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DERMATOLOGY TEACHERS

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JCHMT DERMATOLOGY CURRICULUM

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Teaching Recommendations - Undergraduate Dermatology in the UK

Background

A number of medical schools are currently in the process of introducing a new medical curriculum following the General Medical Council publication "Tomorrow's Doctors". The general theme of this document is that many undergraduate curricula had become congested with factual knowledge and the introduction of a basic core of essential knowledge plus a wide range of options was required to stimulate individual thinking and reduce the amount of textbook learning required.

This core plus options formula has stimulated a number of medical schools to introduce a new or substantially modified medical undergraduate curriculum involving a problem based learning approach and blurring the previous distinction between pre-clinical and clinical years of the undergraduate medical course.

Many of these changes are very welcome. It is however important for dermatological care in the UK that the place of both dermatology and its underpinning foundation of basic skin biology is clarified. In some but not all UK undergraduate curricula, dermatology is part of the core area, but in others it is a very light option. In view of the fact that 10 to 15% of GP consultations are dermatologically related, it is extremely important that all undergraduates have a minimum core of dermatological knowledge at the time of graduation, even if a greater component of dermatology is in future introduced to general practitioner postgraduate training.

Opportunities for dermatology and skin biology contributions to the current undergraduate courses in the UK vary according to the development of the curricula in individual medical schools. Possibilities include:

• Formal lectures to large numbers, nowadays often referred to as major plenary sessions. This option is most often available in the early years of the curriculum and can relate to skin biology, dermatological genetics, relationships between dermatology and immunology etc.
• Additional opportunities to make contact with medical students during the very early sections of the course. These may mainly relate to skin biology in relation for example to immunology , or may relate to a problem based learning scenario, for example wound healing in a scenario based on a road traffic accident.
• For students who opt to do an intercalated B Med Sci degree, a dermatological option or a substantial dermatological contribution to an option on for example malignancy
• Special study modules which may be individual or group based. These modules generally last for 4 to 6 weeks, and are available in different medical schools from years 2 to 5 of the course. There is often an opportunity to contribute a dermatological aspect to SSMs mainly based in other systems, for example dermatological complications to a module on diabetes
• Junior and Senior Electives. These options generally involve a 6 to 8 week period, sometimes spent out with the University in which the student is an undergraduate.
• Problem based learning scenarios. This increasingly popular method of introducing undergraduates to managing patients is available in many undergraduate curricula from year one throughout the course. These scenarios are generally put together by a team of appropriate writers and are handled by a group of students, frequently 8 in number, who discuss the problem, define the range of knowledge required to solve the situation, share amongst themselves the tasks to seek the relevant answers or information needed, and to come together one to two weeks later to resolve the problem. Throughout this period they are assisted as much as is necessary by a member of the Medical School staff trained as a problem based learning facilitator.
• General practice attachments. There is now a greater emphasis on time spent by undergraduates in a general practice setting. Informed general practitioners clearly have the opportunity to introduce undergraduates to patients with a spectrum of dermatological problems which is probably slightly different from that encountered in a hospital setting.
• Case studies. Many of the new undergraduate curricula in UK medical schools have minimised formal examinations and depend rather more on formative assessment. A number of medical schools require students to submit a casebook of up to 50 cases around the time of their final evaluation. There is clearly an opportunity here for a proportion of these cases to have a dermatological flavour.

All of the above approaches can be adopted by academic dermatologists in increasing the content of dermatology in their undergraduate curriculum and developing a measure of vertical integration into the course so that students are aware of dermatological problems and of relevant skin biology from year one onwards. However the majority of these approaches will only involve a proportion of undergraduates in any one year and it is therefore highly desirable that in addition a cognate period of core time is devoted to fundamentals of skin biology and dermatology, and that during this period emphasis is placed on students having direct clinical contact with dermatological patients in an outpatient, day-care or inpatient setting. Those involved in undergraduate education in the UK consider that a minimum of 10 half-day sessions and preferably more be available for this type of contact.

Evaluation

As teaching methods evolve, methods of evaluation also change. It is considered essential that both dermatological topics and patients are included in evaluation, in conventional final examinations or in other methods of evaluation including objective structured clinical examinations (OSCES). Dermatologists should play their full part as examiners in these examinations.

