Back in 1999 I wrote an article (in Education for General Practice) entitled “Teaching dermatology in general practice : the potential of digital cameras and information technology”. How things have changed! Back then we bought a Canon digital camera with a 0.6 megapixel camera and lent it out to registrars so they could come to workshops armed with photos to illustrate the cases they presented to their peers – now we all have phones with around 12 megapixel cameras and can send pictures to specialists for an opinion.
Why did we do it? Because dermatology is so visual and it seemed good to utilise technology. Learning around real cases is more powerful than lectures and the presentations also developed their teaching skills.
Why the emphasis on dermatology? I had been involved in CPD and every needs analysis on established GPs had dermatology at the top of the list. Personally, it would probably still be the most common area in which I call in a colleague for a quick second opinion. Registrars, too, find skin problems daunting. Teaching at the undergraduate level is scant and experience in residency is patchy (no pun intended) yet skin problems comprise 10-15% of GP presentations so it is important that it is addressed in vocational training. But what is the content of these presentations and what therefore needs to be taught?
In dermatology texts, a chapter on blistering diseases might focus on pemphigus and bullous pemphigoid but we might see one or two in a lifetime. Bites, infections, allergies and burns will be encountered more often as a cause for blisters in a general practice patient. Other conditions will have an intermediate prevalence and varicella has slipped down the list. Despite the vast range of dermatological diagnoses, a previous survey of what they see in practice had shown that a dozen conditions represent three quarters of the GP caseload. Fifty per cent would be the different types of dermatitis and infections including fungal problems. A further twenty five per cent is made up of various isolated skin lesions followed by acne and psoriasis. Solar keratoses, BCCs, seborrheic keratoses and SCCs are not high on the list for registrars, reflecting their patient demographic. Do at least have a plan and rationale for what is being addressed. Dermatology is not just skin cancer (which is a large focus of CPD) but knowing how to manage this well is very relevant in Australia. The practice context is the most crucial for learning the relevant skin procedures and the quality of the practice learning environment is therefore important. Additional input from those with expertise in specific areas is invaluable but often depends on availability in non metro areas. Technology may plug these gaps in the future. Outside of training programs CPD workshops and lectures can often be recommended to supplement learning (and reinforce lifelong learning).
In the relatively short time generally allocated to formal teaching about skin problems it is pertinent to focus on the practical management of common conditions in order to instil confidence in the learner – but with a GP emphasis on a patient-centred approach (what is the psychological effect on the patient, can they afford the treatments suggested etc). However, time still needs to be given to the diagnostic strategies for approaching rarer or atypical presentations. Doctors are great at saying “come and see this rash” and it adds value to probe the learner about their reasoning as in the one minute preceptor approach http://www.practicaldoc.ca/practical-prof/teaching-nuts-bolts/one-minute-preceptor/ . It’s useful to ask them about the urgency of a particular diagnosis and remind about possible serious differential diagnoses. A little bit of revision of underlying pathology is interesting and has a place but a repeat of undergraduate learning is not always the most relevant emphasis. A visit to the chemist might be informative to see the range of lotions and potions and, in practice, useful tips can be gained from specialist letters. An audit of histopathology reports of biopsies and excisions can be informative. A lot is learnt from that GP approach of time as a diagnostic tool and issues of follow up and safety netting are integral.
The learning environment has changed and there are now lots of great internet resources (eg www.dermnetnz.org and Telederm) to which registrars can be pointed for self-directed learning. The rapidly improving technology is an irresistible focus for “innovation” so experiment with it but there is always the challenge to not forget sound educational methods such as case-based learning. It is a challenge to find approaches that are successful (so think in terms of evaluating outcomes). It is an area where teaching diagnostic strategies may compete with the universal feedback of “just lots more pictures please”. The use of images also raises the necessity to discuss ethical issues and consent.
* NB consent was obtained (from me!)for all photos (of bits of me) in this post : ant bites; reaction to band-aid; mild golfer’s vasculitis