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Medical Students’ Ability to Diagnose Common Dermatologic Conditions in Skin of Color
Journal Pre-proof Medical Students’ Ability to Diagnose Common Dermatologic Conditions in Skin of Color Anne Fenton, BS, Erika Elliott, BA, Ashkan Shahbandi, BS, Ekene Ezenwa, BS, Chance Morris, MD, Justin McLawhorn, MD, James G. Jackson, PhD, Pamela Allen, MD, Andrea Murina, MD PII:
S0190-9622(20)30144-4
DOI:
https://doi.org/10.1016/j.jaad.2019.12.078
Reference:
YMJD 14193
To appear in:
Journal of the American Academy of Dermatology
Received Date: 11 September 2019 Revised Date:
28 December 2019
Accepted Date: 31 December 2019
Please cite this article as: Fenton A, Elliott E, Shahbandi A, Ezenwa E, Morris C, McLawhorn J, Jackson JG, Allen P, Murina A, Medical Students’ Ability to Diagnose Common Dermatologic Conditions in Skin of Color, Journal of the American Academy of Dermatology (2020), doi: https://doi.org/10.1016/ j.jaad.2019.12.078. 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
Article Type: Research Letter
2
Title: Medical Students’ Ability to Diagnose Common Dermatologic Conditions in Skin of
3
Color
4
Anne Fenton, BS1*; Erika Elliott, BA1*; Ashkan Shahbandi, BS2; Ekene Ezenwa, BS3; Chance
5
Morris, MD4; Justin McLawhorn, MD4; James G. Jackson, PhD2; Pamela Allen, MD4; Andrea
6
Murina, MD1.
7
1
Tulane University School of Medicine, Department of Dermatology, New Orleans, LA.
8
2
Tulane University School of Medicine, Department of Biochemistry and Molecular Biology,
9
New Orleans, LA.
10 11 12
3
University of Oklahoma, College of Medicine, Tulsa, OK.
4
University of Oklahoma Health Science Center, Department of Dermatology, Oklahoma City,
13
OK.
14
*Authors contributed equally to the work.
15 16 17 18 19 20 21 22
Corresponding Author: Erika Elliott 131 S. Robertson St. New Orleans, LA 70112 email: [email protected]
23
Conflicts of Interest: Andrea Murina is a speaker for Abbvie, Amgen, Eli Lilly and Company,
24
Janssen and Novartis. No relevant conflicts of interest.
25
IRB approved status: Reviewed and approved by Tulane IRB and University of Oklahoma
26
Health Sciences Center IRB; approval #2018-2348 and #10264
27 28
Manuscript word count: 481 References: 5
Funding sources: None
29
Figures: 1
30
Attachments: QuizA and Quiz B (DOI: 10.17632/gn7x456jyp.3)
31
Keywords: Skin of color, medical education, health disparities, medical students, dermatologic
32
health disparities
33
Prior Presentation: The findings of this study were reported at the Association of Professors of
34
Dermatology Meeting in September 2019.
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51
52
Dermatologic healthcare disparities disproportionately affect patients with skin of color
53
(SoC) (defined as Fitzpatrick skin phototypes IV-VI), resulting in delayed treatment courses and
54
increased morbidity and mortality.1-3 While many factors contribute to healthcare disparities, a
55
lack of familiarity with disease presentation in SoC patients is a physician-dependent factor that
56
influences care quality.1,2,4,5 The aim of this study was to assess medical students’ diagnostic
57
accuracy using clinical images of SoC and light skin (Fizpatrick phototypes I-III).
58
Medical students at Tulane University School of Medicine and University of Oklahoma,
59
College of Medicine were offered participation in a 10-item multiple choice quiz consisting of
60
photos with a limited vignette without mention of race. Participants were randomized to receive
61
quiz A or B. Each quiz tested the same 10 conditions in the same order. Quiz A used photos from
62
patients with Fitzpatrick I-III skin phototypes for odd numbered questions and Fitzpatrick IV-VI
63
skin phototypes for even numbered questions; quiz B was the reverse.
64
Two hundred and twenty-seven students enrolled in the study (N=227/1420; 16%
65
response rate), 177 completed the study (N=177/227, 78% completion rate). Preclinical medical
66
students (years 1-2) scored an average of 47.3% on both quizzes compared to clinical medical
67
students (years 3-4) who scored an average of 62.0% (p=<0.00001). Both medical schools
68
include didactic lectures in dermatology during the preclinical years and offer elective clinical
69
rotations.
70
Across all Fitzpatrick skin phototypes, the conditions most frequently identified correctly
71
were herpes zoster (83.1%), psoriasis (81.9%), and atopic dermatitis (80.2%). The conditions
72
least frequently identified correctly were verruca vulgaris (26.6%), contact dermatitis (30.5%),
73
and squamous cell carcinoma (30.5%).
