There is sometimes a prejudice in medical education that somehow teaching at the bedside is always best. Of course most medical encounters are not at the bedside (any more) simply because most clinical encounters are not on wards, but in offices, whether the offices are in hospitals or elsewhere. The arguments for the bedside include tradition, but also reflect the fear that medical education will be expropriated from the clinical context. I have a lot of sympathy with the latter view, but it will sometimes lead to error.
Yesterday, I talked about the Dermofit App, to which I contributed. One of the rationales for this whole approach almost a dozen years ago now, was my belated realisation that clinical exposure — however intense — in dermatology might not be as efficient as a learning environment in a virtual world. In dermatology, simulation is over one and a half centuries old, and the history of this simulation, tracks the development of technology. It is just that this simulation relies on something we have got used to because it is all around us: high quality graphics. Pictures of lesions.
Several years later we published a paper, exploring this. We wrote:
“The overwhelming majority of students 82% (n = 41) did not see an example of each of the three major skin cancers (BCC, SCC, melanoma) and only a single student (2%) witnessed two examples of each. The percentage of students witnessing 1, >3 and >5 examples is given for each of the 16 lesions and demonstrates that there was not only a lack of breadth but also of depth to the students’ exposure.”
In one sense this is all very obvious. We know that (perceptual) classification tasks require practice, and that practice requires multiple training examples. The training signal: noise ratio can be higher in the virtual world, and it is easier to manipulate events in the virtual world. If the quip is that technology is everything that gets invented after your teenage years, we don’t recognise the obvious technology here simply because it is has been around so long. It is just that silicon really allows it to be done so much better. The caveat is whether the business model allows this.
Students will prefer the clinic, for reasons I understand. But they will often be to wrong to do so.
The App version of Dermofit is on the App store. Here is a link to a link. I have only just started to play around with it. The App was a commercialisation of some work we did here in Edinburgh, between myself and and Bob Fisher in Informatics. If you search my main site reestheskin.me using the keyword ‘dermofit’ you will find a little more about it and the work that led up to it. It is for iPad only. [Yes, I stand to benefit from any sales, but I do not think I will be giving up the day job anytime soon]. I will write another time about the ‘why’ and rationale behind this whole approach.
A short video on epidermal biology with an emphasis on barrier function and irritant dermatitis.
A basic introduction to clinical photobiology for our students.
I don’t tend to blog or write much about the nitty-gritty of some of the day job. And I try to avoid the partisanship that affects so much of medicine in terms of this disease or that disease being a priority…. can we have more research money or money for more doctors etc. But this post is perhaps an exception, and it is written out of utter frustration at the incompetence of the UK health services.
Some data from a paper in press in the JID looking at age-cohort models of melanoma, trying to predict what might happen over time. When I came into dermatology, crude incidence rates for melanoma /100,000 were 5.8. When I retire (if I get that for) they are estimated to be 31.4/100,000. A timespan of one career.
Some context. Yes, this is incidence not mortality; diagnostic patterns have changed over time; and our knowledge of the natural history of melanoma, incomplete. But, in the absence of a major scientific advance that changes the field ( I see little evidence of this), incidence rates will be a key driver of health care needs. Given that melanoma diagnosis is clinical, and that we need to see 10–20 patients to pick up one melanoma, we are looking at a sixfold change in workload over one clinician’s career. And this ignores the more intensive nature of treatment and follow up, so workload will increase even more. Nor is melanoma the most common cancer we see. If cancer is ‘half our work’, melanoma rates are possibly an underestimate of what changes we will see, as the exponent relating incidence to UVR, is even higher for the non-melanoma skin cancers (NMSC).
At present, perhaps 20% of UK consultant dermatologist posts are vacant, and the UK has the lowest number of dermatologists per unit population in the EU by an order of magnitude (certainly in comparison with the German speaking world). I will repeat that: by an order of magnitude. Primary care is in meltdown, too. And while there are lots of well qualified trainees who want to become dermatologists, training positions are essentially static, reflecting classic market corruption by a monopoly. And to cap it all, the Colleges (‘little Englanders’) have recently made the situation even worse, with bizarre changes to dermatology training, that will worsen care in the UK, rather than reflect the changes that will be necessary looking to the future:bracing forward with their eyes on the rear view mirror.
This is not an easy problem to solve. Nor do I think disease rates have to drive doctor numbers in a 1 for 1 way (they don’t); we need to rethink how this profession works. But if you claim to provide a national health service, it is surely negligent not to at least realise that there is a problem — and tell people. My university produces plans. Yes, lots of padding, but also attempts to think how we will function in 2020 and 2025. If you look at health boards, in any meaningful sense, I just see a void. And of course, this isn’t just about dermatology, as my GP politely joined out to me last night: it is across the board.
