International DermatoEpidemiology Association

Epidemiology Curriculum for Dermatologists

Dermatoepidemiology

Version 1.1 (1999-2000)

The first epidemiology curriculum from the American Academy of Dermatology is now available at www.aad.org (members only section). Many IDEA members were involved in the development of this curriculum. Further details of the curriculum are given below.

Introduction and Acknowledgements:

This curriculum was developed in response to a perceived need for epidemiology training for dermatologists. While epidemiology is not currently listed as a program requirement by the ACGME (http://www.acgme.org/rrc/derm/derm.htm), epidemiologic principles and studies are important to understanding many of our patients’ diseases and outcomes. While there are a number of dermatologists with specific training in epidemiology, their input at residency training programs is not uniformly available.

The Epidemiology Committee of the AAD has been discussing the development of a curriculum for years. The committee will finally release and distribute this curriculum, recognizing that it will not be perfect for every program, especially those programs that already have local experts available for teaching. We will appreciate all comments on this first published curriculum from the AAD Epidemiology Committee and hope to continue to develop the material to better assist each other in teaching dermatoepidemiology to residents (and ourselves).

There are many individuals who deserve acknowledgment, including all those on the AAD Epidemiology Committee for the last 3 years (notably Dr. Mary Spraker, the Chair from 1994-7) and others who participated in an ad hoc meeting at the Chicago combined IDEA (International Dermatoepidemiology Association)/SID meeting in 1999. While all members of the AAD and ad hoc committees deserve credit, special thanks go to Hywell Williams and Martin Weinstock, who both responded with expert opinion and great attention to the earlier versions of this document. We must also acknowledge the assistance of our AAD Staff, especially Cheryl Hayden (chayden@aad.org) and Barbara Lowery for their assistance in many aspects of this project.

Please submit all comments to the current chair of the AAD epidemiology committee, Eliot Mostow (emostow@neoucom.edu, fax 330.535.2600, 157 W.Cedar #101, Akron, OH, USA 44307) or Cheryl Hayden as listed above.

How to use this curriculum and background information:

I. Review the selected topics and suggested resource articles/chapters. We believe the topics and resources might be best approached through a combination of journal club and lecture-discussion formats. The full curriculum review (utilizing perhaps one or more of the suggested resources or others) might be accomplished over 1-2 years of a training program.

II. Assign topics to residents and/or faculty as appropriate.

III. Residents should be aware that the Epidemiology committee members have agreed to develop and submit questions for dermatology board exams (of course, the selection of questions for use is up the board).

IV. Comments and feedback are appreciated. This is the first curriculum to come out of this committee in recent years. We expect it to be most helpful to programs without faculty with specific interest in dermatoepidemiology. However, we hope this may also serve to inspire more residents in the science of epidemiology and assist faculty who may already have their own curriculum developed. Eventually, we hope to provide a more frequently updated resource through a web page format. The next meeting of the AAD Epidemiology Committee will be in San Francisco at 7am, March 13, 2000. If you are not an official committee member but plan to attend, please notify Cheryl Hayden (chayden@aad.org) or Eliot Mostow (emostow@neoucom.edu).

As background, we developed this curriculum with the following points in mind:

1) The general topics to be covered should ultimately be: a) Evidence-based medicine, b) General dermatoepidemiology, and c) Health services research (recognizing overlap in these areas)

2) Whatever is developed through this committee would be available without charge to interested residents or programs worldwide.

3) Availability of materials and references, as much as possible, via internet web sites (perhaps limited by legal issues with respect to full-text reproduction of recommended readings). This goal is not fully achieved at this point.

4) Selection of articles/readings should be motivated first by the idea of “making me a better physician” (i.e. by developing skills in critical appraisal relative to epidemiology and statistics to better assess research on skin diseases).

5) Development and submission of board questions related to all recommended reading materials. Board questions have been and will continue to be submitted by individual committee members.

6) Development of 2-3 objectives for all recommended reading materials (with annotated comments on why the article/reading was chosen also suggested).

7) Eventual development of additional teaching resources might include CD-ROM based teaching, videotaped lectures, and interactive teleconferencing.

8) “Disclaimer”: This curriculum should be viewed as a work in progress. While we believe it can be used effectively today, we see it as Phase I (Version 1.1), with modifications expected based upon comments from residents, program directors, and other interested individuals. The Epidemiology Committee meets annually at the AAD and will try to also meet at the annual IDEA meeting (in conjunction with the SID).

Relevant bibliographic material(s) may include the following along with some specific other references by topic to follow:

· December 1998 issue of Archives of Dermatology, which can be accessed at ama-assn.org/derm

· Critical appraisal series from the Journal of Cutaneous Medicine and Surgery

· The toolbox section (Chapters 1-10, many referenced above) from the text book “Challenge of Dermatoepidemiology”

· July 1995 Dermatologic Clinics

Funding

The group would eventually like the AAD to seek outside support for distribution of the curriculum and supporting materials to approximately 900 residents (PGY 1-3). Reprint requests will probably be required.

Conclusion and results of our last meeting in Chicago at the IDEA/SID meeting:

While we had hoped to distribute the attached document by July, 1999, it was delayed until December, 1999. Throughout 1999-2000, the group will develop tools to assess the effectiveness of the curriculum. The curriculum will be reviewed and revised as indicated by participants’ evaluations of the content and usefulness of the curriculum. A more structured and comprehensive curriculum and an electronic approach will be considered for phase II implementation.

