- Email: [email protected]
Teaching empathy to undergraduate medical students using a temporary tattoo simulating psoriasis
Teaching empathy to undergraduate medical students using a temporary tattoo simulating psoriasis Lesley Latham, MSc,a Aimee MacDonald, BSc,b Alexa B. Kimball, MD, MPH,c and Richard G. Langley, MD, FRCPCa Halifax, Nova Scotia, Canada, and Boston, Massachusetts Background: Psoriasis has a profound negative effect on quality of life that is often underappreciated by health care professionals and the public. Objective: We sought to assess the perception of the burden of psoriasis relative to other medical conditions in first-year medical students, and to determine if wearing a temporary tattoo simulating psoriasis during a teaching exercise would change their perceptions. Methods: Participants completed a questionnaire assessing their perception of the impact of psoriasis and other common medical conditions (visual analog scale). Participants then wore a temporary tattoo of a psoriatic lesion for 24 hours and completed the same questionnaire after this exercise. Results: Of 91 students approached, 61 completed the study. At baseline, psoriasis (mean = 23.6) and eczema (mean = 23.3) were perceived as having the lowest physical burden of diseases queried (P \ .0001), whereas the mental impact of psoriasis was scored comparably with arthritis, heart disease, and diabetes (mean = 45.1-56.7), but lower than cancer (mean = 82.2) and depression (mean = 93.8). After the exercise, the perception of the impact of eczema (physical: mean = 37.3, P \ .0001; mental: mean = 66.6, P = .0005) and psoriasis (physical: mean = 37.8, P = .0014; mental: mean = 68.6, P = .0293) was significantly increased. Limitations: The exercise did not simulate the chronic nature of psoriasis or the scaling and pruritic characteristics of psoriatic lesions. The survey instrument used to assess empathy has not been previously validated and statistical analysis was limited by small sample size and the absence of a control group. Conclusions: Temporary tattoos are a novel and effective method of teaching medical students about the psychological burden of psoriasis. ( J Am Acad Dermatol 2012;67:93-9.) Key words: disease burden; empathy; medical education; morbidity; psoriasis; quality of life; skin disease.
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t is becoming increasingly recognized that psoriasis has a profound negative impact on mental and physical well-being.1 Evidence suggests that patients with psoriasis experience a higher incidence of clinically significant psychiatric symptoms, such as depression and suicidal ideation,2,3 compared with the general population. Furthermore, the burden of psoriasis is often underappreciated and poorly From the Division of Dermatology, Department of Medicine,a and Medical School,b Dalhousie University, Halifax; and Department of Dermatology, Clinical Unit for Research Trials in Skin, Massachusetts General Hospital, Harvard Medical School.c The first two authors contributed equally to this work. Dr Langley receives funding from the Canadian Dermatology Foundation for his research on melanoma. Conflicts of interest: None declared. Accepted for publication July 21, 2011.
Abbreviations used: SF-36: VAS:
short form (36) health survey visual analog scale
understood by the public which, in turn, contributes to stigmatization of these patients.4-8 Reprint requests: Richard G. Langley, MD, FRCPC, Division of Dermatology, Dalhousie University, Room 4-195 Dickson Bldg, QE II Health Science Center, Halifax, Nova Scotia, Canada B3H 2Y9. E-mail: [email protected]. Published online October 10, 2011. 0190-9622/$36.00 Ó 2011 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2011.07.023
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Educating medical students about the impact of converted into a temporary tattoo after color matchpsoriasis can be a challenge as dermatology is often ing using a standardized color-matching system underrepresented in undergraduate medical curric(Pantone Matching System, Pantone Inc, Carlstadt, ula, limiting students’ exposure to patients with NJ). The adhesive side of the tattoo is applied to the chronic skin conditions.9-11 Recently, we developed skin and a water-dampened cloth is then applied a series of temporary tattoos based on high-quality with gentle pressure for 30 seconds. Then the paper digital images of actual skin lesions.12 These tattoos backing is removed, revealing the tattoo on the skin provide realistic, standard(Fig 1). The tattoo is deized representations that signed to last for up to sevCAPSULE SUMMARY have been used in undereral days, but it is easily graduate medical education removed by gently washing Psoriasis has a profound impact on at Canadian universities. In the area of application with quality of life that is often this pilot study, a temporary soap and water. underappreciated by health care tattoo of a psoriatic lesion professionals and the public. was used to temporarily simPre-temporary tattoo Medical students may perceive psoriasis ulate the experience of havexercise questionnaires as less important than other common ing psoriasis in a group of Students were presented medical conditions. undergraduate medical stuwith the opportunity to pardents. Before and after wearticipate in a study about the Temporary tattoos are a novel and ing a temporary tattoo in mental and physical impact effective method of teaching medical public, participants were of different diseases during students, and potentially the general asked about their perception a classroom presentation public, about the psychological burden of the burden of psoriasis by an administrator from of psoriasis. and other acute and chronic Dalhousie Undergraduate diseases, testing the effect of Medical Education who was this exercise on their perception of the severity of not affiliated with the Division of Dermatology. The psoriasis. It was anticipated that psoriasis would be students were assured that participation in the study perceived by entry-level medical students as having was voluntary, that the data collected would remain a low burden on the patient relative to other comanonymous through the use of individual identificamon medical conditions, and that the exercise would tion numbers, and that no part of their study particchange their perception of the effect of psoriasis on ipation or nonparticipation would affect their quality of life. academic standing. A summary of the study methods is presented in Fig 2. The students were not aware METHODS that the study was related to skin disease before Study population and design beginning the questionnaires. In part A of the quesThe study population consisted of 91 first-year tionnaire, participants were asked to report their medical students at the Halifax and Saint John own understanding and prior knowledge of several campuses of Dalhousie University’s Faculty of diseases, including chronic lung disease, arthritis, Medicine in Halifax, Nova Scotia, Canada. The study eczema, ischemic heart disease, psoriasis, depreswas approved by the Capital Health Research Ethics sion, hypertension, diabetes, and cancer, using a 4Board at the Queen Elizabeth II Health Sciences point Likert scale. The conditions were selected Centre in Halifax, Nova Scotia, Canada. Students based on a previous report by Rapp et al6 that were recruited during the first month of classes in investigated the quality of life of patients with psoSeptember 2010. riasis relative to other medical conditions using data from the short form (36) health survey (SF-36). Participants were then asked to rate their perception Temporary tattoo of psoriasis of the severity of the physical and mental impact of We developed a temporary tattoo simulating a each disease, from ‘‘not severe’’ to ‘‘extremely sepsoriatic lesion that could be used in dermatology vere,’’ on a visual analog scale (VAS) 100 mm in medical education. The temporary tattoo of melalength. To assist the first-year students in completing noma has recently been validated in a diagnostic the questionnaire, we used lay terminology for some accuracy study, and the technical details of the of the conditions. Participants were also given the development and application of the temporary tatoption of checking ‘‘I don’t know’’ if they could not too are described there.12 Briefly, we obtained a digital photograph of a psoriatic lesion using a digital provide a response on the VAS. Completion of the camera (D1X, Nikon, Tokyo, Japan). This image was initial questionnaires implied consent to the use of d
d
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assessments, the Skindex-1613 and the Dermatology Life Quality Index.14 Specifically, questions 7, 9, and 10 from the Skindex-16 and questions 2, 4, and 5 from the Dermatology Life Quality Index were adapted for the questionnaire. The words ‘‘skin condition’’ were replaced with ‘‘the tattoo.’’ Finally, participants were asked the same questions as in the initial questionnaire (part A) about their perceived severity of the physical and mental impact of various diseases and their perception of the mental and physical impact of skin disease.