A short video on urticaria and the biology of the mast cells
Here is number 3. My favourite bit of skin biology.
Here is video number 2 in the ‘clinical’ skin biology series.
I have been busy producing and updating some videos. Here is the first in a series on skin biology.
Hywel Williams gets lyrical about atopic dermatitis. Worth a cwtch, as we might say.
This made me laugh. I have got used to MC1R mutations and red hair in Neanderthals, but this article (full research paper in Science here) brought a smile to my face, even if I am still a little hazy on the genetics.
JBS Haldane once commented ‘that God would appear to be inordinately fond of beetles’, based on the observation that the world was so full of different species of beetles.
I have long had similar thoughts about seborrhoeic keratoses. God must be inordinately fond of them. Seborrhoeic keratoses are benign skin tumours, some of which contain identified mutations: they generally attract little serious research interest (apart from yours truly, of course). However, their significance clinically is enormous. This is because they are incredibly common as people move into their fourth decades and beyond, and because they vary so much in their morphological appearance. They mimic everything, including melanoma. So, most things referred as possible melanomas in many clinics, will turn out to be harmless seborrhoeic keratoses. Of course, a more cynical view is that since seborrhoeic keratoses are such great mimics, they in effect create lots of work for dermatologists. I suppose I should say thank you, next time I bump into one of my distant cousins, but the basis of the link — if confirmed — also deserves some serious mechanistic thought.
Remember those compare and contrast questions (UC versus Crohns; DLE versus LP etc.). Well, look at these two quotes from articles in the same edition of Nature.
The first from the tsunami of papers showing that ‘Something in rotten in the state of
Denmark Science’ — essentially that the Mertonian norms for science have been well and truly trampled over.
Journals charge authors to correct others’ mistakes. For one article that we believed contained an invalidating error, our options were to post a comment in an online commenting system or pay a ‘discounted’ submission fee of US$1,716. With another journal from the same publisher, the fee was £1,470 (US$2,100) to publish a letter. Letters from the journal advised that “we are unable to take editorial considerations into account when assessing waiver requests, only the author’s documented ability to pay”.
Discrete Analysis’[the journal] costs are only $10 per submitted paper, says Gowers; money required to make use of Scholastica, software that was developed at the University of Chicago in Illinois for managing peer review and for setting up journal websites. (The journal also relies on the continued existence of arXiv, whose running costs amount to less than $10 per paper). A grant from the University of Cambridge will cover the cost of the first 500 or so submissions, after which Gower hopes to find additional funding or ask researchers for a submission fee.
Well done the Universities of Cambridge and Cornell (arXiv). For science, the way forward is clear. But for much clinical medicine, including much of my own field, we need to break down the barriers between publication and posting online information that others may find useful. This cannot happen until the financial costs approximate to zero.
My main site, reestheskin.me, has had a makeover. The design is in place but some of the content I will need to amend over the next few weeks. If your interests include skin cancer, it includes a new skin cancer atlas with close to ~600 high quality images. Works on mobile too. I will be adding more educational content, including videos soon.
I am at the ESDR 2015 in Rotterdam. Strange sort of place, I haven’t been here before, but I guess there was a lot of war damage (the exact details of which have subsequently been explained to me by a Dutch colleague, Marcel Jonkman). Many parts of the city look like a toy town with buildings that I first saw in comic books when I was a kid. I find it hard to imagine it being a home — but then I don’t live here. On the other hand, lots of nice bars and coffee shops; and bikes. And the Dutch always seem so friendly, and possess a great sense of humour (meaning I tend to laugh, when they laugh).
As for the meeting, well… Leo Szilard, suggested many years ago that presenters should just stand up and announce their conclusions, in a sentence or two. If the audience think the conclusions reasonable, they should quickly then sit down again. On the other hand (and he was a physicist), if the conclusions sounded unreasonable, then they would need to spend time justifying their thinking (or their data). In biology, or medicine, this approach is problematic. Treatment X works better than treatment Y? Not much to say, except that this argument illustrates why so much of scientific conferences no longer consist of science. Second, even biology has so many myriad pathways that it is so hard to frame experiments as tests of hypotheses, rather than stamp collecting. Biology is just messy, and I remain amazed that we can discover anything useful at all. But we can, and we do.
