Dermoscopy is a useful tool for improving accuracy in skin cancer diagnosis, yet there is no standard educational curriculum for using it, and most US dermatology residents do not receive extensive training. Obtaining a new pattern recognition skill can be challenging once beyond residency training, and there are several barriers to implementation with independent study (Table 1).
To address this gap, Janice Wilson, MD, assistant professor of dermatology at the University of Texas Medical Branch, Stephanie Savory, MD, associate professor of dermatology at the University of Texas Southwestern, and I formed DERM:EMD (Dermatology Early Melanoma Detection) to provide telementoring-based dermoscopy education across the state of Texas. Here are some of the strides the program has made over the past year, as well as future endeavors to improve early melanoma detection.
The Need For Better Training
The majority of evidence on the current state of dermoscopy training for US residencies comes from a handful of survey-based populations. In a survey conducted by Patel et al, which included 122 residents and 22 program directors, 38% received no dermoscopy training1; in another small study by Chen et al, the average US resident dermoscopy instruction per academic year was 2 hours.2
Our program is designed to help dermatology residents develop dermoscopic skills to improve their ability to successfully distinguish skin cancers from mimics. The telementoring platform Project ECHO (Extension for Community Health Care Outcomes) supports the development of new clinical skill sets and strengthens health systems through partnerships. It has been the key infrastructure around which we built our dermoscopy curriculum.
Our curriculum uses video conferencing to connect participating dermatology residency programs across the broad geography of Texas; we provide monthly teleconference lectures with peer-reviewed content, accompanied by an educational handout, with educational quizzes to monitor participant improvement over time.
We are currently on our second academic year, and we have learned important lessons on flexibility, innovation, and the specific needs of adult learners. This year, we shifted our content and educational metrics to focus on clinical comparators to more closely parallel clinical decisions that are made at a patient’s bedside. For example, it can be hard to distinguish sebaceous hyperplasia on the face from an early nodular basal cell carcinoma. During our lectures, we show these 2 entities side by side and discuss specific reasons why a lesion is “x” and not “y.”
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Our educational metrics include a dermoscopy quiz and a “self-efficacy instrument,” at both baseline and curriculum end. The dermoscopy quiz includes dermoscopic images, for which we ask the specific diagnosis, and the self-efficacy instrument measures how comfortable a resident feels diagnosing specific skin lesions with a regular clinical examination or with the assistance of dermoscopy. In addition, we have lecture-specific quizzes that are delivered via Kahoot! to gauge learning in real time.
There are several larger scale metrics that are also important but challenging to capture, including the number needed to biopsy for melanoma. We would also like to examine the average depth of diagnosed melanomas biopsied by residents, and whether residents who complete the program are finding melanomas earlier. While we are still analyzing the data from last year, we have received a lot of enthusiastic responses from our participants who say they feel more comfortable using their dermoscopes after going through our course.
Best Practices for Dermoscopy
Using dermscopy during routine skin checks allows dermatologists to refine their clinical skills. As part of our curriculum, we recommend participants have their dermoscopes out and on for every skin exam, and to include it as a part of hand hygiene to minimize possible nosocomial transmission of bacteria. We also recommend using the dermatoscope to provide tangential lighting to pick up the pearly glint of basal cell carcinomas more easily, and to see into patients’ nooks and crannies.
As providers’ skill and comfort improve, we recommend incorporating dermoscopic photography into clinical practice. An unanticipated pathology result (eg, when a lesion clinically consistent with a basal cell carcinoma returns as an amelanotic melanoma), becomes an educational opportunity when a dermoscopic photograph is available.
Next Steps for Dermoscopy Education
The next steps for our dermosopy education program are to refine the educational content and develop a tool kit for other institutions who would want to replicate our educational process. In addition, we are developing an efficient web-based education platform for busy practicing dermatologists who want access to similar materials but might not have the time during the work week to join a 1 hour scheduled video conference.
Practicing dermatologists have access to other resources on the use of dermoscopy, which are outlined in Table 2. These include virtual and online courses, as well as in-person courses, including ones offered at the American Academy of Dermatology meetings.
Disclosure: The author reports no relevant financial relationships.
1. Patel P, Sarika Khanna S, Beth McLellan B, Krishnamurthy K. The need for improved dermoscopy training in residency: a survey of US dermatology residents and program directors. Dermatol Pract Concept. 2017;7(2):17-22.
2. Chen YA, Rill J, Seiverling EV. Analysis of dermoscopy teaching modalities in United States dermatology residency programs. Dermatol Pract Concept. 2017;7(3):38-43.