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Letters to the Editor

BNF, the concept of assessment in the traditional sense has certainly been revolutionized. From a personal perspective, I look forward to reading formal research around the topic – the open book statistical assessment was certainly not a walk in the park. The format of the assessment required significant theoretical application. The book simply allowed for refreshment of factual knowledge. The assessment relied on candidates being able to interpret data provided and comment accordingly. For example, research data with confidence intervals, p values, odds ratios, Wald and degrees of freedom values featured heavily. In addition, candidates were asked to comment on assumptions made, potential confounding variables and additional univariate and multivariate tests of choice, as well as construct potential tables for data we would like to collect for specific research questions. In medical practice, postgraduate training often relies on referring to current literature when managing a patient appropriately, particularly evidence-based specialty guidelines. Of course, it is important for candidates to learn the theory; but I wonder whether the use of open book assessments could potentially be a good thing. If constructed properly, they could provide a more suitable platform of theory application as opposed to simple recall. Dr. Neel Sharma, National University Hospital, Singapore. E-mail: [email protected]

Declaration of interest: The author reports no conflicts of interest.

What medical students need: Virtual patients or real patients?

As medical students from a Latin American country, we believe that a global collaborative approach is needed, where virtual patients and live patient encounters are part of the learning experience. One important factor to assess is the integration of VPs in medical curricula in order to ‘get the best from both worlds’: the quick learning experience from VPs and the real-life heart-touching inspiration a real patient gives you. For Latin American countries, this is hard to accomplish due to the fact that there are no studies regarding the success or failure of curricular implementation of VPs. There are numerous projects that aim to develop VP networks for the sharing of patient cases in Europe (e.g. http://www. virtualpatients.eu/referatory/). However, a Latin American network, if none already exists, would be beneficial to the community here. One solution could be to create a system where resources are shared between medical schools that do have VPs and schools that do not. By doing so, we will not only solve the problem of VP development in developing countries but everyone will benefit. Students in medical schools that do have VPs could do clerkships with real patients and the students who have never experienced VPs could do so as well. We believe that a global education is the only way in which health, technology and society can benefit each other the most. Alvaro Proan˜o* & Eloy F Ruiz*, Facultad de Medicina ‘Alberto Hurtado’, Universidad Peruana Cayetano Heredia, Lima, Peru´. E-mail: [email protected]

Declaration of interest: The authors report no conflicts of interest.

References Cook DA, Triola MM. 2009. Virtual patients: A critical literature review and proposed next steps. Med Educ 43(4):303–311. Poulton T, Balasubramaniam C. 2011. Virtual patients: A year of change. Med Teach 33(11):933–937.

Dear Sir According to Cook & Triola (2009), virtual patients (VP) are a ‘specific type of computer program that simulates real-life clinical scenarios; learners emulate the roles of health care providers to obtain a history, conduct a physical exam, and make diagnostic and therapeutic decisions’. In brief, VPs are simulators that allow medical students to improve its clinical reasoning, knowledge and decision-making skills. Nevertheless, one as a student must not forget that patients are not only beholders of sickness, but human beings. It is clear that VPs will never replace ‘real patients’, but in exchange, the most important contribution of VPs is the safe environment where students can practice without any risk of harming (Poulton & Balasubramaniam 2011).

*Both authors contributed equally.

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Use of a melanoma simulation model in a dermatology Objective Structured Clinical Examination station Dear Sir Various techniques are available to simulate skin cancers including prosthetic adhesives (Goulart et al. 2012) and handpainted moulages (Hernandez et al. 2013), which can be applied to the skin of standardized patients (SPs) during an

