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Curricular factors associated with medical students' practice of the skin cancer examination: an educational enhancement initiative by the integrated skin exam consortium

Garg, Amit; Wang, Joyce; Reddy, Shalini B; Powers, Jennifer; Jacob, Reza; Powers, Michael; Biello, Katie; Cayce, Rachael; Savory, Stephanie; Belazarian, Leah; Domingues, Erik; Korzenko, Adam; Wilson, Lindsay; Grant-Kels, Jane M; George, Paul; Robinson-Bostom, Leslie; Trotter, Shannon C; Geller, Alan C
IMPORTANCE/OBJECTIVE:As medical school curricula become progressively integrated, a need exists to optimize education related to the skin cancer examination (SCE) for melanoma, a relevant competency gap that influences secondary prevention efforts. OBJECTIVES/OBJECTIVE:To identify curricular factors associated with medical students' confidence, intent, and performance regarding the SCE. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Survey-based cross-sectional study from the Integrated Skin Exam Consortium at accredited US medical schools among a volunteer sample of second-year students representing 8 geographically varied public and private institutions. Students were administered a questionnaire to assess characteristics, curricular exposures, and educational and practical experiences related to skin cancer, as well as knowledge of melanoma risk and a detection method. MAIN OUTCOMES AND MEASURES/METHODS:Primary outcomes were confidence in performing the SCE, intent to perform an integrated skin examination, and actual performance of the SCE. RESULTS:Physical diagnosis session and clinical encounter were most predictive of confidence in performance of the SCE (odds ratios [ORs], 15.35 and 11.48, respectively). Other curricular factors associated with confidence included instruction time of at least 60 minutes on skin cancer (OR, 6.35), lecture on the SCE (OR, 7.54), knowledge of melanoma risk (OR, 3.71), and at least 1 opportunity to observe the SCE (OR, 2.70). Physical diagnosis session and at least 4 opportunities to observe the SCE were most predictive of intent to perform an integrated skin examination (ORs, 4.84 and 4.72, respectively). Other curricular factors associated with intent included knowledge of melanoma risk (OR, 1.83), clinical encounter (OR, 2.39), and at least 1 opportunity to observe the SCE (OR, 1.95). Clinical encounter, physical diagnosis session, and at least 1 opportunity to observe the SCE were most predictive of performance of the SCE (ORs, 21.67, 15.48, and 9.92, respectively). Other curricular factors associated with performance included instruction time of at least 60 minutes on skin cancer (OR, 2.42) and lecture on the SCE (OR, 5.04). CONCLUSIONS AND RELEVANCE/CONCLUSIONS:To augment the practice of the SCE among medical students, course directors may design an integrated curriculum that includes at least 60 minutes of instruction related to melanoma and the SCE, a description of the integrated skin examination as part of the physical diagnosis course, and education on high-risk demographic groups and anatomic sites specific to men and women and on the ABCDEs of melanoma, and at least 1 opportunity to observe the SCE.
PMID: 24898482
ISSN: 2168-6084
CID: 5345512

The Integrated Skin Exam film: an educational intervention to promote early detection of melanoma by medical students

Garg, Amit; Wang, Joyce; Reddy, Shalini B; Powers, Jennifer; Jacob, Reza; Powers, Michael; Biello, Katie; Cayce, Rachael; Savory, Stephanie; Belazarian, Leah; Domingues, Erik; Korzenko, Adam; Wilson, Lindsay; Grant-Kels, Jane M; George, Paul; Robinson-Bostom, Leslie; Trotter, Shannon C; Geller, Alan C
BACKGROUND:Knowledge of the skin cancer examination (SCE) and its practice remain relevant competency gaps among medical students. OBJECTIVE:We elaborate on a method of SCE known as the Integrated Skin Exam and discuss the development of an instructional film that illustrates its principles. We assess the tool's effect on knowledge, attitudes, and perceptions related to the SCE. METHODS:Second-year students among 8 randomized schools viewed the film and completed pre-post questionnaires. RESULTS:After viewing The Integrated Skin Exam film, students demonstrated improved melanoma knowledge, including identification of high-risk demographic groups (61% vs 42.9%, P < .001), high-risk anatomic sites in women (88.6% vs 46.5%, P < .001) and men (92.1% vs 34.8%, P < .001), and the ABCDEs of melanoma (98.4% vs 91.2%, P < .001). Students demonstrated increased confidence in the SCE (66.93% vs 16.40%, P < .001) and augmented intentions to practice it (99.05% vs 13.9%, P < .001). A greater proportion (70.4% vs 41.9%, P < .001) of students thought less than 3 minutes were required to integrate SCE into the routine examination. LIMITATIONS/CONCLUSIONS:Longitudinal impact of the film was not assessed. CONCLUSION/CONCLUSIONS:The Integrated Skin Exam film introduces an integrated approach to the SCE that addresses knowledge gaps, mitigates perceived barriers, and augments intention related to practice of the SCE.
PMID: 24220723
ISSN: 1097-6787
CID: 5345502

