Dermatology: Practical and Conceptual 38 Research | Dermatol Pract Concept 2017;7(3):8 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Background Dermoscopy is an in vivo, non-invasive technique utilized when examining the skin. A dermatoscope is a handheld device, which allows illumination and 10-14 times magnifi- cation of the area being analyzed. The dermatoscope allows clinicians to not only magnify skin lesions, but also helps visu- alize subsurface features. Dermoscopy is effective in evalua- tion of both melanocytic and non-melanocytic skin lesions, as well as rashes and infectious dermatoses [4-7]. Dermoscopy improves the diagnostic accuracy for melanoma detection by up to 50% in comparison to unaided visual inspection, but only in examiners experienced with the use of dermoscopy [6,8]. For some non-melanocytic neoplasms, visualization of Analysis of dermoscopy teaching modalities in United States dermatology residency programs Yun An Chen1, Joanne Rill2, Elizabeth V. Seiverling3 1 Penn State College of Medicine, Hershey, PA, USA 2 Department of Dermatology, Penn State Hershey Medical Center, Hershey, PA, USA 3 Department of Dermatology & Department of Family and Community Medicine, Penn State Hershey Medical Center, Hershey, PA, USA Key words: dermoscopy training, dermatology residency, medical education Citation: Chen YA, Rill J, Seiverling EV. Analysis of dermoscopy teaching modalities in United States dermatology residency programs. Dermatol Pract Concept 2017;7(3):8. DOI: https://doi.org/10.5826/dpc.070308 Received: March 25, 2017; Accepted: May 15, 2017; Published: July 31, 2017 Copyright: ©2017 Chen et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: Elizabeth V. Seiverling, MD, Assistant Professor of Dermatology & Family and Community Medicine, Department of Dermatology, Penn State Hershey medical Center, Hershey, PA, USA. Email: eseiverling@pennstatehealth.psu.edu The use of dermoscopy in dermatology residency programs is on the rise (over 94% of chief residents reported using a dermatoscope in 2013) [1]. Despite increased use (100% of our surveyed residents reported using a dermatoscope), dermoscopy training is one of the aspects of United States dermatol- ogy residency training with the lowest resident satisfaction [2]. Diagnostic accuracy with dermoscopy is highly correlated with the amount of dermoscopy training the user has undertaken [3]. We sought to analyze dermoscopy use in US Dermatology residencies to better understand resident dermoscopy utilization and teaching modalities. We found residents learn dermoscopy via multiple teaching mo- dalities. The most commonly reported dermoscopy teaching modality was didactic lectures, followed by time in clinic with a dermoscopy expert. Of the different teaching modalities, time in the clinic with a dermoscopy expert was reported to be the most effective. We also found that the majority of dermatology residents receive didactic dermoscopy lectures and clinical dermoscopy training on the differentiation of benign nevi from melanoma using dermoscopy, the detection of basal cell carcinoma, and the identification of seborrheic keratosis. However, few residents receive dedicated training on the use of dermoscopy in the evaluation of inflammatory dermatoses and skin infections despite dermos- copy’s demonstrated value in both areas [4-7]. ABSTRACT Research | Dermatol Pract Concept 2017;7(3):8 39 curriculum, (7) the analytical methods used when performing dermoscopy, and (8) opinion regarding inclusion of dermos- copy as an Accredited Council for Graduate Medical Educa- tion (ACGME) dermatology core competency (Table 1). Descriptive statistics, such as frequency distribution and percentages, were calculated to quantify the survey responses. Results Study Participants Forty dermatology residents from 16 different US dermatol- ogy residency programs completed the survey. Seventy-seven different US dermatology residency programs were asked to participate, thereby yielding a 21% representation rate of all the US dermatology residency programs as identified by APD as being receptive to receiving surveys. Use of dermoscopy in resident clinical practice All surveyed residents reported using dermoscopy in their clinical practice. The top three reported reasons for using dermoscopy were: (1) helps detect melanoma (97%), (2) helps detect basal cell carcinoma, squamous cell carcinoma, and/ or actinic keratoses (87%), and (3) leads to fewer biopsies and reduces patient anxiety (79%). The majority of respon- dents believed that dermoscopy is useful in: (1) diagnosis of melanoma (85%), (2) evaluation of patients with clinically atypical/dysplastic nevi (77%), and (3) diagnosis of basal cell carcinoma (72%). While the majority of respondents believed that dermoscopy was not useful in: (1) evaluation of inflammatory dermatoses (85%), (2) diagnosis of actinic keratosis (77%), (3) evaluation of skin infections (74%), and (4) diagnosis of squamous cell carcinoma (72%). Dermoscopy Education and Training The most commonly reported