Dermatology for Undergraduates

BAUTOD Curriculum

Learning Objectives

• Demonstrate insight into the scientific basis of dermatology.
• Relate knowledge of skin structure to the physical signs of skin disease.
• Demonstrate ability to take a dermatological history and describe cutaneous physical signs.
• Recognise common skin diseases and skin tumours.
• Recognise important cutaneous signs of systemic disease or adverse reactions to drugs.
• Understand the principles of dermatological treatment.
• Appreciate the impact of skin diseases on patients and their families.

Teaching Methods

• Tutorials
• Work with consultants in outpatient clinics.
• Observation of patients having day-care or phototherapy.
• Observation of practical procedures such as skin biopsy, cryosurgery and wound care.
• Keeping a record of the conditions/treatments seen in an appropriate dermatology curriculum book.
• Access to the dermatology library and slide collection.

Assessment Methods

• Attendance record.
• Continuous evaluation.
• Portfolio/cases.
• Performance in dermatological section of OSCES 4th and 5th year short cases based on 35mm slides.

Feedback

• Educational supervisor will provide feedback to students.
• Students are asked to complete an anonymous feedback form at the end of the attachment.

Undergraduate Curriculum in Dermatology

Knowledge

1. Basic skin biology including the importance of the skin as a tool for the investigation of immunological, genetic and other diseases.

2. Basic principles of wound healing.

3. Dermatological emergencies including the concept of skin failure e.g. toxic epidermal necrolysis, erythema multiforme, acute urticaria, angioedema. Undergraduates should be able to recognise the emergency and initiate first-line management.

4. Inflammatory disease of the skin (atopic dermatitis, contact dermatitis, psoriasis). Diagnosis, differential diagnosis and management.

5. Skin cancer (melanoma, BCC, SCC). Diagnosis, differential diagnosis and management. Prevention of skin cancer and the role of UV exposure.

6. Acne: diagnosis, differential diagnosis and management.

7. Leg ulcers: diagnosis, differential diagnosis, management and prevention.

8. Cutaneous infections (bacterial, viral and fungal), infestations (scabies): diagnosis, differential diagnosis and management.

9. Cutaneous complications of HIV associated disease.

10. The importance of diagnosis and management of cutaneous infection in immunocompromised individuals e.g. in patients with renal transplants.

11. Urticaria: diagnosis, differential diagnosis and management.

12. Cutaneous manifestations and presentations of systemic disease including gastrointestinal, endocrinological, rheumatological disease.

13. Blisters in the skin: causes, diagnosis and management.

14. Drug eruptions: diagnosis, differential diagnosis and management.

15. Introduction to dermatological therapy: Students should understand the principles of topical treatment including: choice of base, e.g. cream versus ointment versus lotion and use of occlusion, e.g. tar bandages. Students should have discussed the indications for and complications of: UVB (phototherapy) and PUVA (photochemotherapy)

Skills

1 Communicate effectively with patients with skin diseases.

2. Take and present an appropriate and reliable history.

3. Examine the skin systematically and describe the physical signs.

4. Describe eczema, psoriasis, scabies, fungal infection and urticaria.

5. Recognise melanoma and non-melanoma skin cancer. Be able to distinguish from premalignant and benign cutaneous lesions.

6. Recognise cutaneous vasculitis, explain the principle causes and formulate a plan of investigation.

7. Be able to differentiate simple venous ulcers from arterial ulcers.

8. Be able to take a skin scrape.

9. Understand how to plan investigation and management of common inflammatory skin diseases.

10. Understand how to apply topical medicaments, compression bandages etc.

11. Write a prescription for topical treatment with an emollient showing knowledge of quantities and bases.

12. Provide advice on care of the hands.

Attitudes

1. Demonstrate ability to communicate with patients with skin diseases and examine the skin in a sensitive and courteous manner.

2. Understand the difficulties, physical and psychological, experience by people with chronic skin diseases.

3. Understand the role of dermatology nurses.

4. Understand the importance of good communication with the GP.

5. Demonstrate a professional attitude by regular attendance and ability to direct own learning.