- Email: [email protected]
Educational Video Improves Dermatology Residents’ Understanding of Mohs Micrographic Surgery: A Survey-Based Matched Cohort Study
Journal Pre-proof Educational Video Improves Dermatology Residents’ Understanding of Mohs Micrographic Surgery: A Survey-Based Matched Cohort Study Evan McNeil, MS, Hilary Reich, MD, Elisabeth Hurliman, MD, PhD PII:
S0190-9622(20)30056-6
DOI:
https://doi.org/10.1016/j.jaad.2020.01.013
Reference:
YMJD 14135
To appear in:
Journal of the American Academy of Dermatology
Received Date: 2 September 2019 Revised Date:
18 December 2019
Accepted Date: 7 January 2020
Please cite this article as: McNeil E, Reich H, Hurliman E, Educational Video Improves Dermatology Residents’ Understanding of Mohs Micrographic Surgery: A Survey-Based Matched Cohort Study, Journal of the American Academy of Dermatology (2020), doi: https://doi.org/10.1016/ j.jaad.2020.01.013. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1
1
Article type: Research Letter
2
Title: Educational Video Improves Dermatology Residents’ Understanding of Mohs
3
Micrographic Surgery: A Survey-Based Matched Cohort Study
4
Evan McNeil, MS1,6, Hilary Reich, MD1,4, Elisabeth Hurliman, MD, PhD1,2,3,5
5
1
6
2
7
3
8
Minnesota
9
4
10
5
11
6
12
Corresponding author:
13
Elisabeth Hurliman, MD, PhD
14
516 Delaware Street Southeast,
15
Minneapolis, MN 55455
16
Email: [email protected]
17
Funding sources: Funded through a PICMED grant through the American Academy of
18
Dermatology; completed during the corresponding author’s Mohs procedural fellowship year
19
Conflicts of Interest: None declared.
20
IRB approval status: Reviewed and exempted by the University of Minnesota IRB
21
Reprint requests: None
22
Manuscript word count: 550 (Body + capsule)
23
Capsule summary word count: 50
24
References: 5
25
Figures: 2
26
Supplements: 1
University of Minnesota Medical School, Department of Dermatology; Minneapolis, Minnesota Veterans Affairs Hospital, Mohs Surgery Service; Minneapolis, Minnesota Hennepin Healthcare Clinic & Specialty Center, Mohs Surgery at Otolaryngology; Minneapolis,
Essentia Health-Duluth Clinic Mohs Surgery; Duluth, Minnesota Zel Skin & Laser Specialists; Edina, Minnesota Dartmouth Geisel School of Medicine; Hanover, New Hampshire
2
27
Tables: 0
28
Supplementary tables: 0
29
Attachments: Copy of survey model for editor/reviewer reference only
30
Keywords: general dermatology; medical dermatology; Mohs micrographic surgery; Mohs;
31
resident education; Mohs education; surgery
32
Body word count: 500
3
33
Capsule summary [cannot exceed 50 words]
34
●
modules of Mohs surgery
35 36
Residents’ self-assessment of basic Mohs concepts improve after viewing educational
●
Because resident experience with Mohs surgery is variable, it is helpful to expose residents
37
to quick, electronic primer material to improve basic knowledge of this gold standard
38
treatment for the majority of skin cancers.
39 40
Body of manuscript Dermatology resident experience with Mohs micrographic surgery is highly variable1,5,
41
and it has been reported that surgical training is often underemphasized in the course of
42
dermatology training compared to other proceduralists2. In surgery, especially dermatologic
43
surgery, there is a need to quickly and intuitively transmit complex information to a wide
44
physician audience, and various creative modalities have been attempted, including YouTube3
45
and metaphor4.
46
We created a mixed live-action and animated video demonstrating an introduction to
47
Mohs surgery in an effort to improve residents’ basic understanding of how, why, and when
48
Mohs surgery is performed with additional information on special considerations for Mohs
49
surgery performed on unique anatomical locations. Though it was never intended to replace any
50
part of a formal Mohs surgery fellowship, we hoped that residents’ confidence with the basic
51
concepts of Mohs would improve with this approachable educational modality.
