BASIC/CLINICAL SCIENCE. Resident Education: Effect of the Sixth National Psoriasis Foundation Chief Residents Meeting

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1 BASIC/CLINICAL SCIENCE Resident Education: Effect of the Sixth National Psoriasis Foundation Chief Residents Meeting Heather M. Greist, Daniel J. Pearce, Molly Blauvelt, and Steven R. Feldman Background: Psoriasis is a common problem, with patients frequently reporting dissatisfaction with their care. The National Psoriasis Foundation held its sixth annual Chief Residents Meeting in October 2004 with the goal of educating dermatology residents about psoriasis. Objective: The purpose of this study is to assess residents knowledge about psoriasis before and after the meeting. Methods: Residents were given the same 11-question multiple-choice test before and after the meeting. Eighty-one residents completed the pretest and 41 completed the post-test. Results: Overall, the mean number of questions answered correctly increased from 5.2 of 11 (47%) on the pretest to 8.9 (81%) on the post-test (p <.00001). Scores improved on the post-test in all subject areas. The greatest percent improvement occurred in the subjects of patient education and phototherapy. Conclusion: Although limited by small numbers and an unknown response bias, the National Psoriasis Foundation Chief Residents Meeting was successful in educating the attendees about psoriasis; it is hoped that topic-specific resident education will lead to better patient care. Antécédents: Il est fréquent que les patients souffrant de psoriasis rapportent une insatisfaction quant à leurs soins. En octobre 2004, la National Psoriasis Foundation a tenu le 6 e congrès annuel de ses médecins résidents avec l objectif d éduquer les dermatologues résidents au sujet du psoriasis. Objectif: L objet de la présente étude est d évaluer les connaissances des résidents sur le psoriasis avant et après cette réunion. Méthodes: On a remis aux résidents le même questionnaire à choix multiple avant et après le congrès. 81 résidents ont rempli le questionnaire avant le congrès et41résidents après. Résultats: Dans l ensemble, le nombre médian des réponses correctes est passé de 5,2 sur 11 questions (47 %) avant la réunion à 8,9 (81 %) après laréunion (p <.00001). Les résultats se sont améliorés après laréunion dans tous les domaines, mais surtout en ce qui a trait à l éducation des patients et à la photothérapie. Conclusion: Malgré le faible nombre de répondants et une déviation inconnue des réponses, le congrès des médecins résidents de la National Psoriasis Foundation a réussi à éduquer les participants au sujet du psoriasis. On espère que cela mènera à de meilleurs soins pour les patients. PSORIASIS is a common and complex disease that can be devastating to patients. Patients need appropriate treatment from their physicians, as well as resources that From the Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, NC; The National Psoriasis Foundation, Portland, OR. The Center for Dermatology Research is supported by an unrestricted educational grant from Galderma Laboratories, LP. Dr. Feldman has received research, speaking, and/or consulting support from Connetics, Roche, Amgen, Biogen, and Genentech. Address reprint requests to: Steven R. Feldman, MD, PhD, Department of Dermatology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC ; sfeldman@wfubmc.edu. DOI / help them cope with psoriasis. Although psoriasis is one of the most common conditions treated by dermatologists, successful treatment can be difficult. The National Psoriasis Foundation holds a meeting for chief residents annually with the purpose of educating and empowering attendees to educate their colleagues about psoriasis. The National Psoriasis Foundation started this meeting to help educate new dermatologists about the many available treatment approaches. Concerns about the decreasing availability of phototherapy also contributed to the need for the meeting. 1 New advancements in psoriasis treatment and patients perceptions that they frequently are not treated aggressively enough 2,3 also contribute to the need for the meeting. Psoriasis is often more devastating to patients than even dermatologists realize 4 ;physiciansshould 16 Journal of Cutaneous Medicine and Surgery, Vol 10, No 1 (January/February), 2006: pp 16 20

