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3 21 How to learn this area of practice

Work-based learning

In primary care

Skin diseases are common and many are chronic. They will therefore necessarily form a large part of your work as a GP. The patient is very likely to be an expert on their own skin and can often tell you a lot about their condition. One of the advantages of working in primary care is the ability to develop a ‘longitudinal consultation’ by inviting the patient to come back to discuss their skin problem. That provides a great opportunity to look up their condition in the meantime.

It is very easy to fall into the trap of dismissing many skin diseases as trivial (acne, for example), but patients tell us that although they have difficulty raising their skin problem or discussing it, even with a health professional. The truth is that it can have a considerable impact on their lives. Recognising this and treating the condition well makes an enormous difference.

Be prepared to ask difficult questions (e.g. ‘Does your skin condition cause you any problems or embarrassment in your relationships or at work?’) and always try to examine and feel skin rashes or lesions (usual hygiene measures of course). For a patient, the ‘laying on of hands’ by a healthcare professional dispels concerns of contagion and being ‘untouchable’, as well as helping them to believe you understand what they are experiencing.

Consider discussing with practice members all referrals that are made to dermatology specialists by yourself and your partners to establish what exactly you and your patients are hoping to achieve from the referral – in what way will it be value added? Review your referral again after the patient has been seen to decide whether the same benefit might have been achieved from resources available in primary care.

Consider arranging a Patient Satisfaction Questionnaire (PSQ) for patients with eczema or psoriasis in order to review your delivery of care. An annual Dermatology Life Quality Index (DLQI) assessment takes less than a minute to complete and would demonstrate to your patient that you are interested in the possible detrimental effect of their disease on their quality of life.

Also consider regularly auditing your patients who are on repeat prescriptions for psoriasis treatments. Have you considered whether they might have psoriatic arthritis, that they have previously dismissed as ‘wear and tear’?

In secondary care

Attending community-based and GPwSI clinics both give you valuable learning opportunities for general practice. You can also reflect on each case and ask yourself: ‘Why was referral deemed necessary and what value-added input has the specialist provided?’

Self-directed learning

Dermatology is high on the learning needs of most professionals working in primary care. As a result, you will find that talks on the subject are regularly included in many continuing education programmes. The Primary Care Dermatology Society (PCDS) mission is to educate and disseminate high standards of dermatology in the community. They run a regular series of ‘Essential Dermatology‘ days up and down the country, as well as education events on minor surgery and dermoscopy (i.e. skin surface microscopy for increasing the accuracy in diagnosing  both pigmented and non-pigmented lesions).

The British Association of Dermatologists, together with CRUK have recently produced a web-based resource for lesion recognition in Primary Care.

On a personal level, your friends and relations will also experience skin problems and talking to them about their experience can be very enlightening.

Learning with other healthcare professionals

Experienced GPs will have seen a lot of skin disease, so ask them for their thoughts. Our nursing colleagues too are a remarkable reservoir of knowledge, approaching patients with skin disease differently from GPs.  Specialist health visitors or district nurses are also worth talking to, as of course is the specialist dermatology nurse practitioner.

Remember that your annual appraisal provides an opportunity to reflect on your particular learning needs and plans.

Formal learning

The Cardiff Diploma in Practical Dermatology (DPD) and the Barts Diploma in London are each largely distance, internet-based learning courses (three terms over a year) with a summative exam and qualification at the end.

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