dermoscopy teaching modality was didactic lecture: 88% of respondents reported having dermoscopy lectures as part of their residency curriculum. An average of two hours of dermoscopy lectures per academic year were reported. The most common topics discussed in lec- tures were: (1) differentiation of benign nevi from melanoma, (2) detection of basal cell carcinoma, and (3) detection of seborrheic keratosis, angiomas, or angiokeratomas. Lectures on the use of dermoscopy in the evaluation of inflammatory dermatoses and skin infections were rare. Dermoscopy teach- ing also occurred in a clinical setting: 59% of the residents reported working with a dermoscopy expert in clinic. The average time spent with the expert was four hours per week. Similarly to dermoscopy lectures, inflammatory dermatoses and skin infections were not topics commonly addressed in clinical dermoscopy training, while differentiation of benign nevi from melanoma and detection of basal cell carcinoma were frequently taught (Figure 1). dermatoscopic structures is 100% specific (i.e. spoke wheels seen in pigmented basal cell carcinoma) [9]. Additionally, there are dermatoscopic structures with a very high specificity for psoriasis [10]. Despite its demonstrated value, dermoscopy is not uni- formly being taught to dermatology residents. In 2002, 50% of US dermatology residents were using dermoscopy for melanocytic lesion evaluation [11]. By 2011, 88% of chief residents in US dermatology programs were using dermos- copy to aid in melanoma detection [12], and by 2013, 94% of chief residents were doing so [1]. Despite the increase in use, dermoscopy training was one of the aspects of US dermatol- ogy residency training with the lowest resident satisfaction [2]. Furthermore, while there is an abundance of literature addressing the use and education of dermoscopy in the diag- nosis of melanocytic lesions, to our knowledge, there has been no published study investigating whether dermoscopy is being utilized and taught in US dermatology residency programs for evaluation of non-melanocytic neoplasms, skin infections, or inflammatory dermatoses. Objective The goal of this study is to analyze current dermoscopy training modalities in US dermatology residency programs and to determine if dermoscopy is being taught for purposes other than evaluation of melanocytic growths, such as non- melanocytic neoplasms, skin infections, and inflammatory dermatoses. Methods Institutional Review Board approval was obtained from the Penn State Hershey Medical Center (STUDY00002833). Anonymous surveys were sent to all US dermatology resi- dency program directors as identified by the Association of Professors of Dermatology (APD) listserv on August 17, 2015. The survey was administered through SurveyMon- key® and dispensed to dermatology residency program directors, who were asked to dispense the survey link to all the dermatology residents at their institution, regardless of post-graduate year. The survey link was resent to program directors on three separate occasions to elicit more responses. The survey was closed on October 1, 2015. Informed consent was obtained by survey responder’s acceptance of participa- tion as elicited on the cover letter of the survey. Questions regarding dermoscopy training within the responder’s current residency program addressed: (1) quantity of dermoscopy education and training, (2) dermoscopy teaching modalities, (3) topics addressed in dermoscopy lectures, (4) aspects of clinical dermoscopy training, (5) effectiveness of dermoscopy teaching modalities, (6) deficiencies within the dermoscopy 40 Research | Dermatol Pract Concept 2017;7(3):8 TABLE 1. Survey questions and possible responses. [Copyright: ©2017 Chen et al.] Do you use dermoscopy in your clinical practice? 4 Yes 4 No What are your reasons for dermoscopy use? (Check all that apply) 4 Helps detect melanoma 4 Helps detect BCC, SCC, and/or AK 4 Helps differentiate between inflammatory dermatoses and skin growths 4 Helps with evaluation of infectious skin conditions (i.e. scabies, molluscum) 4 Leads to fewer biopsies 4 Reduces cost of care through early diagnosis 4 Reduces patient anxiety 4 Documentation for medical liability Do you believe dermoscopy is useful in: (Check all that apply) 4 Diagnosis of melanoma 4 Patients with clinically atypical/dysplastic nevi 4 Diagnosis of BCC 4 Diagnosis of SCC 4 Diagnosis of AK 4 Evaluation of inflammatory dermatoses 4 Evaluation of skin infections Are dermoscopy lectures part of your resident education curriculum? 4 Yes 4 No Do your dermoscopy lectures address: (Check all that apply) 4 Differentiation of benign nevi from melanoma 4 Detection of BCC 4 Detection of SCC 4 Detection of AK 4 Detection of SK 4 Detection of angiomas or angiokeratomas 4 Evaluation of inflammatory dermatoses 4 Evaluation of skin infections Approximately how many hours of dermoscopy lectures does your department provide during an academic year? (Please specify) Do you have dermoscopy “unknown” sessions? 4 Yes 4 No Do you utilize other dermoscopy training resources? 