The epidemiology committee will continue to draft and submit questions for the Board exam and the study questions for the exam.

One text is reference frequently because it is the only comprehensive text on Dermatoepidemiology that we know of to date. If a program does not already have the text “THE CHALLENGE OF DERMATO-EPIDEMIOLOGY” EDITED BY WILLIAMS HC AND STRACHAN DP. CRC PRESS INC., BOCA RATON FL 33431-9868. It can be obtained by FAX 1-800-3743401 OR E-MAIL orders@crcpress.com or your local bookstore with the use of the ISBN no. 0-8493-7689-0. From CRC it is available for a 30day free examination!

Epidemiology Curriculum: Version 1.1

I. Overview of dermatoepidemiology

A. Strachan, DP: “The Nature of Epidemiological Studies” The Challenge of Dermatoepidemiology, Eds. Williams HC, Strachan DP, CRC Press 1997 (ISBN: 0-8493-7689-0, List price $129.95 U.S. @ 800-272-7737) and/or

B. Williams, H “Introduction to Epidemiology and Health Services Research in Dermatology”, Chapter 6 in Rook/Wilkinson/Ebling Textbook of dermatology. 6th ed. / edited by R.H. Champion, et al., Oxford; Malden, MA : Blackwell Science, c1998.Dermatoepidemiolgy”

1. Suggest this might be reviewed by all residents and presented as lecture-discussion format in one or two sessions. If there is a “book club” reading group, that model might be used to cover this important material.

II. Validity

A. Weinstock MA: Validation of a diagnostic test. Arch Derm, Vol. 125, 1209, 1218, 1260-64, Sept. 1989

1. This is easily reviewed as part of any journal club with the hope of combining this article with perhaps a more recent article that relates to validity.

III. Bias in studies

A. Bobak M: Bias—The Silent Menace. Chapter 8 in The Challenge of Dermatoepidemiology. (See I.A above)

1. Bias can be a difficult topic to grasp. This is probably best handled as lecture-discussion format, and might include assistance from local epidemiologist, if available.

IV. Evidence Based Medicine in Dermatology

A. Bigby M: Evidence-based medicine in a nutshell. Arch Dermatol 1998; 134:1609-1618

1. This is an excellent article for either journal club or lecture discussion format. This is what we do everyday (or perhaps ought to be doing).

V. No evidence of effect

A. Williams HC, Seed P. Inadequate Size of ‘Negative’ Clinical Trials In Dermatology. Brit J Dermatol 1993;128:317-326.

1. A common problem for residents is the understanding that “no evidence of effect” is not the same as “no effect”. The article noted above presents some data on gross underpowering of some dermatologic studies, together with a constructive and clinician-friendly discussion of the concept of power and sample size issues.

VI. Case Control Studies

A. Heacock HJ, Rivers JK, et al. Assessing scientific data: The case-control study as it applies to dermatology. Part I, The case-control method: J Cutan Med & Surg. Vol 1, No. 3: 151-56, 1997 and Part II, Interpreting the results: : J Cutan Med & Surg. Vol 2, No. 1: 35-40, 1997

1. This is an important area of epidemiologic study to understand and these articles are clear and concise. The topic would probably best be addressed first as a general lecture-discussion format, but should be reviewed in relation to relevant journal club readings.

VII. Quality of Life Studies

A. Chren M: Understanding Research About Quality of Life and Other Health Outcomes, J Cutan Med & Surg. Vol 3, No. 6: 312-, 1999

1. Since much of what we do in dermatology relates to quality of life, we must attempt to understand whether specific interventions are making a difference. As such, we need to think about outcomes that may be different than lesion counts, cancer recurrence, and death. The topic would probably best be addressed first as a general lecture-discussion format, but should be reviewed in relation to relevant journal club readings.

VIII. Systematic reviews (meta-analyses)

A. Williams HC, Adetugbo K, Po AL, Naldi L, Diepgen T, Murrell D. The Cochrane Skin Group. Preparing, Maintaining and Disseminating Systematic Review of Clinical Interventions In Dermatology. Arch Dermatol 1998;134:1620-6.

B. Po WL, Williams WC. Collating the Evidence, Chapter 9 in The Challenge of Dermatoepidemiology. (See I.A above)

1. Meta-analyses are quite common. Understanding the benefits and caveats of these “studies” is very relevant to clinical dermatologists. This is another topic probably best addressed first as a general lecture-discussion format, but then to be reviewed in relation to relevant journal club readings

IX. Defining disease(s) for study

A. Williams HC. Defining Cases, Chapter 2 in The Challenge of Dermatoepidemiology. (See I.A above)

1. While a chapter, this could reasonable be incorporated as required reading before any journal club with discussion related to the articles reviewed for that session.

X. Confounding

A. Phillips A, Smith GD. Confounding, Chapter 7 in The Challenge of Dermatoepidemiology. (See I.A above)

1. Like bias, confounding can be a difficult topic to grasp. This is probably best handled as lecture-discussion format, and might include assistance from local epidemiologist, if available.

XI. Health Services Research

A. Newton J. Evaluating Services, Chapter 10 in The Challenge of Dermatoepidemiology. (See I.A above)

B. Cheri MM. Dermatologic health services research. Dermatol Clin 1995:13;689

1. While quality-of-life issues are often included in health services research, the committee felt that these really ought to be covered as separate topics. The essential issue to consider is whether our treatment actions are going to achieve the results we and our patients expect. Either of these articles can be used, perhaps as a lecture-discussion format or combined with a journal club.