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1.  Dermatology undergraduate skin cancer training: a disconnect between recommendations, clinical exposure and competence 
BMC Medical Education  2012;12:27.
Background
Skin cancers are the most common malignancies in Caucasian populations. Non-specialists are responsible for the initial assessment of skin lesions and are required to act as the gatekeepers to dermatological cancer services in many healthcare systems. The majority of such physicians receive very limited formal undergraduate or postgraduate dermatology training. The British Association of Dermatologists (BAD) has produced guidelines that list the lesions that students should be able to diagnose on graduation and the majority of UK medical schools’ operate curricula in keeping with these. There is, however, virtually no evidence as to whether these competencies are being achieved. We set out to determine students’ competence at skin lesion diagnosis and to quantify their clinical exposure to examples of such lesions during their dermatology attachment.
Methods
Three linked studies were undertaken. In the first, students’ competence was tested by randomized slideshows of images containing the 16 lesions recommended in the UK guidelines. Students’ accuracy was tested at the beginning (Day 1) and end (Day 10) of their clinical placement, with a random sample of students retested 12 months later. Secondly, students’ exposure to these lesions was recorded during their attachments. Finally a survey of the additional dermatological resources used by the students was undertaken.
Results
Study 1: Students’ diagnostic accuracy increased from 11% on Day 1 to 33% on Day 10 (effect size +2.72). After 12 months half of this effect had disappeared and the students accuracy had dropped to 24%. Study 2: Students’ exposure to the recommended lesions was poor with 82% not even witnessing a single example of each of the 3 major skin cancers. Despite these measurements, only a minority of students reported that they were not confident at diagnosing skin tumours. Study 3: The majority of students use additional resources to supplement their learning.
Conclusions
In the light of what we know about learning in dermatology, our data would suggest, that the current (traditional) undergraduate attachment is inadequate to meet the UK recommendations for graduate competence. As well as critically examining the basis for these recommendations, we need more empirical data on student performance and exposure, in order to improve teaching and learning.
doi:10.1186/1472-6920-12-27
PMCID: PMC3391986  PMID: 22569037
2.  Novice Identification of Melanoma: Not Quite as Straightforward as the ABCDs 
Acta dermato-venereologica  2011;91(2):125-130.
The “ABCD” mnemonic to assist non-experts’ diagnosis of melanoma is widely promoted; however, there are good reasons to be sceptical about public education strategies based on analytical, rule-based approaches – such as ABCD (i.e. Asymmetry, Border Irregularity, Colour Uniformity and Diameter). Evidence suggests that accurate diagnosis of skin lesions is achieved predominately through non-analytical pattern recognition (via training examples) and not by rule-based algorithms. If the ABCD are to function as a useful public education tool they must be used reliably by untrained novices, with low inter-observer and intra-diagnosis variation, but with maximal inter-diagnosis differences. The three subjective properties (the ABCs of the ABCD) were investigated experimentally: 33 laypersons scored 40 randomly selected lesions (10 lesions × 4 diagnoses: benign naevi, dysplastic naevi, melanomas, seborrhoeic keratoses) for the three properties on visual analogue scales. The results (n=3,960) suggest that novices cannot use the ABCs reliably to discern benign from malignant lesions.
doi:10.2340/00015555-1070
PMCID: PMC3325479  PMID: 21311845
ABCD; non-analytical reasoning; pattern recognition; skin cancer; melanoma; dermatology diagnosis
3.  Utility of Non-rule-based Visual Matching as a Strategy to Allow Novices to Achieve Skin Lesion Diagnosis 
Acta dermato-venereologica  2011;91(3):279-283.
Non-analytical reasoning is thought to play a key role in dermatology diagnosis. Considering its potential importance, surprisingly little work has been done to research whether similar identification processes can be supported in non-experts. We describe here a prototype diagnostic support software, which we have used to examine the ability of medical students (at the beginning and end of a dermatology attachment) and lay volunteers, to diagnose 12 images of common skin lesions. Overall, the non-experts using the software had a diagnostic accuracy of 98% (923/936) compared with 33% for the control group (215/648) (Wilcoxon p < 0.0001). We have demonstrated, within the constraints of a simplified clinical model, that novices’ diagnostic scores are significantly increased by the use of a structured image database coupled with matching of index and referent images. The novices achieve this high degree of accuracy without any use of explicit definitions of likeness or rule-based strategies.
doi:10.2340/00015555-1049
PMCID: PMC3160473  PMID: 21461552
non-analytical reasoning; skin cancer; electronic clinical decision support software; melanoma; dermatology diagnosis

Results 1-3 (3)