Influence of time on dermoscopic diagnosis and management

Jaimes, Natalia; Dusza, Stephen W; Quigley, Elizabeth A; Braun, Ralph P; Puig, Susana; Malvehy, Josep; Kittler, Harald; Rabinovitz, Harold S; Oliviero, Margaret C; Soyer, H Peter; Grichnik, James M; Korzenko, Adam; Cabo, Horacio; Carlos-Ortega, Blanca; Ahlgrimm-Siess, Verena; Kopf, Alfred W; Marghoob, Ashfaq A
BACKGROUND/OBJECTIVES: Dermoscopy aids in clinical decision-making. However, time pressure is a common reason precluding its use. We evaluated the effect of time on lesion recognition and management decisions utilising clinical and dermoscopic images. METHOD: In all, 100 dermoscopic images were presented to 15 dermatologists with experience in dermoscopy and seven non-experts (dermatology residents). Each lesion was displayed thrice in succession. The dermoscopic image was initially presented for 1 s (t1). The same dermoscopic image was shown again without time constraints (t2) and then a final time with additional images of the clinical context (t3). Participants provided a diagnosis, their level of confidence and biopsy predilection after evaluating each image. RESULTS: For benign lesions, both groups rarely changed their diagnosis. However, an improvement in the number of correct benign diagnoses was observed when the lesion was shown in a clinical context. For malignant lesions, both groups improved when more time and clinical context was given; nevertheless, non-experts were more likely to change the diagnosis towards the correct one as more time was given and tended to perform more biopsies, in particular of benign lesions. Limitations were a small number of participants and an artificial study setting. CONCLUSION: Dermoscopy uses analytical and non-analytical reasoning approaches. We suggest that non-analytical reasoning is employed when rapid clinical decisions need to be made, especially during the evaluation of benign lesions. We conclude that dermoscopy is relatively rapid and non-time-consuming technique that adds relevant information and guides clinicians towards appropriate management decisions.
PMID: 23190378
ISSN: 0004-8380
CID: 334572

Oral isotretinoin in the treatment and prevention of cutaneous squamous cell carcinoma

Jones, Evan; Korzenko, Adam; Kriegel, David
The clinical uses of oral isotretinoin (13-cis-retinoic acid) are many. They include treatment of acneiform eruptions, diseases of cornification, inflammatory disorders, and neoplastic processes. Isotretinoin has shown greater efficacy in the chemoprevention of squamous cell carcinoma, rather than in the treatment. High-dose isotretinoin has mainly been utilized in those patients at high-risk for multiple new skin cancers where the risk of morbidity from side effects is overshadowed by the benefit to the patient.
PMID: 15552602
ISSN: 1545-9616
CID: 5345482

When deep venous thrombosis fails to respond to therapy [Case Report]

LaPorte, Dawn; Farber, Sharon; Sorin, Sergei; Wabba, Sara; Daneels, Elizabeth; Korzenko, Adam; Kopes-Kerr, Colin P
BACKGROUND:Deep venous thrombosis in primary care is usually treated with rest, analgesics, intravenous or low-molecular-weight heparin, and coumadin. In some cases, however, a less familiar course of diagnosis and management is required. METHODS:We describe the case of a 53-year-old truck driver who had an acute deep venous thrombosis of his right lower extremity, which failed to respond to routine therapy with heparin and warfarin. A literature search was undertaken to research the differential diagnosis and management of deep venous thrombosis and to review specifically the role of venal caval filters and inherited thrombotic disorders and occult cancer in this context. RESULTS AND CONCLUSION/CONCLUSIONS:The ultimate diagnosis in our patient appeared to be signet ring cell cancer of the colon that had metastasized to the right thigh. This case is an example of the inherent limitations of even an aggressive diagnostic and therapeutic approach to the entity of refractory deep venous thrombosis.
PMID: 12755253
ISSN: 0893-8652
CID: 5345472