The incidence of melanoma is greater in non-Hispanic Whites (referred to as Whites) than in Blacks. However, it has recently been recognized that minorities present with more advanced stage disease.1-4 Low levels of suspicion and training in melanoma presentations in skin of color may lead to a bias against performing skin examination in minorities or misdiagnoses of malignant lesions delaying medical care.5 Our group has considerable experience assessing melanoma detection in medical students using standardized patients (SPs) wearing a moulage (realistic tattoo) simulating a melanoma. Building on our expertise, we propose to extend our melanoma detection studies to third-year internal medicine (IM) residents using unannounced (stealth) SP visits to resident ambulatory continuity clinics allowing us to observe actual patient care practices. Our first specific aim is to determine melanoma detection rates for White and Black SPs placed into resident continuity clinics wearing identical melanoma moulages in the same anatomic location. Each unannounced SP-physician encounter will be audio-recorded.
Our second aim i s to review recordings and analyze content using the Inventory of Diagnostic Thinking Processes (DTP) from the Gale and Marsden model for clinical decision-making to determine common sources of diagnostic error. Following completion of initial visits, residents will then be randomized to eithr an educational intervention or control arm with no additional education. The intervention utilized SPs and simulation exercises will help residents identify and correct errors in melanoma medical knowledge, examination skills, clinical data interpretation, or communication.
Our third aim i s to determine if the melanoma detection rate improved and is sustainable, unannounced SPs (both White and Black) will once again be inserted into resident continuity clinics. If physicians fail to detect melanoma in Blacks this could result in diagnostic delays and patient harm. Documenting these deficiencies would be invaluable to improving medical education curriculums.
Health care system factors have long been suspected to play a role in the development of health disparities. Melanoma, the cancer with the fastest rising incidence in the U.S., has recently been recognized to have an outcome disparity between minorities and Whites.1 This project will provide data regarding physician skills in melanoma detection and provide an improved understanding of potential sources of this diagnostic error.
