Recognition of melanoma: A dermatologic clinical competency in medical student education

Competency of Family Medicine Residents in Performing Skin Cancer Examination

Early recognition of skin cancer reduces associated morbidity and improves survival. Most patients with suspicious skin lesions present to family medicine physicians. We aimed to evaluate the self-reported competency of family medicine residents in performing skin cancer examination (SCE) and assess the impact of different factors on their competency. All family medicine residents completed a previously validated questionnaire aimed at evaluating their skin cancer examination competency in this cross-sectional study. In total, 250 residents participated in this study. More than half of the residents never had a rotation in dermatology or received training under the supervision of a dermatologist. Approximately 70%, 72%, and 77% of residents had not observed SCE, received SCE training, and performed SCE, respectively. Although most residents were aware of the risk factors for skin cancer and the ABCD acronym for melanoma, only one out of ten residents screened their patients for these factors, enquired about changes in skin lesions, and personally practiced SCE. Only 16% of family medicine residents consider themselves competent in performing SCE. Training under the guidance of a dermatologist, SCE training, evaluating patients for cancer risk factors and any changes in moles, and SCE practice on personal level were associated with SCE competency. Multivariate analysis showed a significant association between the frequency of observing SCE and competency in performing SCE. Only 16% of family medicine residents considered themselves competent in performing SCE. The frequency of observation of SCE during residency was a significant predictor of self-reported competency in performing SCE.

Multimodal imaging risk factors predictive of small choroidal melanocytic lesion growth to melanoma: An educational study and pictorial guide

BACKGROUND

Risk factors for small choroidal melanocytic lesion growth to melanoma have been redefined using multimodal imaging. We explored provider ability to recognize risk factors for small choroidal melanocytic lesion growth to melanoma before and after image-based education and with and without multimodal imaging.

METHODS

Providers were invited to participate in a survey assessing ability to identify risk factors for small choroidal melanocytic lesion growth to melanoma using either fundus imaging or multimodal imaging. Risk factors included thickness >2 mm on ultrasonography, subretinal fluid on optical coherence tomography, presence of orange pigment by autofluorescence, acoustic hollowness by ultrasonography, and diameter >5 mm by fundus imaging. Performance was assessed before and after reviewing an educational PowerPoint providing pictorial examples of risk factors. Comparison between groups was conducted using two-tailed Fisher's exact test.

RESULTS

Thirty and 26 providers completed the pre-education and post-education assessments, respectively. Post-education participants were more accurate within ±1 risk factor for lesions with zero risk factors (77% vs. 100%, p = 0.01) or two risk factors (79% vs. 91%, p = 0.03). Following education, participants presented with multimodal imaging more often correctly identified lesions with four (12% vs. 42%, p = 0.03) or five (4% vs. 39%, p = 0.004) risk factors, demonstrated lower mean level of concern for lesions with zero risk factors (2.0 vs. 1.4, p < 0.001), and expressed higher level of concern for lesions with 5 risk factors (2.4 vs. 3.6, p < 0.001).

CONCLUSION

Use of multimodal imaging may be more beneficial than education itself to improve accuracy of risk factor identification for small choroidal melanocytic lesions.

Examining the effect of simulation-based learning on intravenous therapy administration' knowledge, performance, and clinical assessment skills of first-year nursing students

BACKGROUND

Most nurses at some point of, or throughout, their career will be involved in infusion care. Therefore, it is important to provide a realistic learning environment to nursing students regarding how to safely practice intravenous (IV) therapy administration.

OBJECTIVES

The aim of this study was examining the effect of simulation-based learning on IV therapy administration knowledge, performance and clinical assessment skills of first-year nursing students.

METHODS

This study was a randomized controlled quasi-experimental study. A total of 62 students was included in the study. The students were randomly assigned to either hybrid simulation (HS) (n = 31) or low fidelity simulation (LFS) (n = 31) groups. In the HS group, each student performed in the standardized patients using moulage, and the LFS group each student was performed with mannequin using visuals. Each of the students' level of IV therapy administration knowledge, performance and clinical assessment and satisfaction and self-confidence score was evaluated.

RESULTS

After the lecture, demonstration and simulation training, there was a statistically significant difference between groups in terms of knowledge (p < 0.05), IV catheter insertion performance in simulation and clinical (p = 0.00; p = 0.00) and clinical assessment to classify IV therapy complications on real patients (p = 0.00). Also, satisfaction and self-confidence scale scores of the students in the HS were significantly higher than in the LFS group (p = 0.00). However, there was no significant difference in simulation design scale scores between the two groups (p = 0.164).