There was a nice keynote by Cédric Blanpain on tumour heterogeneity. I once claimed to know something about this, but since I was reading in this area, technology has moved on. Nonetheless, at the risk of sounding like somebody who always says there is nothing new under the sun, I think many of the key questions that people were framing 25 years ago, still remain unanswered: how do we deal with molecular heterogeneity (and the drivers of tumour heterogeneity), and how do we therapeutically get round this issue? Is there a bigger problem in cancer?
As for the Szilard approach, the ESDR have tried, and it works. Short one or two sentence statements, ending with ‘if you want to find out why, visit my poster’. Neat. And posters can be fun.
This is up on my Vimeo page , as well. How to approach and think about pigmented lesions. #fOAmed.
There was a recent article in the NEJM about regulation and sunscreens. Much of this world is more regulation than science, a la the murky worlds of pharma, and more about shifting units than providing value. I wrote a letter highlighting some of the problems of confusing ‘regulation’ with ‘science’. The text is below. Links here and here.
The role of UVA, and sunscreens in preventing skin cancer
The statement that UVA is ‘most closely linked to cancer’ is lacking in nuance. The evidence is probably firmer for UVB for some types of skin cancer, but there remains genuine debate about UVA, especially for melanoma. The attempt to demarcate sunscreens that prevent burning from those that might prevent cancer, is misplaced. Damage from UVR is a continuous variable,and burning is not a well defined term operationally. Erythema varies across orders of magnitude of UVR exposure,and it is easy to demonstrate DNA damage without erythema. If you prevent ‘erythema’ or ‘sub-erythema’ (that is changes in blood flow that you can measure but not see) you might imagine that you will prevent cancer in the long term, although the evidence to support this reasonable belief is sparse, especially for melanoma. Pretending that only a sunscreen with a SPF greater than 15 can achieve this, whereas those beneath 15 ‘just’ reduce erythema, seems to me to be taking a liberty with scientific common sense. How the sunscreens are used in the real world (thickness, frequency of re-application) probably adds in more variance, as the author notes.
Fairly dismal reading here and here. Much of what has happened in the UK is a result of a health service that is not based around clinical need, and in which most decision makers might as well believe in fairies. The mistake is to imagine that we got into this mess because of a lack of money. We got into this mess for much the same reason that much of UK industry has collapsed: the people making decisions have no technical competence in the relevant domains. If it was left to the NHS, BMW would not employ engineers (‘its just process management, isn’t it, so let’s reorganise the workflow, and set some targets?’).
So, you receive an email about yet another new author-pays online journal. This one is called Global Dermatology, with the modest abbreviation, GOD. (Not certain how that works). Anyway, you click on the links in the email, to find they are invalid. You open up the email in a browser and, yes, the links don’t work. Just where you might want to place your research for eternity…[A Google search leads you here] [direct link to this post]
Chantelle Winnie via the Guardian
There are areas of medical research that are more legitimate than others. Finding genes is OK, as is finding drugs. But other bits of the health enterprise seem immune to rational scrutiny. One area that has bugged me for years is the way hospitals, charities, professional bodies and others plaster images of skin cancer around, on the assumption that this will ‘make things better’. It might, or it might not. So here is a recent paper of ours on this topic. Take away message: if there is a fixed resource envelope, many if not most strategies may make matters worse. The abstract is below. The images will of course remain up — I am not certain the rationale is the obvious one.
Abstract: Using an experimental task in which lay persons were asked to distinguish between 30 images of melanomas and common mimics of melanoma, we compared various training strategies including the ABC(D) method, use of images of both melanomas and mimics of melanoma, and alternative methods of choosing training image exemplars. Based on a sample size of 976 persons, and an online experimental task, we show that all the positive training approaches increased diagnostic sensitivity when compared with no training, but only the simultaneous use of melanoma and benign exemplars, as chosen by experts, increased specificity and diagnostic accuracy. The ABCD method and use of melanoma exemplar images chosen by laypersons decreased specificity in comparison with the control. The method of choosing exemplar images is important. The levels of change in performance are however very modest, with an increase in accuracy between control and best-performing strategy of only 9%.
Authors: Ella Cornell, Karen Robertson, Robert D. McIntosh, Jonathan L. Rees
Full open access paper here.
Our Dermofit library is available for academic researchers. There is a license, and a nominal fee to cover admin charges. Dermofit was funded by the Wellcome Trust, and we are continuing to commercialise some aspects of this work. The work was led by myself and Prof Bob Fisher in Edinburgh Informatics. Dermofit page here with some publications here (incomplete, as I write).
Access to skincancer909 Well, when was the exam?