Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(2):e2023093 1 Dermoscopy in Selected Latin American Countries: A Preliminary Look into Current Trends and Future Opportunities Among Dermatology Residency Programs Mariana Perez1, Natalie M. Williams1, Alejandra M. Avila2, Renato Bakos3, Flavia Bittencourt4, Blanca Carlos-Ortega5, Laura Garzona6, Alejandra Larre-Borges7, Cristian Naverrete-Dechent8, Victor Pinos9,10, Gabriel Salerni11, Jackie Shum-Tien12,13, Natalia Jaimes1,14 1 Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida 2 Department of Dermatology, Universidad Pontificia Bolivariana, Medellin, Colombia 3 Department of Dermatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil 4 Universidade Federal de Minas Gerais, Belo Horizonte, Brazil 5 Consultorio privado, Hospital Durango, Roma Norte, Ciudad de México, México 6 Hospital Clínica Bíblica, San José, Costa Rica 7 Hospital Británico, Montevideo Uruguay. Former Hospital de Clínicas UDELAR, Montevideo, Uruguay 8 Melanoma and Skin Cancer Unit, Department of Dermatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile 9 Department of Dermatology, Hospital Metropolitano, Quito, Ecuador 10 Universidad Central del Ecuador, Quito, Ecuador 11 Department of Dermatology, Hospital Provincial del Centenario de Rosario, Universidad Nacional de Rosario, Argentina 12 Clínica Dermatológica Arosemena, Ciudad de Panamá, Panamá 13 Clínica Mediskin, Ciudad de Panamá, Panamá 14 Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida Key words: dermoscopy, dermatology residency, Latin America, medical education Citation: Perez M, Williams NM, Avila AM, et al. Dermoscopy in Selected Latin American Countries: A Preliminary Look into Current Trends and Future Opportunities among Dermatology Residency Programs. Dermatol Pract Concept. 2023;13(2):e2023093. DOI: https://doi.org/10.5826/dpc.1302a93 Accepted: October 19, 2022; Published: April 2023 Copyright: ©2023 Perez et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Natalia Jaimes, MD, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, Sylvester Comprehensive Cancer Center, Miami, Florida. University of Miami Miller School of Medicine, Dermatology Research Clinic 1600 NW 10th Ave. RSMB 2023A, Miami, FL 33136 Phone: 305-243-6735 E-mail: njaimes@med.miami.edu 2 Original Article | Dermatol Pract Concept. 2023;13(2):e2023093 Introduction Skin cancer continues to be a public health burden glob- ally. Early detection remains the most cost-effective means of improving prognosis and reducing morbidity, mortality, and health-related costs [1-3]. Dermoscopy is a non-invasive, in-vivo imaging technique that allows for the visualization of subsurface structures of the skin that are otherwise not visible to the naked eye [4,5]. Dermoscopy increases the di- agnostic accuracy for skin cancer, including melanoma, by up to 50% compared to the naked eye examination alone; however, this is contingent on adequate training [6,7]. Although dermoscopy has demonstrated its value in early detection of skin cancer, it is not uniformly taught to residents worldwide. Studies show that dermoscopy use among dermatology residents in Europe and Australia is on the rise [8-10]. Similarly, studies assessing the use of dermos- copy among dermatology residents in the United States (US) demonstrate that the majority of trainees are receiving di- dactic lectures and clinical training on the use of this tool in differentiating benign (eg nevi, seborrheic keratosis) from malignant lesions (eg melanoma, basal cell carcinoma, squa- mous cell carcinoma) [11]. Nevertheless, dermoscopy train- ing continues to have one of the lowest satisfaction rates among residency programs [12,13]. Objectives The use of dermoscopy among dermatology residents in Latin America has not been explored. The objective of this study was to better understand current dermoscopy training among dermatology residency programs in Latin America (eg types of training modalities, training modalities con- sidered to be most effective by residents, preferred training modalities by residents, and the diseases/pathologies taught) as a first step toward the creation and implementation of educational and training initiatives. Methods We performed a cross-sectional study using an electronic anonymous survey. Only the chief residents of selected Latin American dermatology residency programs from Argentina, Brazil, Colombia, Costa Rica, Chile, Ecuador, Guatemala, Mexico, Panama, and Uruguay were invited to participate in the study. Only chief residents were invited to answer the survey, since they would be familiar with their curric- ulum and the educational practices of their institution. The survey was distributed via e-mail between March and May of 2021, and participation was voluntary. The survey was available in English, Spanish, and Portuguese on the online Introduction: Skin cancer