Teaching & Learning Tips 9: Case‐based teaching with patients

Challenge: “Case‐based teaching” is a buzzword for engaging clinical teaching through cases, but how can it be implemented effectively in practice? We review popular case‐based teaching methods (i.e., one‐minute preceptor, SNAPPS, and the “Aunt Minnie method”) for use during traditional one‐on‐one clinical preceptorships in the ambulatory dermatological setting.     

Teaching & Learning Tips 11: Teaching a procedure

Challenge: Balancing patient‐centered clinical care with learner‐centered teaching in a clinical setting becomes particularly challenging when it comes to teaching procedures to trainees (e.g. biopsies, excisions, etc.). How can procedures be taught in a way that reinforces repetition and mastery without compromising patient safety, care, and comfort?     

Teaching & Learning Tips 3: Active learning strategies

Challenge: It takes practice and thoughtful planning to inspire trainees to actively process new information instead of passively receive it. In fact, research suggests “active teaching” does not always lead to “active learning,” so what are some general principles to encourage trainees to engage in active learning in any teaching context?     

Teaching & Learning Tips 6: The flipped classroom

Challenge: The “flipped classroom” is a pedagogical model in which instructional materials are delivered to learners outside of class, reserving class time for application of new principles with peers and instructors. Active learning has forever been an elusive ideal in medical education, but the flipped class model is relatively new to medical education. What is the evidence for the “flipped classroom,” and how can these techniques be applied to the teaching of dermatology to trainees at all stages of their medical careers?     

Teaching & Learning Tips 2: Cognitive load theory

Challenge: Dermatology trainees include medical students, residents, and fellows. Variability in level of experience and background knowledge can make clinical teaching challenging. Research also shows novices have different ways of thinking than experts, which must be acknowledged in the preceptor‐trainee interaction for optimal teaching and learning to occur. Herein we explore how “cognitive load” varies with learner level and how reducing cognitive load can enhance learning, especially for novice learners.     

Teaching and Learning Tips 12: Peer observation of teaching

Challenge: How can clinical teachers continually improve their teaching skills? In addition to student feedback, peer and expert opinion can also provide valuable formative and evaluative feedback to guide self‐improvement efforts. Here, we discuss ways to structure peer observation of teaching in dermatological settings and offer tips on how to optimize the learning experience for both the educator and peer observer.     

Teaching & Learning Tips 7: small‐group discussion

Challenge: The success of a small‐group discussion depends in large part on the effectiveness of the facilitator or small‐group tutor. How can a facilitator successfully manage diverse views and knowledge bases of participants while also contributing as a member of the group? Herein, we provide tips for managing small‐group discussions that can be applied widely in dermatology didactics.     

Teaching & Learning Tips 4: Motivation and emotion in learning

Challenge: Trainees’ motivational and emotional states can influence their learning and career decisions, but historically these “affective” learning factors have received little attention in medical education. In this “Tips” piece, we outline strategies to positively influence trainees’ intrinsic motivation and emotion toward their training to ultimately enhance their overall learning experience.     

Teaching & Learning Tips 1: Teaching perspectives – an introduction

Challenge: Clinical and research responsibilities often leave little or no time to plan thoughtful teaching encounters with trainees. This “Teaching & Learning Tips” series is designed to be an accessible guide for dermatologists who want to improve their teaching skills. It is comprised of 12 articles about how to enhance teaching in various settings informed by research about how people learn and expert‐derived or data‐driven best practices for teaching. The series begins with a review of principles to optimize learning in any setting, including cognitive load theory, active learning strategies, and the impact of motivation and emotion on learning. It transitions into a practical “how to” guide format for common teaching scenarios in dermatology, such as lecturing, case‐based teaching, and teaching procedures, among others. Herein, we kickoff the series by unpacking assumptions about teaching and learning. What does it mean to teach and learn?     

Teaching & Learning Tips 8: Preparing to teach in ambulatory settings

Challenge: Clinical teaching in dermatology largely occurs in the outpatient setting. Herein, we review common barriers to teaching in the ambulatory setting and discuss strategies preceptors can take to “teach on the run” during clinic sessions.     

Teaching & Learning Tips 5: Making lectures more “active”

Challenge: Although lecturing is an efficient method for the dissemination of information, it has long been criticized for learner passivity and diminished knowledge retention. Active learning strategies to engage the audience in the learning process can facilitate a bidirectional flow of ideas and content between teacher and students during a lecture to keep learners engaged and participating.     

Pediatric dermatology consultations: a retrospective analysis of inpatient consultations referred to the dermatology service

To analyze the care provided by consultant dermatologists to hospitalized pediatric patients, we retrospectively studied the records of inpatient pediatric consultation requests received by a hospital dermatology department between 2000 and 2009. The diagnoses were recorded according to the International Classification of Diseases, Ninth Revision (ICD-9). In a high percentage of cases, the problem was addressed in a single visit, and few additional tests were ordered. The most common diagnostic groups were diseases of the skin and subcutaneous tissue (ICD-9: 680-709). The most frequent specific diagnosis was atopic dermatitis (ICD-9: 691.8). Our series shows that the role of dermatologists as consultants for pediatric inpatients is similar to their role in outpatient consultations.     