2 Effect of National Psoriasis Foundation Chief Residents Meeting on Education 17 attempt to acknowledge the huge impact that psoriasis can have on patients lives because a dismissive attitude can negatively affect optimal outcome of treatment. 5 In addition, there is a need for busy physicians to understand what resources are available so that patients may receive education, as well as psychosocial and emotional support. 2,3 The National Psoriasis Foundation held its sixth annual Chief Residents Meeting in October 2004 with the goal of educating dermatology residents about psoriasis and the various forms of treatment available, as well as to make them aware of the valuable resources offered by the National Psoriasis Foundation. The purpose of this study is to test the efficacy of the National Psoriasis Foundation s Chief Residents Meeting to meet its educational objectives through comparison of pretest and post-test scores. Methods The sixth annual National Psoriasis Foundation Chief Residents Meeting in October 2004 was made possible by support from Roche, Biogen Idec, Genentech, Centocor, and Connetics. The National Psoriasis Foundation was solely responsible for program development and content. There were 118 attendees representing 80 different residency programs. Attendees were given an identical test to take at the commencement of the meeting and afterward. The test consisted of 11 multiple-choice questions regarding patient education resources and psoriasis treatments, including topical, phototherapy, oral systemic, and biologic treatments (Figure 1). Eighty-one pretests and 41 post-tests were evaluated. Only tests that were fully completed were included. The study was approved for data analysis and reporting by the local intramural review board. To calculate p values, a Fisher exact test was used. Since the pretests and post-tests were taken anonymously and could not be linked with specific residents, the correlated nature of proportions could not be taken into account. Results Overall, the average number of correct questions was 5.2 of 11 (47%) on the pretest and 8.9 of 11 on the post-test (81%), representing an absolute improvement of 34% (p <.00001) (Figure 2). Less than 5% of those surveyed were aware that a course for phototherapists is available through the National Psoriasis Foundation, but this increased to 68% after the conference (p <.001). Before the meeting, 62% of the residents already knew that poor effectiveness of topical treatment for scalp psoriasis could be best explained by poor treatment compliance. After the meeting, 100% answered this question correctly (p <.001). Prior to the meeting, 59% thought that fewer localized phototherapy treatments would be needed compared with total body phototherapy treatments because the initial ultraviolet (UV) doses are higher when treating localized plaques; 78% recognized this in the post-test (p =.04). Only 2 of 81 of those surveyed before the meeting realized that drunkenness prevents patients from being treated with UVB phototherapy. Most thought that it was the unavailability of office-based UVB treatment. The 2.5% on the pretest increased to 46% on the post-test (p <.001). This question was difficult, but the key points were that (1) an intoxicated person is at risk with both office and home UV light and (2) even if office UVB is not available, home UVB units or tanning beds would allow patients to receive treatment if needed. Averaging the two questions on phototherapy resulted in 30.9% correct on the pretest compared with 62.2% on the post-test. The three systemic treatments approved for psoriasis in the United States are acitretin, methotrexate, and cyclosporine. On the pretest, 73% were aware that the side effects of acitretin can usually be managed by lowering the dose, and this increased to 95% on the post-test (p =.003). Sixtyeight percent surveyed chose acitretin as the most appropriate treatment plan for a patient infected with human immunodeficiency virus (HIV) with severe psoriasis who is already on highly active antiretroviral therapy, but 100% chose the correct answer after the meeting, indicating that this was another point that was well conveyed ( p =.0004). Prior to the meeting, 70% already knew that the most appropriate initial dose of methotrexate for a 75-year-old would be 5 mg or less. This went up to 90% after the meeting (p =.0133). Slightly less than half knew the recommended laboratory monitoring for cyclosporine on the pretest, but on the post-test, 85% knew that baseline creatinine should be checked twice, as well as triglycerides, liver function tests, and magnesium ( p <.001). Cyclosporine blood levels do not need to be monitored. Averaging the four questions on systemic treatments resulted in 64.8% correct on the pretest and 92.7% on the post-test. Currently, the biologics approved for psoriasis are alefacept, efalizumab, and etanercept. Less than one-fourth of the residents knew that alefacept has little to no effect on naive T cells prior to the meeting. Sixty-one percent were aware of this afterward (p =.001). Efalizumab is given as a once-weekly subcutaneous injection; 61% answered correctly on the pretest compared with 85% on the post-test (p =.0067). Before the meeting, less than half knew that etanercept is associated with development of antinuclear

3 18 Greist et al antibodies in patients with rheumatoid arthritis compared with more than three-fourths after the meeting (p =.0009). Averaging the three questions on biologics resulted in 43.2% correct on the pretest compared with 74.8% on the post-test. In addition to taking the pre- and post-tests, the residents also qualitatively evaluated the meeting. Of the 94 residents surveyed, 88 rated the program as excellent (94%) and 6 rated it as good (6%). Of these 94, only 6 (6%) rated their awareness and comfort with using the full range of psoriasis treatments as excellent before attending the meeting. Fifty-two rated themselves as good, 31 as fair, and 5 as poor. However, after the meeting, 63 (67%) rated themselves as excellent, 29 as good, and 1 as fair. Eightyfive (90%) thought that the information they obtained from the meeting would affect the way they approach psoriasis therapy, whereas 8 did not. Discussion Attendees of the National Psoriasis Foundation Chief Residents Meeting in October 2004 gained valuable knowledge that it is hoped will improve care of their patients. One goal of the program was that residents would use this knowledge to educate their colleagues. To help the residents with this task, they were given a data memory stick with a PowerPoint presentation on psoriasis treatments with the hope that they would use the presentation to help others achieve a better understanding of psoriasis. Figure 1. continued on next page

4 Effect of National Psoriasis Foundation Chief Residents Meeting on Education 19 Figure 1. Continued Test consisting of 11 multiple-choice questions dealing with psoriasis. Answers appear in italics. FDA = US Food and Drug Administration; HAART = highly active antiretroviral therapy; PASI = Psoriasis Area and Severity Index; UV = ultraviolet. The residents who attended the meeting thought that it was an extremely positive educational experience, as evidenced by the 88 of 94 who rated it as excellent. Attendees reported greater facility with psoriasis after the meeting; before the meeting, only six felt that their awareness and comfort with using the various treatments available was excellent, but this increased impressively to 63 after the meeting. Figure 2. Summary of pre- and post-test results from the sixth annual National Psoriasis Foundation (NPF) Chief Residents Meeting.

