PracticeUpdate Dermatology May 2019

EDITOR’S PICKS 7

Optimizing the Total Body Skin Exam Journal of the American Academy of Dermatology Take-home message

COMMENT By Jeffrey Miller MD , Matthew F. Helm MD and Katherine K. Hallock MD I (Jeffrey) remember calling the patient with a newly diagnosed, deeply invasive mel- anoma. I missed the melanoma near his left axilla on my skin exam 12 months earlier. A total body skin examination (TBSE) is an essential component of every dermatol- ogy patient encounter. Despite being our most important physical exam skill, the TBSE receives minimal research focus. Therefore, we set out to critically review our approach to the TBSE by breaking down the component movements to optimize accuracy and efficiency. Penn State is part of the “Big Ten Academic Alliance.” Not only do we have top athletes seeking to improve performance, we have expert bioengineers eager to collaborate on medical projects. In our study, residents and attending physicians were video-recorded while performing total body skin examination on standardized male and female volunteer patients. Each video subsequently underwent biomechan- ical analysis to identify the most efficient and reproducible technique that is easy to teach, saves time, and eliminates missed body areas. We recognize that there is tremendous variation in how seasoned dermatologists perform a TBSE. Our proposed TBSE can serve as a useful template for teaching and modeling a standardized TBSE for medical students and residents. We plan to validate the efficiency and effectiveness of this standardized TBSE with our residents and primary care colleagues. My (Jeffrey) personal goal is simple yet complex – prevent death from melanoma by not missing it on the TBSE. Dr. Miller is Chair and Professor of Dermatology and Associate Dean for Administration at Penn State Milton S. Hershey Medical Center and Penn State College of Medicine in Hershey, Pennsylvania. Dr. Helm and Dr. Hallock are Dermatologists in the Department of Dermatology at Penn State Health Hershey Medical Centre in Hershey, Pennsylvania.

• Video recordings of 5 dermatology faculty and 5 residents conducting total body skin examinations (TBSE) were obtained to optimize TBSE in practice. Exam time, physician movements, patient movements, sequence of body parts examined, and body parts missed were ana- lyzed. From this analysis, an optimal format for a TBSE that is efficient and accurate was identified. • A standardized way of conducting a TBSE may minimize the chance of missing a body area. These findings may be important while teaching TBSE to medical students, residents, and physicians. InYoung Kim MD, PhD Abstract BACKGROUND Total body skin examinations (TBSE) are commonly performed in clinical prac- tice. There is limited research on best practices for performing a TBSE. OBJECTIVE To optimize the TBSE. METHODS We performed an observational cohort study by video recording 5 dermatology faculty and 5 residents conducting their regular TBSE on both a male and female standardized subject. Exam time, physician movements, subject move- ments, sequence of body parts examined, and body parts missed were analyzed using an ana- lytic hierarchy process (AHP) matrix. Differences were evaluated by a t-test of unequal variance. P-values <0.05 were deemed significant. RESULTS We identified a optimal format for con- ducting a TBSE that is efficient and accurate LIMITATIONS: This study was conducted with only healthy examiners and standardized sub- jects, rather than individuals with a variety of physical and mental disabilities. The structure of the study was not hypothesis driven and assumed that engineers observing physicians performing the total body skin examination would identify the most optimal TBSE. CONCLUSION Our results indicate that a standard- ized process of performing a TBSE minimizes the chance of missing a body area. This could also have implications on teaching a standard- ized TBSE to medical students, residents, and physicians. Optimizing the Total Body Skin Exam: An Observational Cohort Study. J Am Acad Derma- tol 2019 Feb 15;[EPub Ahead of Print], MF Helm,

KK Hallock, E Bisbee, JJ Miller. www.practiceupdate.com/c/80268

VOL. 3 • NO. 2 • 2019