Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 804e807

Palpation as a useful diagnostic tool for skin lesions Puvesh Punj*, Peter G. Devitt, Brendon J. Coventry, Robert J. Whitfield Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, North Terrace, Adelaide 5000, South Australia, Australia Received 28 January 2014; accepted 2 February 2014

KEYWORDS Pigmented; Skin lesions; Tactile; Texture

Summary Introduction: Early identification and accurate diagnosis of malignant pigmented skin lesions is essential for effective management and cost containment. The aim was to investigate the additional value of tactile descriptive information from lesion palpation on the diagnostic accuracy of pigmented skin lesions by medical students using computer-driven learning. Methods: Sixth year medical students (n Z 152) from the University of Adelaide were invited to participate in an online teaching module on pigmented skin lesions. Users were asked to describe, diagnose and manage 15 pigmented skin lesions in three separate case studies based on pertinent clinical history and visual images of the lesions. Tactile descriptive information was then provided and users were asked to reflect on their diagnosis and management. Results: A total of 66 (43%) of the sixth year students successfully completed the online module. Diagnostic accuracy improved significantly with the provision of tactile descriptive information for seborrhoeic keratosis (p Z 0.012), basal cell carcinoma (p Z 0.001), squamous cell carcinoma (p Z 0.02), and dysplastic naevi (p Z 0.035). Tactile descriptive information was stated by 23% of medical students to be important in the clinical diagnosis of pigmented skin lesion. Students managed all malignant pigmented skin lesions with either appropriate biopsy or specialist referral. Conclusions: Palpation information about skin lesions offers useful information for improvement of diagnostic accuracy in an online computer learning setting for medical students. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ61 8 8222 5516; fax: þ61 8 8222 5896. E-mail address: [email protected] (P. Punj). 1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.02.009

Palpation as a useful diagnostic tool for skin lesions

Introduction Australia has the highest incidence of skin cancer in the world with a rising rate of melanoma among the younger population.1,2 Differentiating benign from malignant pigmented skin lesions can present significant diagnostic difficulty, as lesions often display variable levels of pigmentation and other morphology. It is widely appreciated that experienced clinicians, who employ a wide range of techniques and skills, often demonstrate high diagnostic acumen.3 With this background in mind, it is of critical importance that medical practitioners have a keen awareness of these conditions and are able to develop the skills to facilitate early diagnosis and appropriate management decisions. In today’s environment where increasing numbers of medical graduates have fewer direct interactions with patients, the provision of appropriate useful learning opportunities is a challenging task.4 There is increasing interest in innovative teaching techniques with improved validated electronic assessment tools for the diagnosis of skin lesions.5,6 The basic assessment of skin lesions involving analytical versus non-analytical thinking has been extensively investigated.4 The “ABCDE” mnemonic for melanoma detection is an example of a useful analytical approach for better pattern recognition.5 However, a holistic approach taking into account novel details of skin lesion including the use of all diagnostic modalities might be preferable.3 Electronic assessment tools that are visual and interactive are also essential for improved diagnostic scores among medical students.7e9 Palpation is a useful adjunctive diagnostic modality that is seldom mentioned and often undervalued in the assessment of skin lesions.3,5 Palpation provides information on consistency, quality, temperature, and tenderness. Its haptic properties have been shown to influence psychomotor performance in laparoscopy and improvement in telemedicine assessment of head and neck cancers.10,11 Computerised analysis of pigmented skin lesions is an evolving area of research aiming to provide diagnostic tactile information from patients in remote areas to clinicians in central hospitals. However evidence for the value of such an approach is inconclusive.6,12 The absence of this key modality in the context of tele-dermatology has been associated with lower diagnostic accuracy rates and higher need for initial biopsy compared with the assessment of patients with malignant pigmented lesions in the clinical setting.13,14 We hypothesised that the addition of tactile descriptive information, obtained by clinicians at the time of skin lesion photography, adds value to the computer-driven diagnostic and management process. Thus the simulation is sufficiently realistic to appropriately supplement the clinical experience. The current study aims to investigate the additional value of tactile descriptive information from palpation on the diagnostic accuracy of pigmented skin lesions by medical students using computer-driven learning.