CONCLUSION

The students in the HS group better transferred they had learned in the teaching environment to clinical practice. Also, the results show that creating an effective environment in simulation had a positive effect on the development of the students' clinical skills.

Educational methods used in cancer training for health sciences students: An integrative review

OBJECTIVE

To explore the educational methods used in the cancer training of undergraduate students in health sciences.

DESIGN

Integrative review with a systematic methodology was performed to obtain a comprehensive picture of the variety of educational methods used in cancer training.

DATA SOURCES

A search was performed in the PubMed, CINAHL, PsycINFO and Cochrane databases for the period 2008-2020.

REVIEW METHODS

The Critical Appraisal Skills Program (CASP) was used to assess the quality of included studies. Three reviewers extracted data and did quality appraisal.

RESULTS

A total of 40 articles referring to cancer training in medicine and nursing were included in the review; no articles referring to other health disciplines were found. The main educational methods used were expository methods, case studies, exercises and problems, problem-based learning, learning contracts and project-oriented learning.

CONCLUSION

This review shows the need to combine educational methods so that health sciences students acquire competency (knowledge, skill, attitude) for comprehensive cancer care. There is a gap in the training of undergraduate nursing students to provide person/family centered care in oncology. To improve the training and professional practice of future health professionals, interprofessional education and the involvement of people with cancer in simulation education are recommended.

Simulating a self-inflicted facial gunshot wound with moulage to improve perceived realism, immersion, and learning in simulation-based airway management training

Moulage is used to create mock wounds and injuries for clinical education and training. We developed a moulage technique to simulate a facial gunshot wound for use in simulation-based training. We removed sections of a manikin’s face and used moulage materials to mock various aspects of the wound. The manikin was used in a simulated scenario that teaches clinicians how to manage a complicated airway. The moulage was evaluated with a self-report questionnaire that assessed participants’ perceptions of the realism of the wound, the degree to which the wound contributed to their scenario immersion, and the degree to which the wound enhanced their learning experience on a 5-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. Participants’ average response to each item was significantly higher than the neutral midpoint, and the median response was ‘strongly agree’. Our work suggests that the simulated facial gunshot wound contributed to perceived scenario immersion and enhancement of the learning experience, supporting existing literature that suggests moulage is a valuable tool in healthcare simulation. Future work could investigate the effect of moulage using objective measures and explore the potential to use extended reality technology in conjunction with moulage to improve immersion even further.

Expert opinions on the authenticity of moulage in simulation: a Delphi study

BACKGROUND

Moulage is a technique in which special effects makeup is used to create wounds and other effects in simulation to add context and create realism in an otherwise fabricated environment. The degree to which moulage is used in the simulated environment is varied; that is, there is no guide for how authentic it is required to be. To objectively assess whether a higher level of authenticity in moulage influences engagement and better outcomes, a common model to assess authenticity is required. The aim of this study was to explore expert opinions on moulage in simulation and develop an instrument for the classification of moulage in simulation.

METHODS

The instrument was developed in 3 phases: expert panellist recruitment, domain identification, and consensus rounds. A Delphi technique was used to explore themes of authenticity using Dieckmann's Theory of Realism as a frame of reference. An initial list of elements was raised by a panel of international experts. The experts participated in a further four rounds of questioning, identifying and then ranking and/or rating elements of authenticity in moulage. A priori consensus threshold was set at 80%.

RESULTS

In round 1, 18 of 31 invited panellists participated, and a total of 10 completed round 5 (attrition 44%). As a result of the Delphi, the Moulage Authenticity Rating Scale was developed. Under the three domains of realism, 60 elements were identified by experts. A total of 13 elements reached the consensus threshold, whilst tensions regarding the necessity for authentic moulage were identified throughout the rounds.

CONCLUSION

This study demonstrates the complexity of moulage in simulation, with particular challenges surrounding the experts' views on authenticity. A prototype instrument for measuring moulage authenticity is presented in the form of the Moulage Authenticity Rating Scale (MARS) to further aid progress in understanding the role of authentic moulage in simulation.

The use of simulation and moulage in undergraduate diagnostic radiography education: A burns scenario

INTRODUCTION

There is a national drive to increase allied health professions simulation training. However, there is a paucity of literature within diagnostic radiography in relation to clinical simulation. No research could be found regarding the impact of simulation in radiography with complex clinical burns scenarios. This research aims to explore the perceptions of radiography undergraduate students regarding their preparedness for the complex care requirements in imaging examinations of clinical burns cases using a mixed methods approach.