Fig 1. Temporary tattoo of psoriatic lesion.
the participants’ responses in the study. Part A of the questionnaire was collected before proceeding. Participants were then asked to complete a second questionnaire (part B) assessing their attitudes toward skin disease, which was kept in a sealed envelope up to this point. Participants were asked to rate a series of statements about the severity, and emotional and physical impact of skin disease from ‘‘strongly disagree’’ to ‘‘strongly agree’’ on a VAS. Temporary tattoo exercise Before continuing with the tattoo exercise the participants were required to read and sign an informed consent form that explained the temporary tattoo exercise and the rationale of the study. Participants who chose to continue the study were given a temporary tattoo of psoriasis and instructed to apply it to a visible body part such as the forearm, neck, or hand for 24 hours. They were asked to return the following day to complete the post-exercise questionnaire and were also given a one-page body diagram sheet (to be returned the following day after the exercise) on which to mark the location of their tattoo, and record if and why the tattoo was removed before the end of the exercise. Post-temporary tattoo exercise questionnaires The post-temporary tattoo data (part C) were extracted from a classroom-based questionnaire consisting of 3 parts. First, participants were asked about their experience wearing the temporary tattoo. They were provided with a field to record comments about how wearing the temporary tattoo made them feel. They were also asked to report the proportion of the 24-hour period spent with family or friends, in public, or alone. Next, the participants answered questions about how the tattoo affected them during the exercise. Relevant questions were selected and modified from two validated dermatology quality-of-life
Data analysis Pre- and post-temporary tattoo questionnaires were matched using assigned identification numbers. Only data from participants who completed all study questionnaires were analyzed. Data were analyzed using software (SAS, Version 9.2, SAS Institute Inc, Cary, NC). Baseline data were analyzed by Wilcoxon rank sum test. Scores before and after the tattoo exercise were analyzed using the nonparametric sign test for paired data.
RESULTS Of the 91 medical students who were approached to participate in the study, 61 students completed all study procedures. Thirty participants were excluded because they did not return and complete the survey after the temporary tattoo exercise. Although 12 participants reported that the tattoo was removed or washed off before the 24-hour period, these participants were not excluded as they wore the tattoo for an average of 18.5 hours (range: 11.5-20 hours), which was thought to be a sufficient experience to complete the exercise. All participants wore the tattoo in a visible area and reported that they spent at least some time in public. At baseline, the diseases perceived to have the lowest physical impact (VAS) were psoriasis (mean = 23.6, P\.0001) and eczema (mean = 23.3, P\.0001) (Table I). VAS scores for the perception of mental impact were highest for depression (mean = 93.8) and cancer (mean = 82.2), whereas the remaining conditions, including psoriasis, received similar mean scores ranging from 45.1 to 56.7. Participants applied the temporary tattoo to a visible area of their body and wore it for 24 hours spending at least some time in public. After the tattoo exercise, the perception of the physical impact (VAS) of arthritis (mean = 71.3, P = .0198), eczema (mean = 37.3, P \.0001), high blood pressure (mean = 54.5, P = .0001), and psoriasis (mean = 37.8, P = .0014) were significantly higher (Table II) compared with scores given before the exercise. The perception of the mental impact (VAS) of eczema (mean = 66.6,
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Fig 2. Flow chart summarizing study methods. VAS, Visual analog scale.