74
The conditions with the greatest disparity in visual diagnosis based on Fitzpatrick skin
75
phototypes (Fitzpatrick IV-VI vs Fitzpatrick I-III) were squamous cell carcinoma (14.9% vs
76
45.6%, respectively; t(175)=4.662, p=<0.0001), urticaria (57.5% vs 82.2%, respectively;
77
t(175)=3.712, p=0.0003), and atopic dermatitis (74.4% vs 86.2%, respectively; t(175)=-1.975,
78
p=0.0495) (Figure 2). Nearly 34% of students misdiagnosed squamous cell carcinoma in SoC as
79
melanoma, which may be explained by the students’ reliance on dark pigment alone as the
80
feature of melanoma. Students were more likely to correctly identify tinea versicolor in patients
81
with SoC compared to patients with lighter skin phototypes (62.1% correct vs 42.2%
82
respectively t(175)=-2.681, p=0.0082) (figure 2). The increase in diagnostic accuracy for tinea
83
versicolor likely involves the prominent pigmentary change in SoC. Though not all statistically
84
significant, 3 of the 4 diseases more accurately diagnosed in SOC were infections such as tinea
85
corporis and verruca vulgaris. The study was limited by an overall low response rate and that
86
each participant did not serve as their own control.
87
Our study demonstrated that medical students were less accurate in diagnosing squamous cell
88
carcinoma, atopic dermatitis, urticaria in SoC patients, but more accurate in diagnosing tinea
89
versicolor in SoC. These findings highlight the need to present all dermatologic conditions in
90
both light skin and SoC as part of a comprehensive dermatology curriculum.
91 92 93 94 95 96 97 98 99 100 101
102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137
Acknowledgments Dr. Katrina D’Aquin, PhD, for guidance with statistical analysis.
References 1.
2.
3. 4. 5.
Fourniquet SE, Garvie K, Beiter K. Exposure to Dermatological Pathology on Skin of Color Increases Physician and Student Confidence in Diagnosing Pathology in Patients of Color. The FASEB Journal. 2019;33(1_supplement):606.618-606.618. Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United StatesDemographic and SES Differences in Use of US Outpatient Dermatology ServicesDemographic and SES Differences in Use of US Outpatient Dermatology Services. JAMA Dermatology. 2018;154(11):1286-1291. Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012;30(1):53-59, viii. Ezenwa E BK. Health Disparities and Skin Cancer in People of Color Practical Dermatology. 2019(April ):38-42. Stephanie W. Medical Student Melanoma Detection Rates in White and African American Skin using Moulage and Standardized Patients. Journal of Clinical Research in Dermatology. 2015;2(1):01-04.
138
Figure Legend
139
Figure 1: Percent correct by skin condition, stratified by Fitzpatrick skin phototype.
140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172
S0190-9622(20)30144-4
DOI:
https://doi.org/10.1016/j.jaad.2019.12.078
Reference:
YMJD 14193
To appear in:
Journal of the American Academy of Dermatology
Received Date: 11 September 2019 Revised Date:
28 December 2019
Accepted Date: 31 December 2019
Please cite this article as: Fenton A, Elliott E, Shahbandi A, Ezenwa E, Morris C, McLawhorn J, Jackson JG, Allen P, Murina A, Medical Students’ Ability to Diagnose Common Dermatologic Conditions in Skin of Color, Journal of the American Academy of Dermatology (2020), doi: https://doi.org/10.1016/ j.jaad.2019.12.078. 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
Article Type: Research Letter
2
Title: Medical Students’ Ability to Diagnose Common Dermatologic Conditions in Skin of
3
Color
4
Anne Fenton, BS1*; Erika Elliott, BA1*; Ashkan Shahbandi, BS2; Ekene Ezenwa, BS3; Chance
5
Morris, MD4; Justin McLawhorn, MD4; James G. Jackson, PhD2; Pamela Allen, MD4; Andrea
6
Murina, MD1.
7
1
Tulane University School of Medicine, Department of Dermatology, New Orleans, LA.
8
2
Tulane University School of Medicine, Department of Biochemistry and Molecular Biology,
9
New Orleans, LA.
10 11 12
3
University of Oklahoma, College of Medicine, Tulsa, OK.
4
University of Oklahoma Health Science Center, Department of Dermatology, Oklahoma City,
13
OK.
14
*Authors contributed equally to the work.
15 16 17 18 19 20 21 22
Corresponding Author: Erika Elliott 131 S. Robertson St. New Orleans, LA 70112 email: [email protected]
23
Conflicts of Interest: Andrea Murina is a speaker for Abbvie, Amgen, Eli Lilly and Company,
24
Janssen and Novartis. No relevant conflicts of interest.