5 20 Greist et al The residents also made individual comments about the program. Many said that they are not being educated about phototherapy and that they appreciated the phototherapy review. They felt more comfortable with systemic treatments after the meeting. They understood better how to individualize treatments for specific patients. Many said that they will refer patients to the National Psoriasis Foundation. One resident said that she would present the lecture at grand rounds so her colleagues could benefit from her gained knowledge. The residents thought that the information was clinically relevant and unbiased. Overall, they thought that the program was superb and exceeded their expectations. Based on the 11-question test, the residents seemed to have reasonable incoming knowledge about topical and traditional systemic treatments for psoriasis. Baseline scores were lowest in patient education and phototherapy, which may highlight an opportunity for improvement in psoriasis education at the residency program level. Attendees improved the most on the question regarding patient education, specifically about the National Psoriasis Foundation s resources. Dermatologists are not generally well educated about available resources for patients with psoriasis. 2 The National Psoriasis Foundation is a nonprofit organization that was founded in 1968 by Beverly Foster, a patient with psoriasis. The National Psoriasis Foundation s mission statement is...to improve the quality of life of people who have psoriasis and psoriatic arthritis. Through education and advocacy, we promote awareness and understanding, ensure access to treatment and support research that will lead to effective management and, ultimately, a cure. The National Psoriasis Foundation is an excellent resource for patients 6 by providing local support groups and educational resources. It has a comprehensive Web site ( that includes treatment information, a section for finding a doctor, and message boards for connection to others. Advocacy for increased federal funding and for improved access to treatments is a priority of the foundation. The National Psoriasis Foundation is also useful to physicians; benefits include access to a peer-reviewed journal, professional meetings, resources such as pocket guides and a clinical manual, and priority listing in a physician directory. The foundation also offers competitive research grants. This is admittedly a simple study with limitations. First, the low number of overall responses is inadequate for reliable conclusions. Compounding this is that the change in response rate from 81 attendees who took the pretest to only 41 attendees who took the post-test reduces the strength of any interpretation; it may be that the 41 people who submitted the post-test were more interested in psoriasis and, therefore, possibly more knowledgeable about psoriasis prior to the meeting. The converse is also possible; perhaps the educational value of this program is underestimated because those attendees who were comfortable with their psoriasis treatment knowledge were more likely to refrain from the post-test. Future evaluations would benefit from a higher response rate and detailed, valid statistical analyses. Methods that would facilitate completion of the post-test, such as providing stamped addressed envelopes for mailing of the post-test for those who were forced to leave the meeting early, may help improve the response rate. Psoriasis is an important disease because it is common, affecting approximately 2% of people in the United States, and can severely impact quality of life. 4 Dermatologists must be able to effectively treat psoriasis, and to do this, they need to be aware of the available treatments and patient education materials. Although potentially limited by an unknown response bias, after attending the National Psoriasis Foundation Chief Residents Meeting, participants were more aware of the Foundation s resources and had much improved knowledge about the various therapeutic modalities available for the treatment of psoriasis. Overall, the residents thought that it was a stellar meeting and a wonderful supplement to their residency training; ideally, the information the residents obtained will be helpful to them as practicing dermatologists. This study adds support for topic-specific resident education that it is hoped will lead to enhanced patient care in the future. Acknowledgment We would like to extend a special thank you to Fabian Camacho for his assistance with data calculations. References 1. Housman TS, Rohrback JM, Fleischer AB Jr, Feldman SR. Phototherapy utilization for psoriasis is declining in the United States. J Am Acad Dermatol 2002;46: Krueger G, Koo J, Lebwohl M, et al. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol 2001;137: Finlay AY. Psoriasis from the patient s point of view. Arch Dermatol 2001;137: Stern RS, Nijsten T, Feldman SR, et al. Psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction. J Investig Dermatol Symp Proc 2004;9: Choi J, Koo JY. Quality of life issues in psoriasis. J Am Acad Dermatol 2003;49(2 Suppl):S Lebwohl M, Feldman SR, Walther R, et al. Clinical management of psoriasis: principles and practice. Cutis 2001;67(1 Suppl):1 15.