Table I. Summary of students’ perceptions of physical and mental impact of different conditions before tattoo exercise Disease
Physical impact Heart attack Cancer Lung disease Arthritis Depression Diabetes High blood pressure Psoriasis Eczema Mental impact Depression Cancer Heart attack High blood pressure Psoriasis Diabetes Eczema Lung disease Arthritis
Table II. Summary of visual analog scale scores given by participants pre- and post-temporary tattoo exercise Mean VAS score
N
Rank
Mean VAS score
P value
61 61 53 60 60 61 60 49 58
1 2 3 4 5 6 7 8 9
81.8 74.9 72.7 67.4 60.4 49.6 43.4 23.6 23.3
\.0001 \.0001 \.0001 \.0001 \.0001 \.0001 \.0001 N/A .6918
61 60 58 58 49 60 57 52 60
1 2 3 4 5 6 7 8 9
93.8 82.2 56.7 54.3 53.0 49.5 48.7 47.8 45.1
\.0001 \.0001 .5494 .0058 N/A .2783 .0957 .2769 .0413
Variable
Physical impact Lung disease Arthritis Eczema Heart attack Depression High blood pressure Psoriasis Diabetes Cancer Mental impact Lung disease Arthritis Eczema Heart attack Depression High blood pressure Psoriasis Diabetes Cancer
N
Pre
Post
P value
53 60 58 61 60 60 49 61 61
72.7 67.4 23.3 81.8 60.5 43.4 23.6 49.6 74.9
71.6 71.3 37.3 77.9 61.9 54.5 37.6 55.5 77.4
.7798 .0198 \.0001 .0396 .2892 .0001 .0014 .0674 .8957
52 60 57 58 61 58 49 60 60
47.8 45.1 48.7 56.7 93.8 54.3 53.0 49.5 82.2
51.6 50.6 66.6 60.7 91.4 43.7 68.6 53.7 79.0
.6778 .4270 .0005 .7914 \.0001 .4270 .0293 .8974 .0300
P values are based on Wilcoxon rank sum test on difference in score for condition less score for psoriasis. Scores for psoriasis are in bold for emphasis. N/A, Not applicable; VAS, visual analog scale.
P values are based on nonparametric sign test for paired data. Scores for psoriasis are in bold for emphasis. VAS, Visual analog scale.
P = .0005) and psoriasis (mean = 68.6, P = .0293) was significantly higher compared with scores given before the exercise. The perception of the mental impact of both depression (mean = 91.4, P \.0001) and cancer (mean = 79.0, P = .03) was significantly
lower after the exercise. Regarding the questions specific to skin disease (part B), there was a significant change in the response to the phrase ‘‘Noncancerous skin disease has very little impact on someone’s daily function’’ (mean pre = 34.9, mean
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Table III. Summary of participant scores for skin disease questionnaire Mean VAS score Pre
Post
‘‘I consider skin conditions less serious than most other medical conditions’’ 49.7 (SD = 21.5) 43.3 (SD = 20.9) ‘‘I consider skin disease a serious problem’’ 64.5 (SD = 16.9) 67.4 (SD = 19.4) ‘‘The emotional impact of skin disease is negligible’’ 14.30 (SD = 14.9) 12.02 (SD = 13.9) ‘‘Non-cancerous (benign) skin conditions are generally superficial problems’’ 29.7 (SD = 20.5) 30.5 (SD = 21.1) ‘‘Non-cancerous (benign) skin disease has very little impact on someone’s 34.9 (SD = 24.0) 27.4 (SD = 22.0) daily function’’ ‘‘Non-cancerous (benign) skin disease can greatly impact one’s self esteem’’ 85.3 (SD = 16.1) 82.5 (SD = 21.1)
P value
.0925 .2000 .2717 .6989 .0163 .5901
Participants were asked to rate these phrases on VAS from ‘‘strongly disagree’’ (0) to ‘‘strongly agree’’ (100). P values are based on nonparametric sign test for paired data. VAS, Visual analog scale.
post = 27.4, P = .0163), suggesting participants disagreed more strongly with this phrase after the exercise. Scores for the other questions relating to skin disease were not significant and there was a large degree of variability in the responses (Table III). To determine how they were affected by the tattoo during the exercise, participants were asked to score how embarrassed, annoyed, or bothered they were when wearing the tattoo (VAS) and whether wearing the tattoo altered their leisure activities or choice of clothing. They were also asked to provide comments describing their experiences during the exercise. When asked specific questions relating to how wearing the temporary tattoo made them feel, most participants reported that they were somewhat embarrassed (mean = 30.8), annoyed (mean = 22.2), or bothered by the appearance (mean = 29.9) of the tattoo. Fourteen of 61 participants (23%) reported that wearing the tattoo affected their social or leisure activities. Although 28 of 61 participants (46%) reported that wearing the tattoo affected their choice of clothing, 33 of 61 participants (54%) reported that their choice of clothing was not affected. In the freeform comments, 35 of 61 of participants (57.4%) described being affected by the exercise (eg, feelings of self-consciousness or embarrassment), 15 of 61 participants (27.9%) forgot they were wearing the tattoo or thought that the exercise had no effect, and 9 of 61 participants (14.7%) did not provide a comment. Selected comments from participants are presented in Table IV.
DISCUSSION There is evidence that the physical and mental burden of psoriasis and its effect on quality of life compares with that of other chronic diseases such as cancer, arthritis, hypertension, heart disease, and clinical depression.6 We found that first-year medical students perceive psoriasis as having less physical impact on patients
than other common medical conditions. Our results also suggest that students perceive the mental impact of skin disease to be comparable with nonvisible, chronic medical conditions such as arthritis, hypertension, and diabetes. In fact, scores for the perception of mental impact were very similar for all conditions except those that would be expected to have a great mental burden (cancer and depression), suggesting that participants were unsure about how disease impacts mental well-being. It is notable that only 49 of 61 students provided a score for the mental and physical severity of psoriasisea lower response rate than all other conditions queriede possibly reflecting further uncertainty about how to rate the burden of psoriasis relative to other conditions. The complex social, psychological, and physical contributory factors may be difficult to appreciate for entering medical students15 and our findings call attention to the importance of including psychological impact of disease when teaching undergraduate medical students about disease burden. After the temporary tattoo exercise the perception of the mental and physical impact of both psoriasis and eczema increased significantly. Furthermore, the comments of the participants suggest that wearing the temporary tattoo elicited feelings of embarrassment and self-consciousness that might be experienced by a patient with psoriasis. Despite these findings, there appeared to be limited significant changes after the exercise for questions relating specifically to skin disease (Table III). Responses to these questions were difficult to interpret because of the large variability in scores. The inconsistencies of these results and the limited statistical analysis are important limitations to this study. Significant changes in the perception of the physical and mental burden of other conditions were also observed after the temporary tattoo exercise; for example, the physical burden of arthritis
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Table IV. Overview of comments provided by participants after temporary tattoo exercise Description of comment type
Number of participants (%)
Described being affected by temporary tattoo exercise (eg, selfconscious, stared at in public)
35/61 (57.4%)
Forgot they had it on/no effect No comment provided
Comment subcategory
Number of participants (%)
Described being self-conscious, embarrassed, or uncomfortable
30/61 (49.2%)
Noticed or perceived that others were looking/staring at tattoo while in public
15/61 (24.6%)
Attempted to cover tattoo
8/61 (13.1%)
17/61 (27.9%)
9/61 (14.7%)
and high blood pressure was perceived as being significantly higher after the exercise. It is not completely clear why the exercise would have changed the perception of the burden of conditions other than psoriasis; one possible explanation is that the exercise caused participants to consider the physical and mental impact of disease in general more carefully, resulting in a significant change in scores. Another possibility, and a potential limitation of this study, is that the changes in the perception of the burden of psoriasis were a result of nonspecific phenomena such that increased scores after the exercise were a result of participating in a study on disease and not specific to psoriasis. However, considering that more than half (57.4%) of the participants documented that they were impacted by the exercise in their comments, we believe the observed change in the perception of the burden of psoriasis cannot be entirely attributed to nonspecific changes.