25
IRB approved status: Reviewed and approved by Tulane IRB and University of Oklahoma
26
Health Sciences Center IRB; approval #2018-2348 and #10264
27 28
Manuscript word count: 481 References: 5
Funding sources: None
29
Figures: 1
30
Attachments: QuizA and Quiz B (DOI: 10.17632/gn7x456jyp.3)
31
Keywords: Skin of color, medical education, health disparities, medical students, dermatologic
32
health disparities
33
Prior Presentation: The findings of this study were reported at the Association of Professors of
34
Dermatology Meeting in September 2019.
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51
52
Dermatologic healthcare disparities disproportionately affect patients with skin of color
53
(SoC) (defined as Fitzpatrick skin phototypes IV-VI), resulting in delayed treatment courses and
54
increased morbidity and mortality.1-3 While many factors contribute to healthcare disparities, a
55
lack of familiarity with disease presentation in SoC patients is a physician-dependent factor that
56
influences care quality.1,2,4,5 The aim of this study was to assess medical students’ diagnostic
57
accuracy using clinical images of SoC and light skin (Fizpatrick phototypes I-III).
58
Medical students at Tulane University School of Medicine and University of Oklahoma,
59
College of Medicine were offered participation in a 10-item multiple choice quiz consisting of
60
photos with a limited vignette without mention of race. Participants were randomized to receive
61
quiz A or B. Each quiz tested the same 10 conditions in the same order. Quiz A used photos from
62
patients with Fitzpatrick I-III skin phototypes for odd numbered questions and Fitzpatrick IV-VI
63
skin phototypes for even numbered questions; quiz B was the reverse.
64
Two hundred and twenty-seven students enrolled in the study (N=227/1420; 16%
65
response rate), 177 completed the study (N=177/227, 78% completion rate). Preclinical medical
66
students (years 1-2) scored an average of 47.3% on both quizzes compared to clinical medical
67
students (years 3-4) who scored an average of 62.0% (p=<0.00001). Both medical schools
68
include didactic lectures in dermatology during the preclinical years and offer elective clinical
69
rotations.
70
Across all Fitzpatrick skin phototypes, the conditions most frequently identified correctly
71
were herpes zoster (83.1%), psoriasis (81.9%), and atopic dermatitis (80.2%). The conditions
72
least frequently identified correctly were verruca vulgaris (26.6%), contact dermatitis (30.5%),
73
and squamous cell carcinoma (30.5%).
74
The conditions with the greatest disparity in visual diagnosis based on Fitzpatrick skin
75
phototypes (Fitzpatrick IV-VI vs Fitzpatrick I-III) were squamous cell carcinoma (14.9% vs
76
45.6%, respectively; t(175)=4.662, p=<0.0001), urticaria (57.5% vs 82.2%, respectively;
77
t(175)=3.712, p=0.0003), and atopic dermatitis (74.4% vs 86.2%, respectively; t(175)=-1.975,
78
p=0.0495) (Figure 2). Nearly 34% of students misdiagnosed squamous cell carcinoma in SoC as
79
melanoma, which may be explained by the students’ reliance on dark pigment alone as the
80
feature of melanoma. Students were more likely to correctly identify tinea versicolor in patients
81
with SoC compared to patients with lighter skin phototypes (62.1% correct vs 42.2%
82
respectively t(175)=-2.681, p=0.0082) (figure 2). The increase in diagnostic accuracy for tinea
83
versicolor likely involves the prominent pigmentary change in SoC. Though not all statistically
84
significant, 3 of the 4 diseases more accurately diagnosed in SOC were infections such as tinea
85
corporis and verruca vulgaris. The study was limited by an overall low response rate and that
86
each participant did not serve as their own control.
87
Our study demonstrated that medical students were less accurate in diagnosing squamous cell
88
carcinoma, atopic dermatitis, urticaria in SoC patients, but more accurate in diagnosing tinea
89
versicolor in SoC. These findings highlight the need to present all dermatologic conditions in
90
both light skin and SoC as part of a comprehensive dermatology curriculum.
91 92 93 94 95 96 97 98 99 100 101
102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137
Acknowledgments Dr. Katrina D’Aquin, PhD, for guidance with statistical analysis.
References 1.
2.
3. 4. 5.
Fourniquet SE, Garvie K, Beiter K. Exposure to Dermatological Pathology on Skin of Color Increases Physician and Student Confidence in Diagnosing Pathology in Patients of Color. The FASEB Journal. 2019;33(1_supplement):606.618-606.618. Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United StatesDemographic and SES Differences in Use of US Outpatient Dermatology ServicesDemographic and SES Differences in Use of US Outpatient Dermatology Services. JAMA Dermatology. 2018;154(11):1286-1291. Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012;30(1):53-59, viii. Ezenwa E BK. Health Disparities and Skin Cancer in People of Color Practical Dermatology. 2019(April ):38-42. Stephanie W. Medical Student Melanoma Detection Rates in White and African American Skin using Moulage and Standardized Patients. Journal of Clinical Research in Dermatology. 2015;2(1):01-04.
138
Figure Legend
139
Figure 1: Percent correct by skin condition, stratified by Fitzpatrick skin phototype.
140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172