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Dermatology for GP Trainees

This booklet is an addition to a series produced by the Royal College of General Practitioners (RCGP) in association with a number of specialist organisations in 1993 and reprinted in 1998. Each one describes the content of training in a medical discipline relevant to general practice as well as the arrangements that the College would expect to ensure that this is fully covered.

The RCGP, in common with all members of the Academy of Medical Royal Colleges and their Faculties is firmly committed to helping to achieve the maximum educational value from Senior House Officer posts.

These booklets are designed to give trainees and their general practitioner and hospital based teachers clear guidance on the content of vocational training, and will enable trainees to ensure that they are benefiting fully from all the educational aspects of posts. They will also provide the basis for local discussions between hospital consultants and general practitioners so that the local arrangements for vocational training can take account of the College's recommendations.

The booklets will also form the basis for the educational approval and selection of posts for vocational training purposes. They should be read in conjunction with The Quality of Hospital Based Education for General Practice booklet which accompanies the series.

The production of the original series was driven by the enthusiasm of the late Bill Styles when he was chairman of the Education Division RCGP from 1989 to 1992. This booklet has been produced in conjunction with The Royal College of Physicians and The British Association of Dermatologists. The College wishes to thank David McKinlay and Sean Coughlin of the Royal College of General Practitioners. The College also wishes to thank Susan Burge and Roger Allen of the Dermatology Sub-committee of the Royal College of Physicians; and Martin Black and John Savin of the British Association of Dermatologists for their contributions to this booklet.

The College is most grateful to the Medical Protection Society for financial support in the publication and distribution of this series of booklets.

John Toby, Chairman of Council
Royal College of General Practitioners

Introduction

Consultations for skin disease in general practice have increased by almost 50% between 1981 and 1991, reflecting the substantial rise in the prevalence of common problems such as atopic eczema, venous leg ulcers and skin cancer . Approximately a quarter of the population is affected by a skin disease which would benefit from medical care. In the UK skin diseases are a common reason for injury and disablement benefit or periods of certified incapacity to work [2,3].

About 15% of GP consultations relate to problems with the skin. Skin diseases were the fourth most common reason for people consulting their general practitioners in England and Wales in 1991/92 . Although skin diseases are common, dermatology tends to have a low priority in the medical curriculum for undergraduates. Prospective general practitioners must be able to care properly for people of all ages with skin problems so dermatology should be an essential component of any training scheme for general practitioners. Dermatologists, in common with general practitioners have highly developed clinical skills and are less reliant on laboratory and invasive diagnostic tests than other specialties.

Recent figures from the Joint Committee on Postgraduate Training for General Practice (Table 1) showed that only 5 to 6% of doctors applying to the Joint Committee for its certificate offered experience in dermatology. Given the prevalence of skin diseases, this low figure is a cause for concern. The All Party Parliamentary Group on Skin stress the importance of appropriate training for general practitioners to provide an acceptable national service to patients with skin diseases [5].

Table 1
Certificates issued to doctors who had experience in dermatology included as one of the specialities in their vocational training programme

Most trainees learn some dermatology when working within the general practice component of vocational training, but specialist input is minimal except on day release courses. Some doctors are more fortunate, obtaining experience in dermatology as a senior house officer (SHO), and some hospital SHO rotations for general practice trainees do offer an attachment to dermatology. Ideally the SHO post should include no less than the equivalent of 3 months' full-time dermatology. More rotations should include a post in dermatology to meet the need for training.

Patients with skin disease need dermatologists to work closely with skilled general practitioners to help them cope with the demand for skin care. A survey performed by the British Association of Dermatologists revealed that many consultants, principally working in district general hospitals, would be willing to teach a general practice trainee in out-patient clinics . To ensure maximum benefit, these clinical attachments should be maintained for a minimum of 4 months, ideally 6 months, and trainees should attend the clinics at least once a week. General practice course organisers, trainers and consultant dermatologists should develop local programmes.

The educational value of any hospital post must be maximised by ensuring that trainees have formal teaching and clear educational objectives. Dermatology is a varied speciality, with a strong surgical bias as well as medical input. Many general practitioners want to be able to treat small skin tumours surgically. The content of the training programme must be flexible enough to meet the needs of each trainee. Dermatology is a visual speciality and there is no substitute for clinical experience in the out-patient clinic, but this clinical experience should be supplemented by tutorials or other formal teaching (e.g. distance learning courses). It is not appropriate for SHOs in dermatology to spend all their time caring for in-patients. The demands of the service must not be allowed to subsume the educational needs of the trainee.