Examples
‘‘I was not used to having a tattoo so it did make me feel a little more self conscious. My boyfriend/family made a lot of comments about it and noticed it immediately making me feel that if this was real psoriasis they would certainly think it’s unpleasant to look at’’ ‘‘I felt self conscious about it and wanted to keep it covered up as much as possible’’ ‘‘Self-conscious, nervous, ashamed’’ ‘‘People stared at my arm on my walk home. I felt like they thought it looked gross. I hesitated to wear a t shirt today thinking people would react poorly to my appearance’’ ‘‘I got a few odd stares, made me feel self conscious in crowded public areas (malls, elevators)’’ ‘‘Lots of people looked at it. I could feel the eyes’’ ‘‘I felt self-conscious when I caught someone looking at it. From then on I was unable to forget having it unless my sleeve was pulled down all the way to my wrist’’ ‘‘I felt self conscious about it and wanted to keep it covered up as much as possible’’ ‘‘I forgot I had it on, no effect on my feelings’’ ‘‘I honestly kept forgetting that I had it on. I felt no impact in public’’ Not applicable
Although our results indicate that temporary tattoos may be useful in medical education, we acknowledge that there are significant limitations to this study. First, this was a pilot study examining empathy and perceptions of disease burdens, which are difficult to measure quantitatively. Our survey instrument used in part A of the questionnaire has not been previously validated and the statistical analysis for this study is limited because of small sample size and lack of a control group. We also understand that some participants may have been compelled to respond in a more empathetic manner after the exercise simply because they were aware that they were participating in an exercise relating to skin disease. We further acknowledge that the tattoo exercise does not completely simulate the experience of a patient with psoriasis: neither the chronic nature of the disease nor the scaling, pruritic characteristics of psoriatic lesionsefactors that significantly impact patient quality of life.
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Moulages are 3-dimensional representations of skin lesions and have been used for decades to teach dermatology to medical students.16,17 We believe that temporary tattoos have advantages over this traditional method in that they can be produced rapidly and at a low cost, and that they are derived from digital images of real lesions, and may be changed based on the availability of images to suit a specific curriculum. We believe our pilot study demonstrates that temporary tattoos can be used effectively as a novel teaching tool, and that educational interventions, such as the exercise we presented here, may be incorporated into the undergraduate medical curriculum to promote an understanding of skin disease. The authors would like to acknowledge Jessica Corbin, Research Assistant in the Division of Dermatology at Dalhousie University, for her assistance with data collection; Dominique Babin-Muise, medical student, for her assistance in developing the study questionnaire; Dr Laurie Parsons, Assistant Clinical Professor of Dermatology, University of Calgary, for her contribution to the protocol design; Kara Thompson, Biostatistician, for her help with the statistical analysis of data for this project; Mandy Morgan, Coordinator, Undergraduate Medical Education at Dalhousie University, for administrating the study; and Dianne Delva, MD, Associate Dean of Undergraduate Medical Education, for facilitating and supporting this project. REFERENCES 1. Krueger G, Koo J, Lebwohl M, Menter A, Stern RS, Rolstad T. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol 2001;137:280-4. 2. Gupta N. Comorbid disease in psoriasis: don’t forget mental illnesses. BMJ 2010;340:c781. 3. Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol 2006;54:420-6.
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4. Ginsburg IH, Link BG. Psychosocial consequences of rejection and stigma feelings in psoriasis patients. Int J Dermatol 1993; 32:587-91. 5. Evers AW, Lu Y, Duller P, van der Valk PG, Kraaimaat FW, van de Kerkhof PC. Common burden of chronic skin diseases? Contributors to psychological distress in adults with psoriasis and atopic dermatitis. Br J Dermatol 2005;152:1275-81. 6. Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin DM. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol 1999;41:401-7. 7. Weiss SC, Kimball AB, Liewehr DJ, Blauvelt A, Turner ML, Emanuel EJ. Quantifying the harmful effect of psoriasis on health-related quality of life. J Am Acad Dermatol 2002;47: 512-8. 8. Schmid-Ott G, Jaeger B, Kuensebeck HW, Ott R, Lamprecht F. Dimensions of stigmatization in patients with psoriasis in a ‘‘questionnaire on experience with skin complaints.’’ Dermatology 1996;193:304-10. 9. Burge S, British Association of University Teachers of Dermatology. Teaching dermatology to medical students: a survey of current practice in the UK. Br J Dermatol 2002;146:295-303. 10. Hurley KF. OSCE and clinical skills handbook. Toronto, Ontario (Canada): Elsevier Saunders; 2005. 11. Geller AC, Venna S, Prout M, Miller DR, Demierre MF, Koh HK, et al. Should the skin cancer examination be taught in medical school? Arch Dermatol 2002;138:1201-3. 12. Langley RG, Tyler SA, Ornstein AE, Sutherland AE, Mosher LM. Temporary tattoos to simulate skin disease: report and validation of a novel teaching tool. Acad Med 2009;84:950-3. 13. Chren MM, Lasek RJ, Quinn LM, Mostow EN, Zyzanski SJ. Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness. J Invest Dermatol 1996;107:707-13. 14. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)ea simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6. 15. Alahlafi A, Burge S. What should undergraduate medical students know about psoriasis? Involving patients in curriculum development: modified Delphi technique. BMJ 2005;330: 633-6. 16. Garg A, Haley HL, Hatem D. Modern moulage: evaluating the use of 3-dimensional prosthetic mimics in a dermatology teaching program for second-year medical students. Arch Dermatol 2010;146:143-6. 17. Robinson JK, Lio P, Hernandez C, Kim NN, Lee KC, Wickless H, et al. Medical student detection of melanoma: clinical skills. Arch Dermatol 2010;146:1175-7.