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Letters to the Editor

educational exercise or assessment to circumvent the need for real patients to model rare skin diseases. However, subtle variations can occur when using these methods to assess a large class of test subjects over several days. Given the importance of delivering consistent clinical findings, we piloted the use of a melanoma simulation model to improve standardization of clinical findings in a dermatology Objective Structured Clinical Examination (OSCE) station. Two anaplastologists from the University of Illinois at Chicago (UIC) Maxillofacial Prosthetics Clinic assisted in developing a scale model of a forearm featuring a melanoma. Clinical and dermatoscopic images were provided for reference to create the lesions. Two benign lesions (pigmented dermatofibroma, benign nevus) served as distractors. Five UIC dermatology faculty members evaluated the model to assess its realism, and all rated the model as either ‘‘somewhat realistic’’ or ‘‘very realistic’’. The melanoma simulation model was piloted in a dermatology OSCE station by 12 UIC dermatology residents and used alongside an SP trained to present the station’s history. The SP was to state that she wanted to have a physician examine ‘‘moles’’ on her arm and was to provide clinical histories for each lesion, including recent changes in the melanoma and dermatofibroma. The resident was then directed to the model along with corresponding dermatoscopic images of the lesions for review. Images were the same as those used to construct the model’s findings. Following the encounter, residents were asked to rate the extent to which they thought the model enhanced the believability of the encounter on a 4-point Likert scale. Ten of twelve (83.3%) dermatology residents agreed or strongly agreed that the forearm melanoma model enhanced the believability of the encounter. Preliminary pilot data suggests that our melanoma simulation model can help facilitate a more realistic OSCE station encounter and add the important element of standardization for this type of assessment. Individual application of prosthetic adhesives and moulages introduces inherent variation, although our model assures that all students or residents evaluate the same clinical findings. This would be particularly essential during a multi-day high-stakes examination assessing a large medical school class or residency program. Our pilot study suggests that models with dermatologic findings can be incorporated alongside trained SPs to provide a standardized dermatology OSCE experience. Stephanie Wang, Rosemary Seelaus, Camille A. Rea, & Claudia Hernandez, University of Illinois at Chicago, Chicago, IL 60612, USA. E-mail: [email protected]

Declaration of interest: The authors have no financial or other conflicts of interest to disclose.

Hernandez C, Mermelstein R, Robinson JK, Yudkowsky R. 2013. Assessing students’ ability to detect melanomas using standardized patients and moulage. J Am Acad Dermatol 68(3):e83–e88.

Why tomorrow’s doctors need to go .com Dear Sir The internet is changing the way in which we are perceived as physicians; medical professionals are finding themselves being increasingly named on patient-driven rating websites, forums and blogs. Usage of such physician-rating websites is most definitely on the rise; one study found a 100-fold increase in the number of ratings in 2010 compared to 2005 and predicted this trend was likely to continue (Gao et al. 2012). Doctors are now recognising the need to manage their ‘‘online reputation’’. They have begun creating social media profiles, personal websites and accounts on physician-ratings websites to give themselves more control over what appears online. However, are medical students being prepared for this eventuality? It is our experience that medical students are unclear about the things they ought to be taking advantage of online. Since the advent of LinkedIn, we have seen the CV being shifted online. Doctors of the future are likely to see job recruiters routinely scanning online profiles. ResearchGate, a specific social network for academics, can be really useful to those involved in clinical research; the ability to establish contact and collaborate with geographically distant academics is greatly enhanced. We feel that online reputation management is an important aspect of careers and professional development and merits inclusion in the undergraduate course. Universities should also take practical steps to help their students establish an online presence. For example, the University of Manchester allows students to publish their own Personal Web Page, a simple one-page re´sume´ that is openly viewable. We feel that this is a great idea and would be keen to make use of such an asset. Universities can also create alumni groups on social networks such as LinkedIn, allowing their students to better network with each other. The importance of online reputations of doctors has never been of greater significance. Today, we are seeing a need for medical students and trainee doctors to ‘‘market themselves’’ online. We feel medical schools need to adapt to give their students a head start on creating their digital persona. Mohith Shamdas, Nitesh V. Mehta, Neil B. Patel, Department of Medicine, Imperial College London, Exhibition Road, South Kensington Campus, London SW7 2AZ, UK. E-mail: [email protected]

References Goulart JM, Dusza S, Pillsbury A, Soriano RP, Halpern AC, Marghoob AA. 2012. Recognition of melanoma: A dermatologic clinical competency in medical student education. J Am Acad Dermatol 67(4):606–611.

Declaration of interest: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_ disclosure.pdf and declare: no support from any organisation

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Use of a melanoma simulation model in a dermatology objective structured clinical examination station.

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