Materials and methods

805 module on pigmented skin lesions. Users were asked to describe, diagnose and manage a total of 15 pigmented skin lesions in three separate parts, based on visual information with pertinent clinical history. Tactile descriptive information was obtained by the clinician through palpation at the time of image capture of each lesion. The tactile information was then provided to students, who were then asked to reflect on their previous diagnosis and management. All selections were recorded. The correct diagnosis and appropriate management of each pigmented skin lesion was not provided to students during the course of this study. Upon completion of the learning module, students were given the opportunity to complete an online questionnaire that evaluated the effectiveness of the module as a teaching-tool and obtained further information on the use of palpation as a diagnostic modality by the students.

Resource An online self-assessment module entitled ‘Pigmented Skin Lesions: Diagnosis and Management’ was published on www.emedici.com with approval obtained from the Human Research Ethics Committee (HREC), University of Adelaide, South Australia, Australia. eMediciª is an online learning programme containing open-ended series of case studies covering various aspects of medical practice. Participants accessed the online teaching module (eMediciª) using specific user identification details that were later deidentified prior to analysis. The module contained three parts, with each containing five individual case studies, with each case study based on a clinical image of a pigmented skin lesion. A total of three pigmented seborrhoeic keratoses, three pigmented basal cell carcinomas, three pigmented squamous cell carcinomas, three dysplastic naevi and three malignant melanomas were included in this study. Lesions were randomly allocated to each section. Multiple-choice questions were provided for diagnosis and management. Selection options for diagnosis were: solar keratosis, seborrhoeic keratosis, dysplastic naevus, benign melanocytic naevus, basal cell carcinoma, squamous cell carcinoma or malignant melanoma. Selection options for management were: reassure, reassure and monitor, biopsy, or specialist referral. Images included in the modules were obtained with informed consent from patients attending outpatient clinics at the Royal Adelaide Hospital and from a senior consultant image databank. Clinical and tactile descriptive information regarding the lesions was recorded. Diagnosis was based either on histological findings for biopsied lesions or clinical judgement by experienced specialists for nonbiopsied lesions. Recommended management was based on best practice using the National Health and Medical Research Council (NHMRC) clinical practice guidelines for treatment and management of melanoma and nonmelanoma skin cancer in Australia.19,20

Study design

Statistical method

Final (sixth) year medical students from the University of Adelaide were invited to participate in an online teaching

The Student’s t test was used to test score differences for diagnosis (Table 1).

806 Table 1

P. Punj et al. Diagnostic accuracy of pigmented skin lesions.

Type

Pre-tactile (%)

Post-tactile (%)

p Value (Student’s t test)

Malignant melanoma Dysplastic naevus Squamous cell carcinoma (SCC) Basal cell carcinoma (BCC) Seborrhoeic keratosis

72 28 52 40 49

68 36 61 52 56

0.011 0.035 0.002 0.001 0.012

Results

Discussion

A total of 152 final-year medical students were eligible to complete the online learning module with 66 (43%) students successfully completing the task. The accuracy rates pre- and post-provision of tactile descriptive information for individual pigmented skin lesions are shown in Table 1. Malignant melanoma acquired the highest accuracy rate of 72% (pre-tactile) and 68% (post-tactile). The addition of tactile descriptive information resulted in statistically significant increases in the diagnostic accuracy rates for dysplastic naevi, squamous cell carcinomas (SCC), basal cell carcinomas (BCC) and seborrhoeic keratoses. Table 2 summarises the best practice management selections made by medical students for each subtype of pigmented skin lesion after the completion of all three sections within the module. Medical students that accurately diagnosed malignant pigmented skin lesions appropriately managed them with either a biopsy or a request for specialist referral. Students that accurately diagnosed dysplastic naevi and seborrhoeic keratoses were more confident in reassuring and monitoring these lesions. However, 46% of students requested a biopsy for dysplastic naevi. Analysis of the feedback questionnaire showed that the majority (83%) of students had a positive learning experience with the online teaching module. Eleven percent of students rated the online learning tool poorly, citing technical issues in particular the presence of incomplete or unloadable clinical images. Almost half of the students stated that they used either the lesion’s tactile descriptive information (23%) or clinical history of duration of lesion (23%) to aid their clinical diagnosis of individual pigmented skin lesion. Eighty-five percent of students stated they would now utilise palpation of a skin lesion in their assessment of skin lesions in a general practice setting, 11% of students might consider using palpation, and the remaining 4% were undecided.