remains a global public health burden. Dermoscopy is a useful technique that aids in early detection and increases diagnostic accuracy with adequate training. However, der- moscopy is not uniformly taught to residents worldwide. Dermoscopy training in Latin American dermatology residency programs has not been explored. Objectives: To assess current dermoscopy training among dermatology residency programs in Latin America (eg training modalities, preferred/most effective modalities per residents, diseases/pathologies taught). Methods: Cross-sectional survey distributed via e-mail between March and May 2021. Chief resi- dents from Argentina, Brazil, Colombia, Costa Rica, Chile, Ecuador, Guatemala, Mexico, Panama, and Uruguay were invited to participate. Results: 81 chief residents completed the questionnaire (81/126, 64.2%). Seventy-two percent of pro- grams had an established dermoscopy curriculum, with dedicated hours of training varying greatly by program. Institutions commonly utilized sessions with “unknown” dermoscopy images and direct teaching by experts in the clinical setting as supplements to lectures, also described by residents as most effective. The most commonly taught methods included pattern analysis (74.1%), the two-step algorithm (61.7%), and the ABCD rule (59.3%). Almost all respondents reported desiring additional training during residency and believe that dermoscopy training should be a requirement to graduate from residency. Conclusions: This study highlights a preliminary look into current landscape in dermoscopy training among selected Latin American dermatology residency programs, demonstrating room for improve- ment and standardization in dermoscopic education and training. Our results serve as a baseline refer- ence and provide valuable information to guide future educational initiatives incorporating successful teaching strategies (eg. spaced education/repetition, flipped classroom model) used in dermatology and other fields. ABSTRACT Original Article | Dermatol Pract Concept. 2023;13(2):e2023093 3 Qualtrics® platform (Qualtrics, LLC, SAP America Inc. company). Multiple submissions were prevented by use of Qualtrics® software. Participating countries were selected by convenience sampling, based on availability of represen- tative contacts. Based on the number of dermatology resi- dency programs in each country, the estimated sample size was 126. Summary statistics and descriptive frequencies were collected using Microsoft Excel™. The study was approved by the Institutional Review Board at University of Miami. Results The response rate was 64.2% (81/126). Overall, 81 chief residents from dermatology residency programs in Brazil, Argentina, Colombia, Mexico, Chile, Ecuador, Guatemala, Panama, Uruguay, and Costa Rica completed the question- naire (Table 1). Almost all respondents hailed from urban training programs. Half of the participants (54%) reported receiving a dermatoscope from their institution (Table 2). The hybrid Table 1. Participant demographics including location and country of residency. Demographics N (%) All 81 Sex Female 64 (79.0) Male 16 (19.8) Other 1 (1.2) Year of dermatology residency 1st 5 (6.2) 2nd 7 (8.6) 3rd 56 (69.1) Other 13 (16.0) Location Urban 78 (96.3) Suburban 2 (2.5) Rural 1 (1.2) Country Argentina 17 (21.0) Brazil 29 (35.8) Chile 4 (4.9) Colombia 13 (16.0) Costa Rica 1 (1.2) Ecuador 2 (2.5) Guatemala 2 (2.5) Mexico 10 (12.4) Panama 2 (2.5) Uruguay 1 (1.2) Table 2. Participant-reported current dermoscopy use. Current dermoscopy use N (%) All 81 Daily dermatoscope use Yes 80 (98.8) No 1 (1.2) Dermatoscope typea Handheld dermatoscope, hybrid (polarized and non- polarized light) 69 (85.1) Handheld dermatoscope adaptable to photo camera or smartphone 30 (37.0) Specific device for digital dermoscopy 10 (12.3) Handheld dermatoscope, only polarized light 4 (4.9) Dermatoscope provided by institution Yes 44 (54.3) No 37 (45.7) Situations for dermatoscope usea To aid in melanoma detection 81 (100.0) To aid in basal cell carcinoma detection 81 (100.0 To aid in squamous cell carcinoma detection 81 (100.0) To aid in actinic keratosis detection 73 (90.1) To aid in seborrheic keratosis detection 71 (87.7) To aid in vascular neoplasm detection 74 (91.4) To aid in diagnosing infectious skin conditions 56 (69.1) To aid in differentiating cutaneous tumors from inflammatory dermatoses 70 (86.4) To aid in hair diseases 79 (97.5) To aid in nail diseases 68 (84.0) Other: mucosal lesions, guided biopsy 5 (6.2) aMultiple response (ie “select all that apply”). handheld dermatoscope (ie polarized and non-polarized light) was the most commonly used type of dermatoscope. All participants reported using a dermatoscope to aid in the detection of malignant tumoral pathologies such as mela- noma, basal cell carcinoma, and squamous cell carcinoma. 4 Original Article | Dermatol Pract Concept. 