A Clinical Aid for Detecting Skin Cancer: The Triage Amalgamated Dermoscopic Algorithm (TADA).

PURPOSE: Family physicians (FPs) frequently evaluate skin lesions but may not have the necessary training to accurately and confidently identify lesions that require skin biopsy or specialist referral. We evaluated the diagnostic performance of a new, simplified dermoscopy algorithm for skin cancer detection. METHODS: In this cross-sectional, observation study, attendees of a dermoscopy course evaluated 50 polarized dermoscopy images of skin lesions (27 malignant and 23 benign) using the Triage Amalgamated Dermoscopic Algorithm (TADA). The dermoscopic criteria of TADA include architectural disorder (ie, disorganized or asymmetric distribution of colors and/or structures), starburst pattern, blue-black or gray color, white structures, negative network, ulcer, and vessels. The study occurred after 1 day of basic dermoscopy training. Clinical information related to palpation (ie, firm, dimpling) was provided when relevant. RESULTS: Of 200 course attendees, 120 (60%) participated in the study. Participants included 64 (53.3%) dermatologists and 41 (34.2%) primary care physicians, 19 (46.3%) of whom were FPs. Fifty-two (43%) individuals had no previous dermoscopy training. Overall, the sensitivity and specificity of TADA for malignant skin lesions was 94.8% and 72.3%, respectively. Previous dermoscopy training and years of dermoscopy experience were not associated with diagnostic sensitivity (P = .13 and P = .05, respectively) or specificity (P = .36 and P = .21, respectively). Specialty type was not associated with sensitivity (P = .37) but dermatologists had a higher specificity than nondermatologists (79% v. 72%, P = .008). CONCLUSIONS: After basic instruction, TADA may be a useful dermoscopy algorithm for FPs who examine skin lesions as it has a high sensitivity for detecting skin cancer.

Health, homelessness, and poverty. A study of clinic users.

When seeking medical care, homeless persons often turn to health centers that were designed to treat the poor who have homes. To provide for effective medical care, personnel in such facilities need to know how the health care needs of the homeless are different from those of other clinic users. To compare the physical health of these two groups, we conducted a health survey and screening physical examination of 464 patients who attended the general adult and homeless clinic sessions of one of the main neighborhood health centers in Los Angeles County, California. As compared with the poor who have homes, homeless persons were more likely to have dermatological problems (32% vs 21%), functional limitations (median, 2 vs 0 per person), seizures (14% vs 6%), chronic obstructive pulmonary disease (21% vs 12%), social isolation, serious vision problems (22% vs 12%), foot pain, and grossly decayed teeth (median, 1 vs 0 per person). We conclude that to care more optimally for homeless adults, health centers must pay attention to their functional disabilities, substance abuse, skin abnormalities, vision impairment, dental problems, and foot problems.

Time-efficient preceptors in ambulatory care settings.

PURPOSE: With increasing amounts of medical education occurring in ambulatory care and managed care settings, time-efficient and educationally effective teaching methods are in high demand. To identify such methods, four exemplary preceptors who taught in a family medicine clerkship in the context of their managed care clinics were observed in two consecutive years. The purpose of this second observational case study was to look at the teaching and practice strategies of these four exemplary preceptors in more detail and to directly measure the use of strategies that have previously been identified. METHOD: Observation of 44 patient encounters by four exemplary preceptors in ambulatory managed-care settings. RESULTS: On average, these preceptors spent one minute per patient more when the student was involved. With students present, the preceptors saved 3.3 minutes per patient in charting time, while spending 2.2 minutes more listening to student presentations and 1.6 minutes more in pure teaching time. The preceptors spent half a minute less time in direct contact with each patient when a student was present. However, the patients received 12.4 additional minutes from the health-care team. CONCLUSION: Time savings from student charting may allow preceptors to teach and care for patients without losing valuable practice time.

Four exemplary preceptors' strategies for efficient teaching in managed care settings.

To identify time-efficient and educationally effective methods for teaching in ambulatory care and managed care settings, the authors studied four exemplary preceptors who taught family medicine clerks in managed care clinics. They interviewed all four preceptors and observed three of them. All of these preceptors claimed to practice more efficiently with students than without them. Analysis of 33 patients encounters involving students revealed that each of the five students observed spent an average of 12.0 minutes conducting a history and physical examination, 2.2 minutes presenting the case to the preceptor, 7.9 minutes observing the preceptor reviewing and/or repeating the examination with the patient, and 1.8 minutes receiving direct instruction and feedback from the preceptor. The total time per patient encounter was 23.7 minutes, 11.7 minutes of which directly involved the preceptor. The authors then compared these 33 encounters with encounters involving the preceptors alone; these encounters took an average of 10.6 minutes of the preceptors' time. The 1.1-minute difference between the amount of time preceptors spent in encounters involving students and the amount of time they spent in encounters on their own was not statistically significant as measured by t-test (p < .05). However, in calculating this time difference, possible time saved by students' assistance with charting was not accounted for. In interviews the preceptors identified three major instructional strategies for time-efficient teaching; planning and preparing; teaching with patients; and charting, giving feedback, and reflecting. Students described these preceptors as enthusiastic teachers and good role models; however, they also felt that their first two years of education had not prepared them for seeing patients in fast-paced ambulatory care settings. The challenge for medical schools is to better prepare both students and preceptors for learning and teaching in productivity driven ambulatory care and managed care environments.