4 Yes 4 No What are these other resources? (Check all that apply) 4 Online dermatology lectures 4 Online dermoscopy quizzes 4 Dermatology textbooks Have you attended a dermoscopy conference at a regional or national dermatology meeting? 4 Yes 4 No (Continued next page) Research | Dermatol Pract Concept 2017;7(3):8 41 Did your institution/residency program provide you with a dermatoscope? 4 Yes 4 No What analytic method(s) do you use when performing dermoscopy? (Check all that applies) 4 Pattern analysis or revised pattern analysis 4 ABCD Rule of Dermoscopy 4 Menzies method 4 7-point score or checklist 4 CASH algorithm (i.e. Colors Architecture Symmetry Homogeneity) Do you work with a dermoscopy expert in a clinical setting? 4 Yes 4 No Approximately how many hours per week do you work with a dermoscopy expert in a clinical setting? (Please specify) In a clinical setting, are you taught how to use dermoscopy for: (Check all that apply) 4 Differentiation of benign nevi from melanoma 4 Detection of BCC 4 Detection of SCC 4 Detection of AK 4 Detection of SK 4 Detection of angiomas or angiokeratomas 4 Evaluation of inflammatory dermatoses 4 Evaluation of skin infections Which method of teaching dermoscopy do you find most effective? (Check all that applies) 4 Structured lectures 4 “Unknown” sessions 4 Time in clinic with a dermoscopy expert Are you satisfied with the dermoscopy education you receive as part of your residency program? 4 Yes 4 No Do you feel dermoscopy training should be an ACGME (Accreditation Council for Graduate Medical Education) dermatology core competency? 4 Yes 4 No *BCC=basal cell carcinoma, SCC=squamous cell carcinoma, AK=actinic keratosis, SK=seborrheic keratoses TABLE 1. Survey questions and possible responses. (continued) Other reported forms of dermoscopy education were: attending dermoscopy conferences (15% of respondents) and dermoscopy “unknown sessions (23% of respondents). Fifty- four percent of respondents supplement with other dermos- copy training resources, with dermatology textbooks being the most commonly utilized other resource. Of the different dermoscopy teaching modalities, time in clinic with a dermos- copy expert was reported to be the most effective modality for learning dermoscopy (72% of respondents reported this method to be effective), followed by structured lectures (61%), and “unknown” sessions (36%). Eighty-nine percent of the residents were taught pattern analysis, which has the highest diagnostic accuracy for detecting melanoma [8], as the main analytical approach when using dermatoscopes, followed by 53% who were also taught the ABCD Rule of Dermoscopy. Forty-two percent of residents felt dissatisfied with the der- moscopy training they receive in their residency program. Lastly, the majority (78%) of the respondents felt dermoscopy training should be an ACGME dermatology core competency. Conclusions Dermoscopy is widely used in US dermatology residency programs (100% dermoscopy use in our study). In 2010, 42 Research | Dermatol Pract Concept 2017;7(3):8 found in dermoscopy training in the clinical setting (with a dermoscopy expert): 97% of residents reported being taught how to differentiate benign nevi from melanoma with a der- matoscope, but only 31% and 11% were taught how to use dermoscopy in the evaluation of skin infections and inflam- matory dermatoses, respectively (Figure 1). Lack of training in the full capacity of dermoscopy might account for the following: while the majority (85%) of our participants considered dermoscopy useful in the diagnosis of melanoma, the majority (85%) did not consider dermoscopy to be useful in the evaluation of inflammatory dermatoses, diagnosis of actinic keratosis (77%), evaluation of skin infections (74%), and diagnosis of squamous cell carcinoma (72%). The benefits of dermoscopy for detection of mela- noma are well documented; however, there is an expanding body of literature supporting dermoscopy use in evaluating non-melanocytic tumors, skin infections, and inflammatory dermatoses [5,7,9,10]. An increased number of hours of structured dermoscopy lectures and increased clinic time with a dermoscopy expert may allow for more dermoscopy topics to be addressed in resident education. Additionally, inclusion of dermoscopy as an ACGME dermatology core competency, which 78% of the surveyed residents favored, might allow for standardization of resident dermoscopy education. In summary, resident satisfaction with their dermoscopy training is low and resident dermoscopy teaching is limited mostly to the evaluation of skin neoplasms, specifically mela- noma and basal cell carcinoma. Increased resident clinic time with a dermoscopy expert, more structured dermoscopy lec- tures, and inclusion of dermoscopy as a dermatology ACGME core competency has the potential to increase dermoscopy despite high rates of use by US dermatology residents, only 48% of practicing US dermatologists were using dermoscopy. The main reason reported by the practicing US dermatologists for not using