2023;13(2):e2023093 not all of them had a formal training program. Specifically, 72% reported an established dermoscopy training curricu- lum as part of the residency program, and hours of training varied greatly by institution (Table 3). Dermoscopy lectures frequently covered topics such as differentiation of nevi from melanoma, non-melanoma malignancies, benign lesions in- cluding seborrheic keratoses; facial lesions, acral lesions, and hair dermoscopy. Less commonly covered topics in- cluded mucosal lesions, nail dermoscopy, and inflammatory A large majority of participants also reported using derma- toscopes to assist in the diagnosis of hair diseases (97.5%), actinic keratoses (90.1%), vascular neoplasms (91.4%), seborrheic keratoses (87.7%), inflammatory dermatoses (86.4%), nail diseases (84.0%), and infectious skin condi- tions (69.1%). Other cited uses included guided biopsies and mucosal lesions. Although almost all participants (99%) reported using a dermatoscope in their everyday clinical practice (Table 2), Current dermoscopy training N (%) Dermoscopy training is part of residency curriculum Yes 58 (71.6) No 23 (28.4) Hours of training per academic year 0 9 (11.1) 1-5 9 (11.1) 5-10 10 (12.4) 10-20 15 (18.5) 20-30 9 (11.1) >30 29 (35.8) Topics covered in dermoscopy lecturesa Differentiation of nevi from melanoma 73 (90.1) Non-melanoma malignancies (ie basal cell carcinoma, squamous cell carcinoma) 71 (87.7) Benign lesions (ie seborrheic keratoses, angiomas) 64 (79.0) Skin infections 30 (37.0) Inflammatory condition 32 (39.5) Hair dermoscopy 53 (65.4) Nail dermoscopy 39 (48.1) Mucosae 27 (33.3) Facial lesions 54 (66.7) Acral Lesions 60 (74.0) Other 4 (4.9) N/A (do not receive dermoscopy lectures) 8 (9.9) Dermoscopy sessions using images (aka “Kodachromes” or “unknowns”) provided by institution Yes 51 (63.0) No 29 (35.8) No answer 1 (1.2) Methods taught by institutiona ABCD rule of dermoscopy 48 (59.3) Menzies method 28 (34.6) Current dermoscopy training N (%) Pattern analysis or revised pattern analysis 60 (74.1) 7-point checklist 29 (35.8) CASH algorithm (Colors, Architecture, Symmetry, Homogeneity) 10 (12.3) Two-step algorithm 50 (61.7) TADA (Triage Amalgamated Dermoscopy Algorithm) 8 (9.9.) None 5 (6.2) Other 3 (3.7) No answer available 1 (1.2) Use of other dermoscopy training resources No 20 (24.7) No answer available 1 (1.2) Yes 60 (74.1) If answer to “use of other dermoscopy training resources” is yes, What are other resources used?a Online quizzes 32/60 (53.3) Online lectures 41/60 (68.3) Textbooks 53/60 (88.3) Online text 43/60 (71.7) Online forums/discussion groups 27/60 (45.0) Other 4/60 (6.7) Training by dermoscopy expert No 35 (43.2) No answer available 2 (2.5) Yes 44 (54.3) Hours per month spent with dermoscopy expert in clinical setting 1-5 15/44 (34.1) 5-10 7/44 (15.9) 10-20 10/44 (22.7) 20-30 2/44 (4.5) >30 8/44 (18.2) No answer available 2/44 (4.5) Table 3. Participant-reported current dermoscopy training. aMultiple response (ie “select all that apply”). Original Article | Dermatol Pract Concept. 2023;13(2):e2023093 5 conditions. More than half of programs employed case-based sessions with dermoscopy images (63%) and direct teach- ing by a dermoscopy expert in the clinical setting (54.3%). Pattern analysis was the most commonly reported method (74.1%), followed by the two-step algorithm (61.7%) and the ABCD rule (59.3%). In addition to institutional lectures, sessions using dermoscopy images and expert training, 74% of respondents reported utilizing other dermoscopy training resources, such as textbooks and online material. Almost all chief residents reported desiring additional training during residency (91.3%) and believe that dermos- copy training should be a requirement to graduate from residency (93.8%) (Table 4). Although the ideal training duration varied greatly among respondents, sessions using Table 4. Participant preferences for dermoscopy training. Dermoscopy Training Preferences N (%) Additional dermoscopy training desired in residency Yes 74 (91.3) No 3 (3.7) No answer available 4 (4.9) Dermoscopy training should be required to graduate residency Yes 76 (93.8) No 1 (1.2) No answer available 4 (4.9) Most effective method of traininga Sessions with dermoscopy images/cases (aka unknowns /Kodachromes) 66 (81.5) Didactic lectures 57 (70.3) Hands-on training with expert 66 (81.5) Independent learning (online, textbook) 32 (39.5) Other 3 (3.7) Ideal duration of hands-on training Hours (mean ± sd) (18.5 ± 40.2) Days (mean ± sd) (12.7 ± 21.7) Ideal duration of in-person course Hours (mean ± sd) (12.3 ± 11.6) Days (mean ± sd) (10.5 ± 13.3) Ideal duration of online dermoscopy video Hours (mean ± sd) (5.7 ± 11.2) Sessions (mean ± sd) (11.8 ± 13.3) Sd = standard deviation.aMultiple response (ie “select all that apply”). dermoscopy images, hands-on training with experts, and