Web-based education in family medicine predoctoral programs.

BACKGROUND AND OBJECTIVES: New technologies and widespread Internet access make Web-based education feasible for family medicine predoctoral programs. Offering educational activities and resources through the Web can support community-based education and improve communication. We assessed the status of Web-based education nationally and explored the interest and opportunities for collaboration. METHODS: A survey assessed the inclusion of Web-based educational methods in family medicine predoctoral programs and school-wide programs, the level of national interest in collaborative development, and common obstacles to progress. The survey was mailed to all US family medicine predoctoral directors. RESULTS: The response rate was 61%. Results showed nearly universal use of e-mail and Web pages. The most common educational use of the Internet was posting text information. One third of the responding programs used the Web for evaluation. Barriers to development of Web-based educational programs are faculty time and funding. Most respondents were interested in collaborative Web development and would value a national, Society of Teachers of Family Medicine-based network for this purpose. CONCLUSIONS: Web-based educational activities are commonly offered by family medicine programs. To realize the full potential of Web-based education, collaborative development of new methods and materials will be needed to overcome the limiting factors of faculty time and funding.

Reactions of family medicine community preceptors to teaching medical students.

BACKGROUND AND OBJECTIVES: In 1993, the University of California, Los Angeles introduced an interdisciplinary course called ¿Doctoring¿ for all first-year medical students in which students visited family physicians' offices once a month for a total of four visits. The study's objectives were to ascertain preceptors' attitudes about having students in their offices and determine if this experience resulted in professional growth. METHODS: A survey was mailed to the 101 preceptors recruited to teach in the ¿Doctoring¿ course. Thirty of the respondents were selected randomly for a follow-up telephone interview. In addition, a second survey was mailed to the 31 preceptors who chose not to participate in the course the following year. RESULTS: More than 75% of the preceptors surveyed reported that the medical students had positive effects on their patients' satisfaction with their care. However, interviews with some respondents revealed worries about balancing time with the student vs maintaining a busy practice. Preceptors reported professional growth in the teaching process and greater knowledge and skills in the specific medical content areas of the ¿Doctoring¿ course. Preceptors who did not participate in the course during the subsequent year reported that their decision was based on issues other than satisfaction with the course. CONCLUSIONS: Based on the results of the study, preceptors experience professional growth through students' direct presence in their offices. Time management while precepting is the greatest challenge reported by preceptors.

Pearls in the management of acne: an advanced approach.

Acne is a common condition of the sebaceous follicle. The primary care physician can have a large impact on patients with acne by properly classifying the type of acne (obstructive versus inflammatory) and successfully treating the acne based on its severity. Reduction of acne lesions by appropriate topical and oral medications provides great psychological and physical benefits to these patients. By understanding how acne develops and its many manifestations and treatment options, the primary care physician can become an expert in acne diagnosis and treatment.

Faculty perceptions of learning while teaching in Doctoring.

PURPOSE: To assess the acquisition of clinical knowledge and skills by faculty teaching in Doctoring. METHOD: Thirty-six faculty teaching in Doctoring II were given surveys at the start and end of six educational modules. These surveys assessed faculty perceptions of their own knowledge and skills related to key learning objectives for each module. Pre-test and post-test means were compared using paired t-tests and 95% confidence limits were calculated. RESULTS: The average response rate was 72% for each module. Faculty reported increases in knowledge and skills for each of the six modules. Post-test mean ratings were significantly higher than pre-test mean ratings for 48 out of the 56 learning objectives. The greatest increases were seen in the domestic violence and smoking cessation modules. Faculty rated tutorial sessions with students highest in terms of contribution to their own learning. CONCLUSION: The results suggest that faculty acquire new knowledge and skills as a result of teaching in Doctoring. Problem-based courses such as Doctoring that deal in an integrated fashion with subjects such as ethics, law, prevention, evidence-based medicine and domestic violence can serve as important and effective vehicles for faculty development.

Acne vulgaris: a treatment update.

Though acne is not generally cured, treatment can reduce the severity and frequency of outbreaks, lessen discomfort from inflamed lesions, improve appearance, and prevent or minimize scarring, thereby averting or ameliorating potentially serious adverse psychosocial effects. A number of new agents are available; combination therapies that achieve synergism are described.

Health care for the homeless: a family medicine perspective.

Many factors contribute to the health problems of homeless persons, including exposure to adverse weather, trauma and crime, overcrowding in shelters, unusual sleeping accommodations, poor hygiene and nutritional status, alcoholism, drug abuse and psychiatric illness. It is common for homeless adults to have skin ailments, respiratory infections, traumatic injuries and chronic gastrointestinal, vascular, dental and neurologic disorders. Homeless children may have respiratory, ear and skin diseases, as well as special problems, including failure to thrive, developmental delay, neglect and abuse. Important questions to ask during history-taking include questions about sleeping conditions, sources of food, past psychiatric problems and substance abuse, and sources of social support. Special attention should be given to examination of the skin, teeth and feet. Supplemental food, immunizations, psychologic counseling and social service referrals should be considered for homeless pediatric patients.