Samena Chaudhry urges greater attention to training in skin diseases

The inadequacy of undergraduate training in dermatology is well documented. The reports of the All Party Parliamentary Group on Skin (March 1997 and July 1998) highlighted the urgent need to improve the training at undergraduate and postgraduate levels.¹ A survey of the undergraduate curriculums at 28 medical schools found that teaching in dermatology was generally unsatisfactory because of "variable objectives," "too little time," and "student groups too large with not enough teachers." ²

The graduate who has sufficient knowledge to assume the responsibilities of a preregistration house officer has been described as a "sad interpretation of medical education," merely shifting the problems to postgraduate level. ³

Some people might argue that doctors who need to know about dermatology should gain experience during their postgraduate training as the skill only comes with years of experience. Should it not be possible for us to be taught equally in all specialties? But if the goal is to attract more students to the specialty then most dermatologists would disagree because compared with the whole body of consultants the number of posts in dermatology are few. ⁴

A very common problem

Yet skin disease is a common problem with approximately 10% of a general practitioner's workload and 6% of outpatient referrals accounted for by such problems.5 Skin disease is the single most common cause of loss of time from work and the commonest industrial disease. Since we are told as medical students that a large proportion of us are destined to become GPs, it means that few doctors can escape encountering skin diseases. Paediatricians, doctors in accident and emergency medicine, general physicians, and house officers on call may also have to face skin problems as part of their job.

Doctors who treat skin diseases are at a disadvantage compared with other branches of medicine. They are dealing with an organ which can be seen and felt. It is impossible to make a patient believe that the complaint has improved when it so obviously has not. Many believe that a lesion on the surface should be easy to cure and any failure to do so might imply that the doctor is a fool. The patient who has spent a night feeling sore, burning, or itching might even become aggressive, and this often makes the consultation difficult to handle. Undertreating or overtreating as well as being tempted to change medication too early may also result in a patient losing faith in the GP.

GPs are afraid of skin disorders

Prevalence studies in London have shown that only a fraction of skin morbidity ever reaches the medical profession.6 In one study, 73% of patients had not sought advice while one fifth of adults in Lambeth were found to have a skin condition worthy of medical attention. Patients preferred to use self medication and tended to rely on pharmacists and non-orthodox practitioners. What such patients perhaps show is their perception of a doctor being unable to help. This is not surprising since it is well known that primary care physicians are often unable to recognise the 20 most common skin complaints. ⁷ As one GP I talked to put it, "most of us are just afraid of skin disorders."

Yet surely it cannot be all that difficult to treat skin conditions. Changes in a person's skin can be a reflection of systemic or psychological disease as well as be an aid to the diagnosis of general disease. As undergraduates, we spend a large proportion of the clinical years taking histories and examining. Early exposure to a skin department could give us the advantage of learning the basis for all examinations - inspection. We readily palpate for murmurs, percuss for dullness, and auscultate for bowel sounds, but forget to inspect - possibly because it does not seem so important in other areas of medicine.

As undergraduates we should certainly be competent in dealing with the more prevalent disorders, such as eczema, psoriasis, warts, and skin tumours and the fact that these may vary according to the geographical location and demographic characteristics of particular populations. It would also be helpful to gain at least some knowledge of the systemic disorders which present with cutaneous manifestations as well as the life threatening dermatoses. With an increasing elderly population, it is important to know that the incidence of skin disease rises with age. Because skin structure changes with a lifetime accumulation of insults, more than 60% of people aged 65 or over will have at least one dermatosis which merits medical attention. ⁸ Poor undergraduate teaching may also play a part in the way malignant melanoma has been managed in primary care since the majority of patients have been found to have "excessive contact" with their GPs in the year before diagnosis but not to have had their skin examined. ⁹

More than skin deep

My own lifetime's experience of skin disease has shown that my condition is more than skin deep. These days, I try and console my brother, who lives in a depressed and paranoid world of his own, staring into mirrors, picking out the white flakes, and trying to normalise himself with thick steroid creams.

Lack of knowledge in dermatology probably results in extra trips to the doctor, lost time, costs of referral to a dermatologist, and disability. If we are not competent in the management of skin disease we have only ourselves to blame if we are superseded in this role by other healthcare professionals. The task of improving knowledge about dermatology during postgraduate training is difficult because of competing calls on the curriculum. A good undergraduate grounding of the subject would solve this problem. Learning about skin disease is an extra effort we owe to all our future patients.