References

1. Williams HC (1997) Increasing demand for dermatological services: how much is needed? J R Coll Physicians 31, 261-2
2. Department of Social Security (1994) Social security Statistics 1994. London, HMSO.
3. Health and Safety Commission (1992) Annual Report 1991/1992. London. HMSO.
4. Royal College of General Practitioners (1995) Morbidity Statistics from General Practice. Fourth National Study 1991-2. London HMSO.
5. An investigation into the adequacy of service provision and treatments for patients with skin diseases in the UK. A report of the All Party Parliamentary Group on Skin. 1997 London, All Party Parliamentary Group on Skin.
6. Survey by the British Association of Dermatologists, 1997.

Curriculum for Trainees in Dermatology

1. Educational Content
a. To recognise and manage appropriately common and life-threatening skin diseases.

b. Dermatology is an out-patient based speciality so the post should consist mainly of work in out-patient clinics. The trainee may also have an opportunity to work in a daycare treatment centre and look after patients with skin diseases on the wards. It is important that learning is based on practical experience and not just observation of specialists.

c. The trainee should become familiar with standard dermatological terminology.

d. The trainee should gain insight into their own limitations and know the indications for a referral to a consultant dermatologist. Trainees should be able to make an appropriate referral which allows the specialist to assess priority and urgency.

e. The post should offer opportunities for practical training in obtaining skin scrapings for mycology, examination with Wood's Light, simple skin surgery, skin biopsy, intralesional injection and cryosurgery.

f. The trainees should develop their communication skills, particularly those required to deal with patients handicapped by chronic skin diseases.

2. Educational Method
a. Each trainee should have a named educational supervisor who is accountable for the overall educational experience of the job.

b. Most training in dermatology takes place during the out-patient clinics. Teaching also should also occur on a formal basis, for at least one session per week, with complete release from clinical responsibilities during that time.

c. A core curriculum defining training needs should be provided at the start of the job. The curriculum can also be used as a tool for assessment of the trainee.

d. The trainee should record progress in a learning log / training record.

e. Critical assessment of the current literature should be encouraged by a Journal Club or a topic review involving peer criticism.

f. Access to a departmental or hospital library is essential.

g. Trainees should be actively involved in audits.

h. An induction course or hand-book should be provided to acquaint trainees with their duties and responsibilities as well as describing the facilities available.

i. Trainees should be encouraged to make clinical presentations and attend local dermatology meetings.

3. Appraisal and Educational Assessment
a. Trainees should be appraised at the beginning of their job and after every three months to provide educational feedback and suggest the way forward.

b. Educational assessment needs to be valid, objective, reliable and consistent. It should be based upon the core curriculum or learning log / training record.

c. At the end of the appointment the educational supervisor should complete a written assessment which is given to the trainee. At the same time the trainee should complete a written evaluation of the training post.

d. Competency in skin surgical techniques learnt should be assessed.

4. General Aspects of the Educational Content of Individual Posts
a. Postholders should receive a job description outlining the service and educational components of the post.

b. Study leave should be granted as appropriate.

c. Cover appropriate to the experience of the trainee should always be available.

d. Career advice and counselling should be available from the educational supervisor and clinical tutor.

e. The trainee's end-of-post written evaluation should be available to visitors on joint hospital visits.

Core Curriculum in Dermatology

1. General Topics
a. The trainee should know the indications for referral to a dermatologist and recognise his/her own limitations.

b. The trainee is expected to be able to recognise and manage common dermatoses and skin malignancies in the out-patient clinic (see below).

c. Counselling / Preventative Medicine.

the role of dermatology nurses
the use of emollients
care of the hands
protection against the sun
liaison with fellow professionals e.g. the paediatric nurse and dietician in the management of children with atopic eczema, the health visitor in the management of scabies
d. Inpatients / Day Care.

psoriasis, eczema and erythroderma
cellulitis
leg ulcer - venous and arterial, use of Doppler
pemphigus and bullous pemphigoid.
e. The trainee should be aware of the psychological impact of skin disease.