a dermatoscope was lack of training [13]. Euro- pean literature has shown that resident dermoscopy training is highly correlated with dermoscopy use for melanoma detection [14]. Little is published on European dermoscopy teaching modalities for residents. In our US-based study, we found that residents learn dermoscopy through a variety of teaching modalities. Of these, the most common dermoscopy teaching modality is didactic lecture, followed by clinic time with a dermoscopy expert. Time in clinic with a dedicated dermoscopy expert was reported to be the most effective way residents learn dermoscopy. However, only 59% of the residents in our study had the opportunity to work with a der- moscopy expert in a clinical setting. Prior research supports this finding: dedicated time in clinic with a “pigmented lesion specialist” is one of the most effective ways to learn dermos- copy [1]. Therefore, program directors should strive to have residents spend more time in clinic with a dermoscopy expert. Structured lectures were reported to be the second most effective modality for learning dermoscopy. While 88% of residents in our study reported having formal dermoscopy lectures, making it the most commonly reported modality for learning dermoscopy, the residents only receive an aver- age of two hours of dermoscopy lectures per year. Of the residents who had dermoscopy lectures, all of them received lectures addressing dermoscopy in the differentiation of benign nevi from melanoma, but only 27% and 18% received lectures on using dermoscopy to evaluate skin infections and inflammatory dermatoses, respectively. The same pattern was Figure 1. Dermoscopy topics addressed. [Copyright: ©2017 Chen et al. ] Research | Dermatol Pract Concept 2017;7(3):8 43 5. Dupuy A, Dehen L, Bourrat E, Lacroix C, et al. Accuracy of stan- dard dermoscopy for diagnosing scabies. J Am Acad Dermatol. 2007;56(1):53-62. 6. Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accu- racy of dermoscopy. Lancet Oncol. 2002;3(3):159-165. 7. Lacarrubba F, Verzi AE, Dinotta F, et al. Dermatoscopy in inflam- matory and infectious skin disorders. G Ital Dermatol Venereol. 2015;50(5):521-531. 8. Vestergaard ME, Macaskill P, Holt PE, Menzies SW. Dermoscopy compared with naked eye examination for the diagnosis of pri- mary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol. 2008;159(3):669-676. 9. Popadic M. Statstical Evaluation of Dermoscopic Features in Basal Cell Carcinomas. Dermatologic Surgery. 2014;40(7):718- 724. 10. Pan Y, Chamberlain AJ, Bailey M, et al. Dermatoscopy aids in the diagnosis of the solitary red scaly patch or plaque-features distinguishing superficial basal cell carcinoma, intraepidermal carcinoma, and psoriasis. J Am Acad Dermatol. 2008;59(2):268- 274. 11. Nehal KS, Oliveria SA, Marghoob AA, et al. Use of and beliefs about dermoscopy in the management of patients with pigmented lesions: a survey of dermatology residency programmes in the United States. Melanoma Res. 2002;12(6):601-605. 12. Terushkin V, Oliveria SA, Marghoob AA, et al. Use of and beliefs about total body photography and dermatoscopy among US dermatology training programs: an update. J Am Acad Dermatol. 2010;62(5):794-803. 13. Engasser HC, Warshaw EM. Dermatoscopy use by US dermatolo- gists: a cross- sectional survey. J Am Acad Dermatol. 2010;63(3): 412-419, 419.e1-2. 14. Forsea AM, Tschandl P, Del Marmol V, et al. Factors driving the use of dermoscopy in Europe: a pan-European survey. Br J Der- matol. 2016;175(6):1329-1337. use for non-melanocytic conditions, including inflammatory dermatoses and skin infections, and increase resident satisfac- tion with their dermoscopy training. Limitations Our study was limited by our number of responses: this data represents 21% of the US dermatology residency programs as identified by APD as being receptive to receiving surveys. We used the APD listserv to identify program directors and asked the program directors to distribute the survey to their resi- dents. Distribution of the survey using a different modality, targeting individual residents as opposed to program direc- tors, may have allowed for inclusion of more US dermatology residents and programs. References 1. Wu TP, Newlove T, Smith L, et al. The importance of dedicated dermoscopy training during residency: a survey of US dermatol- ogy chief residents. J Am Acad Dermatol. 2013;68(6): 1000-1005. 2. Freeman SR, Greene RE, Kimball AB, et al. US dermatology residents’ satisfaction with training and mentoring: survey results from the 2005 and 2006 Las Vegas Dermatology Seminars. Arch Dermatol. 2008;144(7):896-900. 3. Bafounta ML, Beauchet A, Aegerter P, Saiag P. Is dermoscopy (epi- luminescence microscopy) useful for the diagnosis of melanoma? Results of a meta-analysis using techniques adapted to the evalu- ation of diagnostic tests. Arch Dermatol. 2001;137:1343–1350. 4. Errichetti E, Lacarrubba F, Micali G, et al. Differentiation of pity- riasis lichenoides chronica from guttate psoriasis by dermoscopy. Clin Exper Dermatol. 2015;40:804-806.