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t is becoming increasingly recognized that psoriasis has a profound negative impact on mental and physical well-being.1 Evidence suggests that patients with psoriasis experience a higher incidence of clinically significant psychiatric symptoms, such as depression and suicidal ideation,2,3 compared with the general population. Furthermore, the burden of psoriasis is often underappreciated and poorly From the Division of Dermatology, Department of Medicine,a and Medical School,b Dalhousie University, Halifax; and Department of Dermatology, Clinical Unit for Research Trials in Skin, Massachusetts General Hospital, Harvard Medical School.c The first two authors contributed equally to this work. Dr Langley receives funding from the Canadian Dermatology Foundation for his research on melanoma. Conflicts of interest: None declared. Accepted for publication July 21, 2011.
Abbreviations used: SF-36: VAS:
short form (36) health survey visual analog scale
understood by the public which, in turn, contributes to stigmatization of these patients.4-8 Reprint requests: Richard G. Langley, MD, FRCPC, Division of Dermatology, Dalhousie University, Room 4-195 Dickson Bldg, QE II Health Science Center, Halifax, Nova Scotia, Canada B3H 2Y9. E-mail: [email protected]. Published online October 10, 2011. 0190-9622/$36.00 Ó 2011 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2011.07.023
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Educating medical students about the impact of converted into a temporary tattoo after color matchpsoriasis can be a challenge as dermatology is often ing using a standardized color-matching system underrepresented in undergraduate medical curric(Pantone Matching System, Pantone Inc, Carlstadt, ula, limiting students’ exposure to patients with NJ). The adhesive side of the tattoo is applied to the chronic skin conditions.9-11 Recently, we developed skin and a water-dampened cloth is then applied a series of temporary tattoos based on high-quality with gentle pressure for 30 seconds. Then the paper digital images of actual skin lesions.12 These tattoos backing is removed, revealing the tattoo on the skin provide realistic, standard(Fig 1). The tattoo is deized representations that signed to last for up to sevCAPSULE SUMMARY have been used in undereral days, but it is easily graduate medical education removed by gently washing Psoriasis has a profound impact on at Canadian universities. In the area of application with quality of life that is often this pilot study, a temporary soap and water. underappreciated by health care tattoo of a psoriatic lesion professionals and the public. was used to temporarily simPre-temporary tattoo Medical students may perceive psoriasis ulate the experience of havexercise questionnaires as less important than other common ing psoriasis in a group of Students were presented medical conditions. undergraduate medical stuwith the opportunity to pardents. Before and after wearticipate in a study about the Temporary tattoos are a novel and ing a temporary tattoo in mental and physical impact effective method of teaching medical public, participants were of different diseases during students, and potentially the general asked about their perception a classroom presentation public, about the psychological burden of the burden of psoriasis by an administrator from of psoriasis. and other acute and chronic Dalhousie Undergraduate diseases, testing the effect of Medical Education who was this exercise on their perception of the severity of not affiliated with the Division of Dermatology. The psoriasis. It was anticipated that psoriasis would be students were assured that participation in the study perceived by entry-level medical students as having was voluntary, that the data collected would remain a low burden on the patient relative to other comanonymous through the use of individual identificamon medical conditions, and that the exercise would tion numbers, and that no part of their study particchange their perception of the effect of psoriasis on ipation or nonparticipation would affect their quality of life. academic standing. A summary of the study methods is presented in Fig 2. The students were not aware METHODS that the study was related to skin disease before Study population and design beginning the questionnaires. In part A of the quesThe study population consisted of 91 first-year tionnaire, participants were asked to report their medical students at the Halifax and Saint John own understanding and prior knowledge of several campuses of Dalhousie University’s Faculty of diseases, including chronic lung disease, arthritis, Medicine in Halifax, Nova Scotia, Canada. The study eczema, ischemic heart disease, psoriasis, depreswas approved by the Capital Health Research Ethics sion, hypertension, diabetes, and cancer, using a 4Board at the Queen Elizabeth II Health Sciences point Likert scale. The conditions were selected Centre in Halifax, Nova Scotia, Canada. Students based on a previous report by Rapp et al6 that were recruited during the first month of classes in investigated the quality of life of patients with psoSeptember 2010. riasis relative to other medical conditions using data from the short form (36) health survey (SF-36). Participants were then asked to rate their perception Temporary tattoo of psoriasis of the severity of the physical and mental impact of We developed a temporary tattoo simulating a each disease, from ‘‘not severe’’ to ‘‘extremely sepsoriatic lesion that could be used in dermatology vere,’’ on a visual analog scale (VAS) 100 mm in medical education. The temporary tattoo of melalength. To assist the first-year students in completing noma has recently been validated in a diagnostic the questionnaire, we used lay terminology for some accuracy study, and the technical details of the of the conditions. Participants were also given the development and application of the temporary tatoption of checking ‘‘I don’t know’’ if they could not too are described there.12 Briefly, we obtained a digital photograph of a psoriatic lesion using a digital provide a response on the VAS. Completion of the camera (D1X, Nikon, Tokyo, Japan). This image was initial questionnaires implied consent to the use of d
d
d
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assessments, the Skindex-1613 and the Dermatology Life Quality Index.14 Specifically, questions 7, 9, and 10 from the Skindex-16 and questions 2, 4, and 5 from the Dermatology Life Quality Index were adapted for the questionnaire. The words ‘‘skin condition’’ were replaced with ‘‘the tattoo.’’ Finally, participants were asked the same questions as in the initial questionnaire (part A) about their perceived severity of the physical and mental impact of various diseases and their perception of the mental and physical impact of skin disease.