di- dactic lectures were regarded as effective teaching methods, followed by independent learning. Conclusions Dermoscopy has proved to be a valuable instrument in the early detection of skin cancer, thus reducing morbidity, mor- tality, and health-related costs, while improving patient care and quality of life. The efficacy and thereby utility of this device, however, depends on adequate training [6,7]. Data shows that at least 62%-84% of dermatology residents in the US receive training during residency [13,14]. Residents in Europe have not been specifically studied, but surveys of practicing dermatologists show that at least 32%-42% re- ceived training during residency [15]. In Australia, dermos- copy education is a core part of residency training, with all residents receiving formal didactic training and most pro- grams providing dermatoscopes for resident use [16]. In our study, almost all surveyed residents from Latin American der- matology programs reported using a dermatoscope in their everyday practice in a variety of clinical contexts, but only half reported receiving a dermatoscope from their training program. Dermoscopy was formally included in the didac- tic curriculum of more than two thirds of programs (72%), with lectures spanning a broad range of topics, including differentiation of nevi from melanoma and non-melanoma malignancies. Given the different modalities for teaching dermoscopy and associated learning preferences, in addition to under- standing the current landscape of dermoscopy use among trainees in a given region, it is also important to understand the modalities taught, the effectiveness of these strategies, and the trainee learning preferences before embarking on larger dermoscopy education initiatives. Among the surveyed residents, pattern-analysis was taught in 74% of programs, followed by the two-step algorithm (61.7%) and the ABCD rule (59.3%). Institutions employed the use of lectures, ses- sions with dermoscopy images, and expert training, though 74% of residents reported utilizing supplemental training resources such as textbooks and online content. Importantly, almost all residents believed dermoscopy training should be a requirement for graduation and desired additional training than they were currently receiving. There is limited evidence in the literature regarding specific approaches to dermoscopic education and their long-term efficacy. At one US institution, a flipped classroom approach for dermoscopic education (students review pre- paratory instructional content outside the classroom and participate in faculty-guided active learning within the class- room) was suggested to improve satisfaction and learning by promoting accountability, though data was mostly anecdotal 6 Original Article | Dermatol Pract Concept. 2023;13(2):e2023093 [17]. In France, a spaced-education internet dermoscopy module (involving question-based educational content with spaced repetition as well as an adaptive rescheduling al- gorithm) combined with in-class training implemented in dermatologists and senior residents led to improved perfor- mance and learning retention compared to in-class training alone [18]. In Belgium, a two-stage training course taught by experts (consisting of a 3-hour basic course followed by a 3-hour advanced course six weeks later) improved diag- nostic accuracy in residents even more than practicing der- matologists and showed sustained effects in learning [19]. These and other teaching strategies have also been employed with success in various medical specialties, including online spaced-education in urology and cardiology, and mobile app technology with spaced repetition in otolaryngology [20-22]. Limitations of the study include a low response rate (64%), which could represent lack of interest in the study or in dermoscopy, but can be expected with anonymous surveys. Further, the evaluation of dermoscopic education practices of each institution was based on responses from a single resident (ie chief resident) and therefore may repre- sent only a single opinion. In addition, the length of training programs is not standardized between countries and may impact the amount of dermoscopy training provided. Last, the convenience sampling (ie surveying chief residents from countries selected based on available representative contacts) impedes generalization of survey results and may result in biased data due to underrepresentation of the population. Of note, the total number of residents of all years represented by the survey amounts to more than 1,300; though specific in- formation regarding the precise number of residents in each program and each country was not available for all coun- tries. Therefore, these results can be considered preliminary and may be improved upon with a larger and more represen- tative sample. 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