f. Simple surgical skills (see below)

2. Skin diseases
The trainee should obtain a working knowledge of these common and/or important skin diseases

Infections and infestations

• fungal and yeast infections: Candida, pityriasis versicolor, tinea
  
• bacterial infections: impetigo, cellulitis
  
• viral infections: herpes simplex and zoster, molluscum contagiosum, viral warts, viral exanthem, pityriasis rosea
  
• infestations: scabies, lice, insect bites
  

Eczema (dermatitis)

• atopic (children and adults)
• contact (irritant and allergic) including hand dermatitis; pompholyx
  
• seborrhoeic, discoid, asteatotic, stasis
  

Psoriasis

• chronic plaque, guttate, flexural, scalp
• palmo-plantar pustulosis

Psychosomatic

• dermatitis artefacta
  
• acne excoriee
  
• dysmorphophobia
  

Other Conditions

• leg ulcers
  
• prurigo / pruritus
  
• acne, rosacea
  
• alopecia, hirsutes, vitiligo
  
• blistering diseases, erythema multiforme, drug eruptions, photosensitivity
  
• genital dermatoses including lichen sclerosus
  
• granuloma annulare
  
• urticaria, vasculitis, erythema nodosum
  
• lichen planus, discoid lupus erythematosus

Tumours

a. Benign

• melanocytic naevus (mole)
  
• dermatofibroma, seborrhoeic wart, keratoacanthoma
  
• epidermal / pilar cyst,
  
• pyogenic granuloma, spider naevus, haemangioma
  

  b. Premalignant

• solar keratosis,
• Bowen's disease
  

  c. Malignant

• basal cell cancer,
• squamous cell cancer,
• malignant melanoma

Dermatological Emergencies
The trainee should discuss the management of the following problems:

• disseminated herpes simplex
  
• angio-oedema and anaphylaxis
  
• acute contact dermatitis and erythroderma
  
• toxic epidermal necrolysis
  
• pustular psoriasis

3. Practical Skills

Outpatient Procedures

• skin scrape for mycology/scabies
  
• intralesional injection of corticosteroid (acne cyst, keloid)
  
• examination with Woods light.

Skin Surgery
Procedures should be performed under supervision 2 or 3 times

• skin biopsy (punch)
  
• shave biopsy
  
• curettage and cautery
  
• excision and closure
  
• cryosurgery
  

Management of Leg Ulcers

• choice of dressings
  
• use of Doppler for measuring the ankle-brachial systolic resting pressure index
  
• compression bandaging
  
• paste bandages
  
• indications for patch testing

4. Treatments
Effective treatments are available at low cost for most skin problems.

Topical treatments
The trainee should understand the principles of topical treatment including:

• choice of base, eg. cream versus ointment versus lotion.
  
• quantity to prescribe
  
• how to apply
  
• use of occlusion, eg. tar bandages, hydrocolloid dressings

The trainee should be familiar with the use of:

• emollients
  
• topical corticosteroids
  
• tar, dithranol, calcipotriol,
  
• scalp treatments (keratolytics)
  
• topical antibiotics / antiseptics
  
• potassium permanganate soaks
  
• topical retinoids.

Oral Treatments
The trainee should have discussed the indications for the following oral medications:

• corticosteroids
  
• azathioprine
  
• methotrexate
  
• dapsone
  
• retinoids
  
• cyclosporin
  
• Ultraviolet Light

The trainee should understand the indications for:

• UVB (phototherapy)
  
• PUVA (photochemotherapy)

Patch Testing
The trainee should understand the indications for patch testing.
The trainee should have an opportunity to see patch tests applied and read.

Suggestions for further reading

Hunter JAA, Savin JA, Dahl MV (1995) Clinical Dermatology. 2nd edition Blackwell Scientific Publications

Graham-Brown RAC, Burns AT (1990) Lecture notes in dermatology. 6th edition. Blackwell Scientific Publications Ltd. (Out of print. See also 7th edition by same author).

Burge SM, Colver G, Lester R (1996) Simple Skin Surgery. 2nd edition Blackwell Scientific Publications

Textbook of Dermatology (1998) 6th edition ed Champion RH, Burton JL, Ebling FJG . Oxford, Blackwell Scientific Publications.