Fig 1. Temporary tattoo of psoriatic lesion.
the participants’ responses in the study. Part A of the questionnaire was collected before proceeding. Participants were then asked to complete a second questionnaire (part B) assessing their attitudes toward skin disease, which was kept in a sealed envelope up to this point. Participants were asked to rate a series of statements about the severity, and emotional and physical impact of skin disease from ‘‘strongly disagree’’ to ‘‘strongly agree’’ on a VAS. Temporary tattoo exercise Before continuing with the tattoo exercise the participants were required to read and sign an informed consent form that explained the temporary tattoo exercise and the rationale of the study. Participants who chose to continue the study were given a temporary tattoo of psoriasis and instructed to apply it to a visible body part such as the forearm, neck, or hand for 24 hours. They were asked to return the following day to complete the post-exercise questionnaire and were also given a one-page body diagram sheet (to be returned the following day after the exercise) on which to mark the location of their tattoo, and record if and why the tattoo was removed before the end of the exercise. Post-temporary tattoo exercise questionnaires The post-temporary tattoo data (part C) were extracted from a classroom-based questionnaire consisting of 3 parts. First, participants were asked about their experience wearing the temporary tattoo. They were provided with a field to record comments about how wearing the temporary tattoo made them feel. They were also asked to report the proportion of the 24-hour period spent with family or friends, in public, or alone. Next, the participants answered questions about how the tattoo affected them during the exercise. Relevant questions were selected and modified from two validated dermatology quality-of-life
Data analysis Pre- and post-temporary tattoo questionnaires were matched using assigned identification numbers. Only data from participants who completed all study questionnaires were analyzed. Data were analyzed using software (SAS, Version 9.2, SAS Institute Inc, Cary, NC). Baseline data were analyzed by Wilcoxon rank sum test. Scores before and after the tattoo exercise were analyzed using the nonparametric sign test for paired data.
RESULTS Of the 91 medical students who were approached to participate in the study, 61 students completed all study procedures. Thirty participants were excluded because they did not return and complete the survey after the temporary tattoo exercise. Although 12 participants reported that the tattoo was removed or washed off before the 24-hour period, these participants were not excluded as they wore the tattoo for an average of 18.5 hours (range: 11.5-20 hours), which was thought to be a sufficient experience to complete the exercise. All participants wore the tattoo in a visible area and reported that they spent at least some time in public. At baseline, the diseases perceived to have the lowest physical impact (VAS) were psoriasis (mean = 23.6, P\.0001) and eczema (mean = 23.3, P\.0001) (Table I). VAS scores for the perception of mental impact were highest for depression (mean = 93.8) and cancer (mean = 82.2), whereas the remaining conditions, including psoriasis, received similar mean scores ranging from 45.1 to 56.7. Participants applied the temporary tattoo to a visible area of their body and wore it for 24 hours spending at least some time in public. After the tattoo exercise, the perception of the physical impact (VAS) of arthritis (mean = 71.3, P = .0198), eczema (mean = 37.3, P \.0001), high blood pressure (mean = 54.5, P = .0001), and psoriasis (mean = 37.8, P = .0014) were significantly higher (Table II) compared with scores given before the exercise. The perception of the mental impact (VAS) of eczema (mean = 66.6,
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Fig 2. Flow chart summarizing study methods. VAS, Visual analog scale.
Table I. Summary of students’ perceptions of physical and mental impact of different conditions before tattoo exercise Disease
Physical impact Heart attack Cancer Lung disease Arthritis Depression Diabetes High blood pressure Psoriasis Eczema Mental impact Depression Cancer Heart attack High blood pressure Psoriasis Diabetes Eczema Lung disease Arthritis
Table II. Summary of visual analog scale scores given by participants pre- and post-temporary tattoo exercise Mean VAS score
N
Rank
Mean VAS score
P value
61 61 53 60 60 61 60 49 58
1 2 3 4 5 6 7 8 9
81.8 74.9 72.7 67.4 60.4 49.6 43.4 23.6 23.3
\.0001 \.0001 \.0001 \.0001 \.0001 \.0001 \.0001 N/A .6918
61 60 58 58 49 60 57 52 60
1 2 3 4 5 6 7 8 9
93.8 82.2 56.7 54.3 53.0 49.5 48.7 47.8 45.1
\.0001 \.0001 .5494 .0058 N/A .2783 .0957 .2769 .0413
Variable
Physical impact Lung disease Arthritis Eczema Heart attack Depression High blood pressure Psoriasis Diabetes Cancer Mental impact Lung disease Arthritis Eczema Heart attack Depression High blood pressure Psoriasis Diabetes Cancer
N
Pre
Post
P value
53 60 58 61 60 60 49 61 61
72.7 67.4 23.3 81.8 60.5 43.4 23.6 49.6 74.9
71.6 71.3 37.3 77.9 61.9 54.5 37.6 55.5 77.4
.7798 .0198 \.0001 .0396 .2892 .0001 .0014 .0674 .8957
52 60 57 58 61 58 49 60 60
47.8 45.1 48.7 56.7 93.8 54.3 53.0 49.5 82.2
51.6 50.6 66.6 60.7 91.4 43.7 68.6 53.7 79.0
.6778 .4270 .0005 .7914 \.0001 .4270 .0293 .8974 .0300
P values are based on Wilcoxon rank sum test on difference in score for condition less score for psoriasis. Scores for psoriasis are in bold for emphasis. N/A, Not applicable; VAS, visual analog scale.