We have shown that use of the additional tactile component of skin lesion assessment obtained via palpation offers useful information for improved diagnosis in an online computer learning setting for medical students. This is despite the relatively small number of lesions that were used for the investigation, which might indicate the relatively high value of the use of palpation as an adjunctive tool for skin lesion evaluation in clinical diagnosis. The change in accuracy before and after the provision of palpation information appeared greatest for basal cell carcinomas and dysplastic naevi. This may reflect a relative familiarity that Australian medical students have with these lesions, given their increased prevalence in Australia in comparison with other lesions.2 Alternately the visual characteristics of the clinical images utilised in this study for these lesions may have provided added value in their assessment. Rather unexpectedly, the addition of the tactile descriptive reduced students’ diagnostic skills in the cases of malignant melanoma shown to them. The reasons for this reduction are not clear. Melanoma can be difficult to diagnose and appears in numerous morphological forms. The high initial accuracy of detection of 72% before palpation information was provided is gratifying and may reflect the fact that Australian medical students are perhaps highly tuned to the detection of melanoma. Although the provision of tactile information did not improve medical students’ diagnostic accuracy for melanoma in our study, their performance overall compared favourably with general practitioners (50% accuracy) in a study by Brochez et al., where colour image slides were used for the evaluation of 13 pigmented skin lesions.15 Dermatologists performed better in this study (84% accuracy) which did not include the use of tactile information. Students appropriately instituted best practice management for all malignant pigmented skin lesions in our study, either recommending biopsy of the lesion or specialist referral. It has been shown that computer-

Table 2

A summary of best-practice management selected by medical students for individual pigmented skin lesions.

Lesion

Malignant melanoma Squamous cell carcinoma (SCC) Basal cell carcinoma (BCC) Dysplastic naevus Seborrhoeic keratosis

Management Reassure (%)

Reassure and monitor (%)

Biopsy (%)

Specialist referral (%)

0 0 0 1 23

0 0 0 25 56

43 29 59 46 12

57 71 41 28 9

Palpation as a useful diagnostic tool for skin lesions directed learning is capable of teaching and improving management skills of skin cancers among its users.7 We also provided all participants upon completion of the study with feedback on their management options according to the National Health and Medical Research council (NHMRC) guidelines to stimulate a concept of appropriate referral in view of the current demand for specialist services.16 Additional value of tactile sensation has also been shown to be beneficial in a clinical study distinguishing other skin conditions such as plaque psoriasis and atopic dermatitis.13 The present study was originally designed to compare the dynamic of palpation in a clinical setting utilising direct patient contact with that of computer-based clinical scenarios with an image and a text-based tactile description. However, the practicalities of coordinating patients with real skin lesions to be examined by a sufficiently large cohort of medical students proved to be logistically problematic. A more practical alternative utilising a computerdriven learning package including tactile descriptive information was instead instituted to accommodate the requirements of a large medical student cohort. Apart from remoteness from the real patient setting, another limitation was the lack of an appropriate direct threedimensional visual perspective. Programme users were required to rely on single two-dimensional images for the analysis of individual pigmented skin lesion. A more realistic approach to this type of teaching could make use of video-assisted or other enhanced imagery systems. Another option is the use of prosthetic mimics in simulated patients.17,18 All these strategies take time, effort and funding, and it is reasonable to question the cost-effectiveness of such approaches. Our study would suggest that such approaches are indeed beneficial. A potential limitation of the study was the small number of lesions images used, and ideally the results would be validated using more images and over multiple consecutive years, and perhaps in different medical schools. Computer-based interpretation of pigmented skin lesions is a useful alternative to the clinical experience, especially where experience is difficult or impractical to obtain, and can be enhanced with the expression of tactile descriptive information. Palpation of skin lesions is a useful additional parameter to clinical history taking and the current standard diagnostic appearance criteria used in clinical practice.

Funding source None.

Conflict of interest None.

Acknowledgements The authors would like to acknowledge the exceptional assistance provided by Mr. Hong Chan, Online Developer and eLearning Adviser for eMediciª Learning Technologies, University of Adelaide.

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Palpation as a useful diagnostic tool for skin lesions.

Early identification and accurate diagnosis of malignant pigmented skin lesions is essential for effective management and cost containment. The aim wa...
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