52
In this survey-based, matched cohort study, dermatology resident physicians (N=83)
53
were recruited by contacting ACGME program coordinators and requesting dispersal within their
54
programs through the Association of Professors of Dermatology listserv. The residents were
55
asked to complete a preliminary survey to self-rate their comfort level of Mohs micrographic
56
surgery. The survey consists of five basic Mohs competencies, and participants were asked to
57
rate their comfort with each competency 1 (low) through 5 (high). They were then asked to view
58
two short, educational video modules on Mohs surgery. The first video demonstrates the
4
59
excision of a sample and its histological preparation--and how uniquely in Mohs surgery this
60
allows for evaluation of complete margins with accurate reference to surrounding surface
61
anatomy. The second video demonstrates special anatomical considerations for excising and
62
preparing samples taken from the eyelids, lips, and nails. After viewing the two modules,
63
residents re-answer the same survey questions (Fig. 1).
64
The combination of pre-module and post-module answers are presented in a cross-
65
tabulation table for each of the five questions. Values above the descending diagonal represent
66
higher responses on the post-survey and values below this diagonal indicated higher responses
67
on the pre-survey. Due to non-normal distributions for the survey questions, a non-parametric
68
Wilcoxon signed rank test was used to compare the paired responses. This analysis was
69
carried out using SAS version 9.4 (SAS Institute Inc., Cary NC) and a p-value less than 0.05
70
was considered statistically significant.
71
Our results demonstrated that the video modules significantly improved residents’ self-
72
rated comfort in all survey questions (p<0.05) (Figure 2). After viewing the video modules,
73
residents assessed themselves as more comfortable with how the layer is taken by the surgeon,
74
how the layer is inked by the surgeon, how the tissue is positioned on the slide, how 100% of
75
the margin is cleared by the surgeon, and unique issues for specific anatomical locations.
76
With wide variation in Mohs surgery experience among dermatology residents, there is a
77
need for an approachable medium for resident exposure to Mohs, and a module conveying
78
three-dimensional content may fill that need. Our Mohs surgery video modules improve
79
residents’ self-rated confidence with the basics of Mohs micrographic surgery.
80 81 82 83 84
5
85
References
86
1. Lee EH, Nehal KS, Dusza SW, Hale EK, Levine VJ. Procedural dermatology training during
87
dermatology residency: a survey of third-year dermatology residents. J Am Acad
88
Dermatol. 2011;64(3):475-483.
89 90 91 92
2. Alam M. Dermatologic surgery training during residency: room for improvement. Dermatologic Surg. 2001;27(5):508-509. 3. Koya KD, Bhatia KR. Hsu JT & Bhatia AC. (2012). YouTube and the expanding role of videos in dermatologic surgery education. SeminCutanMed Surg, 31 (3), 163-7.
93
4. Lee E, Wolverton JE & SomaniAK (2017). A simple, effective analogy to elucidate the Mohs
94
Micrographic Surgery Procedure – The peanut butter cup. Jama Dermatol, 153 (8), 743-
95
44.
96 97
5. Reichel JL, Peirson RP & Berg D (2004). Teaching and evaluation of surgical skills in Dermatology: results of a survey. Arch Dermatol, 140 (11), 1365-9.
98 99
Attachment. Educational module
100 101
Figure 1 Title. “Protocol Flowchart”
102
Figure 1 legend. The protocol was to first ask the residents to take a 5-question survey to self-
103
rate their competence in each area 1 (low) to 5 (high). Residents were asked their
104
understanding of: 1. How a Mohs layer is taken by the surgeon; 2. How the Mohs layer is inked
105
by the surgeon; 3. How the Mohs layer allows for evaluation of 100% of the tissue margins; 4.
106
How tissue is positioned on the glass slide; and 5. Unique issues for specific anatomical
107
locations (eyelid, lip, nail). The residents then viewed two educational videos. The residents then
108
retook the self-assessment survey.
109 110
Figure 2 Title. “Pre-Module vs. Post-Module Comparison of Resident Physician Self-Ratings”
6
111
Figure 2 legend. Mean scores for each Mohs surgery competency (1 is low self-confidence; 5 is
112
high self-confidence) before (blue) and after (orange) viewing the video module. Self-rated
113
confidence was significantly improved after viewing the video modules in all areas. Error bars
114
represent a 95% confidence interval of the means. Asterisk represents a P value of <0.05.