METHOD

A small-scale simulation-based teaching session was developed in a Scottish HEI, using role play and moulage to create realism. Twenty-eight undergraduate student radiographers participated in the scenario. Students completed pre and post-scenario questionnaires using Likert scale and free response data. Focus groups were undertaken three months after the simulation to obtain rich qualitative data. Common themes were identified via a process of initial coding and a 6-phase thematic analysis.

RESULTS

Thematic analysis demonstrated a marked increased perception of preparedness post-scenario; students felt more prepared to undertake their role in the imaging of complex care patients (Likert scoring increased with both mode and median post-scenario). Common themes that were identified were patient centeredness, realism and learning.

CONCLUSION

Within this limited pilot project, the use of simulation was an effective means of preparing students to understand their role within the complex care setting (with respect to the traumatic realism of burns) in preparedness for professional practice. Additionally, students related to the practical understanding of the complexity of human factors that exist within clinical practice.

Comparing Teaching Methods on Skin Disorders Using Standardized Patients Dressed in Moulage vs Paper Cases

Objective. To determine whether using standardized patients dressed in moulage improves pharmacy students' ability to assess skin disorders compared to using picture-based paper cases. To determine pharmacy student preferences when learning assessment of skin disorders through these two educational methods. Methods. Faculty members investigated student assessments of drug-induced skin disorders and contact dermatitis by using picture-based paper cases compared with using standardized patients dressed in moulage in a patient assessment course. Faculty members measured student knowledge via multiple-choice questions before laboratory, immediately after laboratory, and during a final examination 3 weeks later. Student preferences were measured immediately after laboratory via survey instrument in this randomized, non-blinded, crossover design educational study. Results. No significant differences in knowledge scores related to skin disorders were found after laboratory or 3 weeks later when comparing the two educational methods. However, survey results suggested student preferences for using standardized patients dressed in moulage for drug-induced skin disorders. No significant differences were found for contact dermatitis cases. Conclusion. Using standardized patients dressed in moulage did not improve pharmacy students' ability to assess skin disorders compared to using picture-based paper cases. Pharmacy students preferred standardized patients dressed in moulage only when learning assessment of drug-induced skin disorders.

Use of Moulage to Evaluate Student Assessment of Skin in an Objective Structured Clinical Examination

PURPOSE

This study investigated the physician assistant (PA) student evaluation of skin and the use of moulage in an objective structured clinical examination (OSCE).

METHODS

Clinical-year PA students participated in an OSCE, taking a history, completing a physical examination, and writing a focused clinical note. The standardized patient's history simulated a primary diagnosis of right-sided carpal tunnel syndrome and an incidental skin lesion consistent with melanoma, only if the student made an inquiry in this replication study. Faculty members' assessments of students' physical examinations were standardized using an agreed-upon rubric. Students completed an anonymous survey on the OSCE experience immediately following the activity.

RESULTS

All students identified the primary diagnosis of carpal tunnel. Sixty-three percent of students verbalized examination of the skin; however, only 38% identified an atypical skin lesion in their clinical note documentation. Of those, only 33% of students referred the patient for biopsy. Most students believed that the use of moulage increased the realism of the standardized patient encounter. Sixty percent of students reported that they noticed a skin lesion but did not believe that it was part of the simulated experience.

CONCLUSIONS

Moulage increased the realism of the OSCE. This study found that the ability of a student to verbalize the evaluation of a particular body system did not necessarily mean that they adequately or correctly assessed that system upon physical examination. Implementation of an OSCE and use of moulage provided an opportunity to explicitly assess student performance related to evaluation and assessment of skin. It provided a mechanism for meaningful, formative feedback of students' performance.

Investigating the impact of moulage on simulation engagement - A systematic review

BACKGROUND

Simulation Based Education (SBE) is used as a primer for clinical education in nursing and other health professions. Participant engagement strategies and good debriefing have been identified as key for effective simulations. The environment in which the simulation is situated also plays a large role in the degree of participant engagement. Various cues are staged within simulations to enhance this engagement process. Moulage techniques are used in current-day simulation to mimic illnesses and wounds, acting as visual and tactile cues for the learner. To effectively utilise moulage in simulation, significant expense is required to train simulation staff and to purchase relevant equipment.

OBJECTIVE

Explore the use of moulage in simulation practice today and its influence on participant engagement.