Microbiologic evaluation of skin wounds: alarming trend toward antibiotic resistance in an inpatient dermatology service during a 10-year period

BACKGROUND: Increasing resistance to commonly used antibiotics has been seen for patients with superficial skin wounds and leg ulcers. OBJECTIVES: We sought to evaluate bacterial isolates from leg ulcers and superficial wounds for resistance to commonly used antibiotics and to compare current data with previous data. METHODS: We performed a chart review for patients admitted to a tertiary care dermatology inpatient unit from January to December 2001. Comparison was made with 2 previous surveys of the same inpatient service from 1992 and 1996. RESULTS: Bacterial isolates were cultured from 148 patients, 84% (72 of 86) with leg ulcers and 38% (76 of 202) with superficial wounds. Staphylococcus aureus and Pseudomonas aeruginosa were the most common bacterial isolates in both groups. For patients with leg ulcers, S aureus grew in 67% of isolates (48/72) of which 75% (36/48) were methicillin-resistant (MRSA). Of leg ulcers, 35% (25/72) grew P aeruginosa, which was resistant to quinolones in 56% of cultures (14/25). For patients with superficial wounds, S aureus was isolated in 75% (57/76) and 44% were MRSA (25/57). P aeruginosa grew in 17% of isolates (13/76) and was resistant to quinolones in 18%. We found a marked increase in antibiotic resistance for both leg ulcers and superficial wounds. Over time, MRSA increased in leg ulcers from 26% in 1992 to 75% in 2001. For superficial wounds, MRSA increased from 7% in 1992 to 44% in 2001. P aeruginosa resistance to quinolones in leg ulcers increased from 19% in 1992 to 56% in 2001, whereas for superficial wounds there was no resistance in 1992 and 18% resistance in 2001. CONCLUSION: Rapid emergence of antibiotic-resistant bacteria continues and is a problem of increasing significance in dermatology. Common pathogenic bacteria, S aureus and P aeruginosa, showed increased resistance to commonly used antibiotics. Selection of antibiotics should be on the basis of local surveillance programs.     

Case mix measures and diagnosis-related groups: opportunities and threats for inpatient dermatology

OBJECTIVE: The changing healthcare environment world-wide is leading to extensive use of per case payment systems based on diagnosis-related groups (DRG). The aim of this study was to examine the impact of application of different DRG systems used in the German healthcare system. METHODS: We retrospectively analysed 2334 clinical data sets of inpatients discharged from an academic dermatological inpatient unit in 2003. Data were regarded as providing high coding quality in compliance with the diagnosis and procedure classifications as well as coding standards. The application of the Australian AR-DRG version 4.1, the German G-DRG version 1.0, and the German G-DRG version 2004 was considered in detail. To evaluate more specific aspects, data were broken down into 11 groups based on the principle diagnosis. MAIN OUTCOME MEASURE: DRG cost weights and case mix index were used to compare coverage of inpatient dermatological services. Economic impacts were illustrated by case mix volumes and calculation of DRG payments. RESULTS: Case mix index results and the pending prospective revenues vary tremendously from the application of one or another of the DRG systems. The G-DRG version 2004 provides increased levels of case mix index that encourages, in particular, medical dermatology. CONCLUSIONS: The AR-DRG version 4.1 and the first German DRG version 1.0 appear to be less suitable to adequately cover inpatient dermatology. The G-DRG version 2004 has been greatly improved, probably due to proceeding calculation standards and DRG adjustments. The future of inpatient dermatology is subject to appropriate depiction of well-established treatment standards.     

Dermatology referrals in an East Asian tertiary hospital: a need for inpatient medical dermatology

Background. Within hospitals, there is a need for dermatological expertise, as hospitalized patients have a wider spectrum of severe and serious dermatological conditions, associated with significant morbidity. Aim. To characterize the patient profile and referral pattern of inpatient dermatology consultations, and to evaluate the diagnostic accuracy of non‐dermatologists. Methods. This was a retrospective study reviewing all inpatient referrals for dermatology consultations during a 1‐year period from July 2005 to June 2006 (inclusive), at the largest multi‐disciplinary tertiary hospital in Singapore. Results. Of the 731 referrals made for dermatology consultations, 26.9% of patients had ≥ 3 important underlying comorbidities. Eczema/dermatitis (33.1%; n = 242) and cutaneous infections (23.4%; n = 171) accounted for over half of the dermatological consultations, followed by cutaneous adverse drug reactions (12.3%; n = 90). The provisional diagnoses of the referring doctors agreed with the final diagnoses confirmed by dermatologists in only 30.2% of all referrals; incorrect diagnoses were made in 35.2% of cases, and no provisional diagnoses were made in the remaining 34.6% of cases. Most misdiagnosed skin diseases were in fact common dermatoses (such as eczemas, cutaneous infections, drug rash) that required only standard treatment. Conclusion. Our study reiterates the importance of inpatient medical dermatology in terms of both service and education. There should be continual efforts to ensure that dermatologists have the highest level of training and experience in medical dermatology, to provide collaborative optimum care for hospitalized patients with dermatological diseases.