S0190-9622(20)30056-6
DOI:
https://doi.org/10.1016/j.jaad.2020.01.013
Reference:
YMJD 14135
To appear in:
Journal of the American Academy of Dermatology
Received Date: 2 September 2019 Revised Date:
18 December 2019
Accepted Date: 7 January 2020
Please cite this article as: McNeil E, Reich H, Hurliman E, Educational Video Improves Dermatology Residents’ Understanding of Mohs Micrographic Surgery: A Survey-Based Matched Cohort Study, Journal of the American Academy of Dermatology (2020), doi: https://doi.org/10.1016/ j.jaad.2020.01.013. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
1
1
Article type: Research Letter
2
Title: Educational Video Improves Dermatology Residents’ Understanding of Mohs
3
Micrographic Surgery: A Survey-Based Matched Cohort Study
4
Evan McNeil, MS1,6, Hilary Reich, MD1,4, Elisabeth Hurliman, MD, PhD1,2,3,5
5
1
6
2
7
3
8
Minnesota
9
4
10
5
11
6
12
Corresponding author:
13
Elisabeth Hurliman, MD, PhD
14
516 Delaware Street Southeast,
15
Minneapolis, MN 55455
16
Email: [email protected]
17
Funding sources: Funded through a PICMED grant through the American Academy of
18
Dermatology; completed during the corresponding author’s Mohs procedural fellowship year
19
Conflicts of Interest: None declared.
20
IRB approval status: Reviewed and exempted by the University of Minnesota IRB
21
Reprint requests: None
22
Manuscript word count: 550 (Body + capsule)
23
Capsule summary word count: 50
24
References: 5
25
Figures: 2
26
Supplements: 1
University of Minnesota Medical School, Department of Dermatology; Minneapolis, Minnesota Veterans Affairs Hospital, Mohs Surgery Service; Minneapolis, Minnesota Hennepin Healthcare Clinic & Specialty Center, Mohs Surgery at Otolaryngology; Minneapolis,
Essentia Health-Duluth Clinic Mohs Surgery; Duluth, Minnesota Zel Skin & Laser Specialists; Edina, Minnesota Dartmouth Geisel School of Medicine; Hanover, New Hampshire
2
27
Tables: 0
28
Supplementary tables: 0
29
Attachments: Copy of survey model for editor/reviewer reference only
30
Keywords: general dermatology; medical dermatology; Mohs micrographic surgery; Mohs;
31
resident education; Mohs education; surgery
32
Body word count: 500
3
33
Capsule summary [cannot exceed 50 words]
34
●
modules of Mohs surgery
35 36
Residents’ self-assessment of basic Mohs concepts improve after viewing educational
●
Because resident experience with Mohs surgery is variable, it is helpful to expose residents
37
to quick, electronic primer material to improve basic knowledge of this gold standard
38
treatment for the majority of skin cancers.
39 40
Body of manuscript Dermatology resident experience with Mohs micrographic surgery is highly variable1,5,
41
and it has been reported that surgical training is often underemphasized in the course of
42
dermatology training compared to other proceduralists2. In surgery, especially dermatologic
43
surgery, there is a need to quickly and intuitively transmit complex information to a wide
44
physician audience, and various creative modalities have been attempted, including YouTube3
45
and metaphor4.
46
We created a mixed live-action and animated video demonstrating an introduction to
47
Mohs surgery in an effort to improve residents’ basic understanding of how, why, and when
48
Mohs surgery is performed with additional information on special considerations for Mohs
49
surgery performed on unique anatomical locations. Though it was never intended to replace any
50
part of a formal Mohs surgery fellowship, we hoped that residents’ confidence with the basic
51
concepts of Mohs would improve with this approachable educational modality.