DESIGN

Using a systematic process to extract papers, we reviewed the literature with a critical-realist lens.

DATA SOURCES

CINAHL Complete, ERIC, Embase, Medline, PsycINFO, SCOPUS, Web of Science, Proquest, Science Direct and SAGE.

REVIEW METHODS

10 databases were systematically reviewed using the keyword "moulage" to answer the question "How does the authenticity of moulage impact on participant engagement?". 1318 records were identified prior to exclusion criterion were applied. 10 articles were targeted for review, following exclusion for English language and publication between 2005 and 2015.

RESULTS

The resulting 10 papers were assessed for quality using the Medical Education Research Study Quality Instrument (MERSQI). The majority of papers were situated in dermatology teaching, with only one nursing paper. Study participants were both undergraduate and postgraduate. Most of the studies were undertaken at a university setting. No papers comprehensively addressed whether the authenticity of moulage influences learner engagement.

CONCLUSIONS

Results were limited, yet clearly outline a widely held assumption that moulage is essential in simulation-based education for improved realism and subsequent learner engagement. Despite this, there is no clear evidence from the literature that this is the case, suggesting that further research to explore the impact of moulage on participant engagement is warranted. A number of recommendations are made for future research.

Objective Structured Clinical Examination as an Assessment Tool for Clinical Skills in Dermatology

BACKGROUND

Objective Structured Clinical Evaluation (OSCE) is an excellent method to evaluate student's abilities, but there are no previous reports implementing it in dermatology.

OBJECTIVES

To determine the feasibility of implementation of a dermatology OSCE in the medical school.

METHODS

Five stations with standardized patients and image-based assessment were designed. A specific checklist was elaborated in each station with different items which evaluated one competency and were classified into five groups (medical history, physical examination, technical skills, case management and prevention).

RESULTS

A total of 28 students were tested. Twenty-five of them (83.3%) passed the exam globally. Concerning each group of items tested: medical interrogation had a mean score of 71.0; physical examination had a mean score of 63.0; management had a mean score of 58.0; and prevention had a mean score of 58.0 points. The highest results were obtained in interpersonal skills items with 91.8 points.

LIMITATIONS

Testing a small sample of voluntary students may hinder generalization of our study.

CONCLUSIONS

OSCE is an useful tool for assessing clinical skills in dermatology and it is possible to carry it out. Our experience enhances that medical school curriculum needs to establish OSCE as an assessment tool in dermatology.

The Skin Cancer Objective Structured Clinical Examination (SCOSCE): A multi-institutional collaboration to develop and validate a clinical skills assessment for melanoma

BACKGROUND

Assessing medical students on core skills related to melanoma detection is challenging in the absence of a well-developed instrument.

OBJECTIVE

We sought to develop an objective structured clinical examination for the detection and evaluation of melanoma among medical students.

METHODS

This was a prospective cohort analysis of student and objective rater agreement on performance of clinical skills and assessment of differences in performance across 3 schools.

RESULTS

Kappa coefficients indicated excellent agreement for 3 of 5 core skills including commenting on the presence of the moulage (k = 0.87, 95% confidence interval 0.77-0.96), obtaining a history for the moulage (k = 0.84, 95% confidence interval 0.74-0.94), and making a clinical impression (k = 0.80, 95% confidence interval 0.68-0.92). There were no differences in performance across schools with respect to 3 of 5 core skills: commenting on the presence of the moulage (P = .15), initiating a history (P = .53), and managing the suspicious lesion (P value range .07-.17). Overall, 54.2% and 44.7% of students commented on the presence of the moulage and achieved maximum performance of core skills, respectively, with no difference in performance across schools.

LIMITATIONS

Limitations include overall sample size of students and schools.

CONCLUSION

The Skin Cancer Objective Structured Clinical Examination represents a potentially important instrument to measure students' performance on the optimal step-by-step evaluation of a melanoma.

Screening for melanoma

Although melanoma is a deadly cancer that is rising in incidence, the USA does not have uniform guidelines for melanoma screening. Screening for melanoma requires no specialized equipment and has little associated morbidity. However, screening has the greatest impact when performed among patients with the highest risk for melanoma incidence and mortality. Screening lower-risk patients may result in prohibitively high costs, unnecessary biopsies of benign lesions, and decreased access to a dermatologic specialist for patients who are actually at a higher risk. We advocate targeting melanoma screening efforts toward those patients at high risk of developing and dying from melanoma, as well as toward those at-risk patients who are least likely to detect their own melanoma.