P values are based on nonparametric sign test for paired data. Scores for psoriasis are in bold for emphasis. VAS, Visual analog scale.
P = .0005) and psoriasis (mean = 68.6, P = .0293) was significantly higher compared with scores given before the exercise. The perception of the mental impact of both depression (mean = 91.4, P \.0001) and cancer (mean = 79.0, P = .03) was significantly
lower after the exercise. Regarding the questions specific to skin disease (part B), there was a significant change in the response to the phrase ‘‘Noncancerous skin disease has very little impact on someone’s daily function’’ (mean pre = 34.9, mean
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Table III. Summary of participant scores for skin disease questionnaire Mean VAS score Pre
Post
‘‘I consider skin conditions less serious than most other medical conditions’’ 49.7 (SD = 21.5) 43.3 (SD = 20.9) ‘‘I consider skin disease a serious problem’’ 64.5 (SD = 16.9) 67.4 (SD = 19.4) ‘‘The emotional impact of skin disease is negligible’’ 14.30 (SD = 14.9) 12.02 (SD = 13.9) ‘‘Non-cancerous (benign) skin conditions are generally superficial problems’’ 29.7 (SD = 20.5) 30.5 (SD = 21.1) ‘‘Non-cancerous (benign) skin disease has very little impact on someone’s 34.9 (SD = 24.0) 27.4 (SD = 22.0) daily function’’ ‘‘Non-cancerous (benign) skin disease can greatly impact one’s self esteem’’ 85.3 (SD = 16.1) 82.5 (SD = 21.1)
P value
.0925 .2000 .2717 .6989 .0163 .5901
Participants were asked to rate these phrases on VAS from ‘‘strongly disagree’’ (0) to ‘‘strongly agree’’ (100). P values are based on nonparametric sign test for paired data. VAS, Visual analog scale.
post = 27.4, P = .0163), suggesting participants disagreed more strongly with this phrase after the exercise. Scores for the other questions relating to skin disease were not significant and there was a large degree of variability in the responses (Table III). To determine how they were affected by the tattoo during the exercise, participants were asked to score how embarrassed, annoyed, or bothered they were when wearing the tattoo (VAS) and whether wearing the tattoo altered their leisure activities or choice of clothing. They were also asked to provide comments describing their experiences during the exercise. When asked specific questions relating to how wearing the temporary tattoo made them feel, most participants reported that they were somewhat embarrassed (mean = 30.8), annoyed (mean = 22.2), or bothered by the appearance (mean = 29.9) of the tattoo. Fourteen of 61 participants (23%) reported that wearing the tattoo affected their social or leisure activities. Although 28 of 61 participants (46%) reported that wearing the tattoo affected their choice of clothing, 33 of 61 participants (54%) reported that their choice of clothing was not affected. In the freeform comments, 35 of 61 of participants (57.4%) described being affected by the exercise (eg, feelings of self-consciousness or embarrassment), 15 of 61 participants (27.9%) forgot they were wearing the tattoo or thought that the exercise had no effect, and 9 of 61 participants (14.7%) did not provide a comment. Selected comments from participants are presented in Table IV.
DISCUSSION There is evidence that the physical and mental burden of psoriasis and its effect on quality of life compares with that of other chronic diseases such as cancer, arthritis, hypertension, heart disease, and clinical depression.6 We found that first-year medical students perceive psoriasis as having less physical impact on patients
than other common medical conditions. Our results also suggest that students perceive the mental impact of skin disease to be comparable with nonvisible, chronic medical conditions such as arthritis, hypertension, and diabetes. In fact, scores for the perception of mental impact were very similar for all conditions except those that would be expected to have a great mental burden (cancer and depression), suggesting that participants were unsure about how disease impacts mental well-being. It is notable that only 49 of 61 students provided a score for the mental and physical severity of psoriasisea lower response rate than all other conditions queriede possibly reflecting further uncertainty about how to rate the burden of psoriasis relative to other conditions. The complex social, psychological, and physical contributory factors may be difficult to appreciate for entering medical students15 and our findings call attention to the importance of including psychological impact of disease when teaching undergraduate medical students about disease burden. After the temporary tattoo exercise the perception of the mental and physical impact of both psoriasis and eczema increased significantly. Furthermore, the comments of the participants suggest that wearing the temporary tattoo elicited feelings of embarrassment and self-consciousness that might be experienced by a patient with psoriasis. Despite these findings, there appeared to be limited significant changes after the exercise for questions relating specifically to skin disease (Table III). Responses to these questions were difficult to interpret because of the large variability in scores. The inconsistencies of these results and the limited statistical analysis are important limitations to this study. Significant changes in the perception of the physical and mental burden of other conditions were also observed after the temporary tattoo exercise; for example, the physical burden of arthritis
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Table IV. Overview of comments provided by participants after temporary tattoo exercise Description of comment type
Number of participants (%)
Described being affected by temporary tattoo exercise (eg, selfconscious, stared at in public)
35/61 (57.4%)
Forgot they had it on/no effect No comment provided
Comment subcategory
Number of participants (%)
Described being self-conscious, embarrassed, or uncomfortable
30/61 (49.2%)
Noticed or perceived that others were looking/staring at tattoo while in public
15/61 (24.6%)
Attempted to cover tattoo
8/61 (13.1%)
17/61 (27.9%)
9/61 (14.7%)
and high blood pressure was perceived as being significantly higher after the exercise. It is not completely clear why the exercise would have changed the perception of the burden of conditions other than psoriasis; one possible explanation is that the exercise caused participants to consider the physical and mental impact of disease in general more carefully, resulting in a significant change in scores. Another possibility, and a potential limitation of this study, is that the changes in the perception of the burden of psoriasis were a result of nonspecific phenomena such that increased scores after the exercise were a result of participating in a study on disease and not specific to psoriasis. However, considering that more than half (57.4%) of the participants documented that they were impacted by the exercise in their comments, we believe the observed change in the perception of the burden of psoriasis cannot be entirely attributed to nonspecific changes.
