a physician perform a skin cancer examination four or more times during residency (OR 10.97, 95% CI 4.57 to 26.36)
* Receiving training in performing a skin cancer examination during residency (OR 6.28, 95% CI 3 to 13.13)
* Performing four or more skin cancer examinations (OR 10.03, 95% CI 4.23 to 23.79)
The survey also asked residents about their own personal practices and found that only 31.8% performed self skin examinations and 21.3% had ever had a skin cancer examination by a physician.
Among residents who performed self examinations, 19.4% considered themselves skilled in patient skin examinations.
The researchers pointed out that nearly two-thirds of patients diagnosed with melanoma had seen a physician within the previous year.
“Primary care physicians are thus ideally suited to screen and triage high-risk patients and those with suspicious lesions,” they wrote.
But barriers clearly exist to more extensive integration of skin cancer examination into medical training, such as the lack of evidence from randomized trials demonstrating a mortality benefit from skin examination. Still, other types of examinations routinely taught, such as digital rectal exams, also lack convincing evidence for mortality benefits.
And there is the ever-increasing volume of information that must be taught and an insufficient number of dermatology faculty members to do the teaching, the researchers said.
There are, however, “small but important steps” that residency programs can introduce to increase the opportunities for learning, according to the researchers.
For example, they suggested that the American Academy of Dermatology institute a national initiative to encourage Web-based skin examination training among residency program directors and chief residents, who could then serve as instructors.
Such Web-based instruction tools have already proven popular among students and residents.
The potential benefits of even small steps was illustrated in this study by the observation that the performance of only four skin cancer examinations — slightly more than one per year of residency — was associated with “manifold increases in self-reported skill levels.”
“We see reasons for strong concern mixed with cautious optimism,” the authors concluded.
They acknowledged limitations to their study, including the fact that it included only four residency programs and all data were self-reported.
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