The goal of this proposal is to develop an interactive melanoma early detection skills training program for primary care physicians, practicing clinicians, using the principals of mastery learning. A randomized controlled trial will determine f the program reduces the benign lesions and increases the malignant ones referred to dermatology. In 2014, an estimated 63,770 United States (US) individuals will develop melanoma in situ that may progress to invasive melanoma and 76,100 will develop invasive melanoma that will progress to cause an estimated 9,710 deaths.1 Patients presenting with melanoma in situ, Stage 0, have a 99% five-year survival rate when treated with excision, while those with a tumor thickness of 2.01-4.0 mm, Stage II B, have a 65% five year survival. Ideally, surveillance occurs opportunistically during the physical exam. For example, the back which is a common location for melanoma in men, may be viewed while listening to airflow in the lungs.2 Approximately 355 million office visits occur annually with primary care physicians (PCPs), who have an opportunity to provide surveillance for melanoma during physical examinations.3 Sixty-three percent of melanoma patients saw their PCPs in the year prior to diagnosis of melanoma and 19% of these melanoma patients had their melanoma discovered by PCPs.4 While PCPs have an unparalleled opportunity to discover melanoma by visual inspection of their at-risk patients, such as men aged 60 and over, they may not do so due to inadequate training, low confidence in their skills, and infrequent clinical experience with melanoma. A focused intervention is required to improve PCPs' early detection of melanoma and mitigate the near-term consequences of an aging US population with an expected increase in melanoma incidence. Scalable and easily disseminated training for future and current PCPs to learn to perform opportunistic surveillance for melanoma is needed. Our hypothesis is that personalizing Internet-based PCP skills training with four phases of education providing feedback to the learner will enable skills acquisition and support development of clinical proficiency. Enhancing the immediacy of learning skin examination by smartphone delivery of case-based skills assessment and deliberate practice of unaided visual inspection and dermoscopy, a hand-held magnifying device that assists with diagnosis, will improve skills retention and aid in the transition of its use into clinical practice. Skills learned in simulation are transitioned into clnical practice by the PCP using a smartphone equipped with a dermoscope to interact with and be coached by the teleconsultant (PI). The outcome measures of the randomized trial (change in physician knowledge, attitude, competence and diagnostic performance) will be correlated with the dose of the intervention (duration and number of deliberate cases). The referral of lesions to dermatology and other services 3 months before and 3 months after the intervention for the control and intervention groups will be analyzed. We expect that PCPS will refer = 20% benign and 90% malignant lesions.
Early detection underpins the rationale for surveillance of individuals at risk of melanoma as stage of diagnosis affects prognosis for the almost 140,000 patients who will develop melanoma in 2014. Reduction of patient anxiety and costs of referral of benign lesions to dermatologists by primary care physicians (PCPs) is a secondary benefit of this training program for PCPs.