Examples
‘‘I was not used to having a tattoo so it did make me feel a little more self conscious. My boyfriend/family made a lot of comments about it and noticed it immediately making me feel that if this was real psoriasis they would certainly think it’s unpleasant to look at’’ ‘‘I felt self conscious about it and wanted to keep it covered up as much as possible’’ ‘‘Self-conscious, nervous, ashamed’’ ‘‘People stared at my arm on my walk home. I felt like they thought it looked gross. I hesitated to wear a t shirt today thinking people would react poorly to my appearance’’ ‘‘I got a few odd stares, made me feel self conscious in crowded public areas (malls, elevators)’’ ‘‘Lots of people looked at it. I could feel the eyes’’ ‘‘I felt self-conscious when I caught someone looking at it. From then on I was unable to forget having it unless my sleeve was pulled down all the way to my wrist’’ ‘‘I felt self conscious about it and wanted to keep it covered up as much as possible’’ ‘‘I forgot I had it on, no effect on my feelings’’ ‘‘I honestly kept forgetting that I had it on. I felt no impact in public’’ Not applicable
Although our results indicate that temporary tattoos may be useful in medical education, we acknowledge that there are significant limitations to this study. First, this was a pilot study examining empathy and perceptions of disease burdens, which are difficult to measure quantitatively. Our survey instrument used in part A of the questionnaire has not been previously validated and the statistical analysis for this study is limited because of small sample size and lack of a control group. We also understand that some participants may have been compelled to respond in a more empathetic manner after the exercise simply because they were aware that they were participating in an exercise relating to skin disease. We further acknowledge that the tattoo exercise does not completely simulate the experience of a patient with psoriasis: neither the chronic nature of the disease nor the scaling, pruritic characteristics of psoriatic lesionsefactors that significantly impact patient quality of life.
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Moulages are 3-dimensional representations of skin lesions and have been used for decades to teach dermatology to medical students.16,17 We believe that temporary tattoos have advantages over this traditional method in that they can be produced rapidly and at a low cost, and that they are derived from digital images of real lesions, and may be changed based on the availability of images to suit a specific curriculum. We believe our pilot study demonstrates that temporary tattoos can be used effectively as a novel teaching tool, and that educational interventions, such as the exercise we presented here, may be incorporated into the undergraduate medical curriculum to promote an understanding of skin disease. The authors would like to acknowledge Jessica Corbin, Research Assistant in the Division of Dermatology at Dalhousie University, for her assistance with data collection; Dominique Babin-Muise, medical student, for her assistance in developing the study questionnaire; Dr Laurie Parsons, Assistant Clinical Professor of Dermatology, University of Calgary, for her contribution to the protocol design; Kara Thompson, Biostatistician, for her help with the statistical analysis of data for this project; Mandy Morgan, Coordinator, Undergraduate Medical Education at Dalhousie University, for administrating the study; and Dianne Delva, MD, Associate Dean of Undergraduate Medical Education, for facilitating and supporting this project. REFERENCES 1. Krueger G, Koo J, Lebwohl M, Menter A, Stern RS, Rolstad T. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol 2001;137:280-4. 2. Gupta N. Comorbid disease in psoriasis: don’t forget mental illnesses. BMJ 2010;340:c781. 3. Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol 2006;54:420-6.
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4. Ginsburg IH, Link BG. Psychosocial consequences of rejection and stigma feelings in psoriasis patients. Int J Dermatol 1993; 32:587-91. 5. Evers AW, Lu Y, Duller P, van der Valk PG, Kraaimaat FW, van de Kerkhof PC. Common burden of chronic skin diseases? Contributors to psychological distress in adults with psoriasis and atopic dermatitis. Br J Dermatol 2005;152:1275-81. 6. Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin DM. Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol 1999;41:401-7. 7. Weiss SC, Kimball AB, Liewehr DJ, Blauvelt A, Turner ML, Emanuel EJ. Quantifying the harmful effect of psoriasis on health-related quality of life. J Am Acad Dermatol 2002;47: 512-8. 8. Schmid-Ott G, Jaeger B, Kuensebeck HW, Ott R, Lamprecht F. Dimensions of stigmatization in patients with psoriasis in a ‘‘questionnaire on experience with skin complaints.’’ Dermatology 1996;193:304-10. 9. Burge S, British Association of University Teachers of Dermatology. Teaching dermatology to medical students: a survey of current practice in the UK. Br J Dermatol 2002;146:295-303. 10. Hurley KF. OSCE and clinical skills handbook. Toronto, Ontario (Canada): Elsevier Saunders; 2005. 11. Geller AC, Venna S, Prout M, Miller DR, Demierre MF, Koh HK, et al. Should the skin cancer examination be taught in medical school? Arch Dermatol 2002;138:1201-3. 12. Langley RG, Tyler SA, Ornstein AE, Sutherland AE, Mosher LM. Temporary tattoos to simulate skin disease: report and validation of a novel teaching tool. Acad Med 2009;84:950-3. 13. Chren MM, Lasek RJ, Quinn LM, Mostow EN, Zyzanski SJ. Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness. J Invest Dermatol 1996;107:707-13. 14. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)ea simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19:210-6. 15. Alahlafi A, Burge S. What should undergraduate medical students know about psoriasis? Involving patients in curriculum development: modified Delphi technique. BMJ 2005;330: 633-6. 16. Garg A, Haley HL, Hatem D. Modern moulage: evaluating the use of 3-dimensional prosthetic mimics in a dermatology teaching program for second-year medical students. Arch Dermatol 2010;146:143-6. 17. Robinson JK, Lio P, Hernandez C, Kim NN, Lee KC, Wickless H, et al. Medical student detection of melanoma: clinical skills. Arch Dermatol 2010;146:1175-7.