COEUR D’ALENE, IDAHO – Thought leaders in pediatrics, family practice medicine, and pediatric dermatology all agree: Primary care providers need to know more – a lot more – about pediatric skin conditions.
A 20-member expert committee drawn from these disciplines has reached consensus on a lengthy wish list of educational objectives. The committee members scrutinized 235 proposed objectives in 16 content areas of pediatric dermatology. Their task was to rate the importance of each of these objectives for resident physicians who plan to see children in their general practice of primary ambulatory care or urgent care.
Dr. Erin Mathes
Ultimately 72% of the items were approved by the panel, which used the Delphi method of achieving consensus, Dr. Erin Mathes reported at the annual meeting of the Society for Pediatric Dermatology.
It’s a successful initial step in the long-term goal of creating an online pediatric dermatology curriculum for primary care providers. Such a tool is badly needed because primary care physicians, not dermatologists, see most children with skin disease. By some estimates, skin complaints account for up to 30% of all primary care and emergency department visits. Moreover, primary care physicians rate their access to pediatric dermatologists as the third worst of all pediatric subspecialties, behind only child psychiatry and developmental and behavioral pediatrics.
Education in dermatology in medical school is quite limited. At the University of California, San Francisco, for example, where Dr. Mathes serves on the pediatric dermatology faculty, medical students receive a grand total of 7 hours of dermatologic education.
To help with this unmet need, the American Academy of Dermatology has created its online basic dermatology curriculum for self-directed learning. It has been a big hit with primary care providers and trainees. In 2013, the website received 317,000 page views, and 18% of the visitors to the site were international.
"But the AAD site lacks important pediatric dermatology content and is not particularly sophisticated in certain areas. There is a lot of room for improvement, and we can help out," Dr. Mathes explained by way of background to the SPD-supported curriculum development project.
Items that made the panel’s final cut generally fell into two broad categories: diagnosis and management of common conditions such as acne, warts, atopic dermatitis, reactive erythemas, and viral and bacterial skin disease; and recognition, triage, and appropriate referral of more rare or dangerous conditions, including Stevens-Johnson syndrome, vasculitis, and drug reactions.
What did not make the list were benign conditions such as lichen striatus, cysts, juvenile xanthogranuloma, and nail disorders. "A lot of the lumps and bumps weren’t deemed important," said Dr. Mathes.
Also shot down was education regarding inherited conditions, with two notable exceptions: neurofibromatosis and tuberous sclerosis. Ichthyosis and epidermolysis bullosa were not considered to be important.
A specialty-based split emerged regarding the perceived importance of learning to perform fungal cultures and other office-based diagnostic tests. The pediatricians on the expert panel felt for the most part that they shouldn’t ask pediatric residents to know how to do them, while the family physicians and pediatric dermatologists rated that as clinically important information.
The next step will be to create educational modules to address the approved educational objectives. The modules will then be evaluated in test runs involving medical residents at collaborating institutions. Partnerships are being pursued with major medical societies, including the American Academy of Pediatrics, the American Academy of Dermatology, the American Academy of Family Physicians, and the physician assistant organizations.
Several audience members at the SPD meeting rose to complain that some of the panel’s recommendations just don’t seem to make sense.
"It seems like, for example, primary care providers need to understand at least the basics of the pathophysiology of atopic dermatitis or they’ll never stop referring patients to us, they’ll never understand why we treat it the way we do, and they’ll never be able to take ownership of atopic dermatitis in some small way. It seems glaringly obvious," one pediatric dermatologist asserted.
Dr. Mathes replied: "You have a very expert opinion on this. It’s what many pediatric dermatologists would think," she said. "The pediatricians and family physicians feel differently. They would counter, ‘I do not have time to know the pathophysiology of all these things.’ They have a lot of other stuff they need to know. They have to know about the heart, the lungs, about normal development – all sorts of stuff. They have just too much to know."
The educational objectives consensus project was funded by the Society for Pediatric Dermatology. Dr. Mathes reported having no financial conflicts.