52
In this survey-based, matched cohort study, dermatology resident physicians (N=83)
53
were recruited by contacting ACGME program coordinators and requesting dispersal within their
54
programs through the Association of Professors of Dermatology listserv. The residents were
55
asked to complete a preliminary survey to self-rate their comfort level of Mohs micrographic
56
surgery. The survey consists of five basic Mohs competencies, and participants were asked to
57
rate their comfort with each competency 1 (low) through 5 (high). They were then asked to view
58
two short, educational video modules on Mohs surgery. The first video demonstrates the
4
59
excision of a sample and its histological preparation--and how uniquely in Mohs surgery this
60
allows for evaluation of complete margins with accurate reference to surrounding surface
61
anatomy. The second video demonstrates special anatomical considerations for excising and
62
preparing samples taken from the eyelids, lips, and nails. After viewing the two modules,
63
residents re-answer the same survey questions (Fig. 1).
64
The combination of pre-module and post-module answers are presented in a cross-
65
tabulation table for each of the five questions. Values above the descending diagonal represent
66
higher responses on the post-survey and values below this diagonal indicated higher responses
67
on the pre-survey. Due to non-normal distributions for the survey questions, a non-parametric
68
Wilcoxon signed rank test was used to compare the paired responses. This analysis was
69
carried out using SAS version 9.4 (SAS Institute Inc., Cary NC) and a p-value less than 0.05
70
was considered statistically significant.
71
Our results demonstrated that the video modules significantly improved residents’ self-
72
rated comfort in all survey questions (p<0.05) (Figure 2). After viewing the video modules,
73
residents assessed themselves as more comfortable with how the layer is taken by the surgeon,
74
how the layer is inked by the surgeon, how the tissue is positioned on the slide, how 100% of
75
the margin is cleared by the surgeon, and unique issues for specific anatomical locations.
76
With wide variation in Mohs surgery experience among dermatology residents, there is a
77
need for an approachable medium for resident exposure to Mohs, and a module conveying
78
three-dimensional content may fill that need. Our Mohs surgery video modules improve
79
residents’ self-rated confidence with the basics of Mohs micrographic surgery.
80 81 82 83 84
5
85
References
86
1. Lee EH, Nehal KS, Dusza SW, Hale EK, Levine VJ. Procedural dermatology training during
87
dermatology residency: a survey of third-year dermatology residents. J Am Acad
88
Dermatol. 2011;64(3):475-483.
89 90 91 92
2. Alam M. Dermatologic surgery training during residency: room for improvement. Dermatologic Surg. 2001;27(5):508-509. 3. Koya KD, Bhatia KR. Hsu JT & Bhatia AC. (2012). YouTube and the expanding role of videos in dermatologic surgery education. SeminCutanMed Surg, 31 (3), 163-7.
93
4. Lee E, Wolverton JE & SomaniAK (2017). A simple, effective analogy to elucidate the Mohs
94
Micrographic Surgery Procedure – The peanut butter cup. Jama Dermatol, 153 (8), 743-
95
44.
96 97
5. Reichel JL, Peirson RP & Berg D (2004). Teaching and evaluation of surgical skills in Dermatology: results of a survey. Arch Dermatol, 140 (11), 1365-9.
98 99
Attachment. Educational module
100 101
Figure 1 Title. “Protocol Flowchart”
102
Figure 1 legend. The protocol was to first ask the residents to take a 5-question survey to self-
103
rate their competence in each area 1 (low) to 5 (high). Residents were asked their
104
understanding of: 1. How a Mohs layer is taken by the surgeon; 2. How the Mohs layer is inked
105
by the surgeon; 3. How the Mohs layer allows for evaluation of 100% of the tissue margins; 4.
106
How tissue is positioned on the glass slide; and 5. Unique issues for specific anatomical
107
locations (eyelid, lip, nail). The residents then viewed two educational videos. The residents then
108
retook the self-assessment survey.
109 110
Figure 2 Title. “Pre-Module vs. Post-Module Comparison of Resident Physician Self-Ratings”
6
111
Figure 2 legend. Mean scores for each Mohs surgery competency (1 is low self-confidence; 5 is
112
high self-confidence) before (blue) and after (orange) viewing the video module. Self-rated
113
confidence was significantly improved after viewing the video modules in all areas. Error bars
114
represent a 95% confidence interval of the means. Asterisk represents a P value of <0.05.