Survey of genitourinary medicine specialist registrars in the United Kingdom regarding genital dermatology training

Introduction

There has been no recent review of genital dermatology (GD) training for genitourinary medicine (GUM) trainees. Patients with genital dermatoses frequently present to sexual health clinics, with one survey reporting that 13% of sexual health clinics see over 50 GD cases each month. ¹ Specialist registrar training in GD is fundamental to ensure future consultants are appropriately able to manage such cases.

The British Association for Sexual Health and HIV (BASHH) Genital Dermatology Special Interest Group (SIG) conducted a survey of specialist registrar training in GD to inform future training provision provided by the SIG and other services.

Methods

An online survey was written and cascaded to trainees across the UK in August 2014. Results were analysed using the online survey platform and Microsoft Excel.

Results

Forty-two trainees responded to the survey, representing all grades (ST3 12%, ST4 29%, ST5 27%, ST6 32%) and most deaneries (48% London, 12% North Western, 10% Scotland, 10% Yorkshire and Humber, 7% Mersey, 5% Kent, Surrey, Sussex, 2% Northern, 2% East Midlands, 2% Severn, 2% Wales).

With regard to GD training (Figure 1), 68% of trainees have received training through ad hoc clinical teaching and 85% through formal lectures. A total of 26, 32 and 37% have attended specialist GD clinics which are led primarily by a gynaecologist, GUM physician or dermatologist, respectively (by ST6 42, 50 and 42%, respectively, have attended the above clinics). Trainees in London, compared to those training outside London, were more likely to have attended specialist GD clinics run by a GUM physician (35% versus 24%) or dermatologist (45% versus 13%). Those training outside London were more likely to have received training from a gynaecologist (32% versus 26%). Overall, 31% had never attended a GD clinic with 36% having attended 1–5 GD clinics, 17% 6–10 GD clinics, 16% ≥11 GD clinics. The amount of clinics attended increased through the grades, rising mainly in ST6 (median 6–10 clinics for ST6 responders, range 0 to >20 clinics). Formal clinical dermatology attachments had been completed by 30% of ST5 and 75% ST6 trainees (no ST3 or ST4 trainees). The BASHH GD SIG runs an annual one-day GD course which 39% of trainees had attended. OPEN IN VIEWER

On a confidence scale of 1–10, mean confidence in managing specific conditions varied from 5 (vulval pain syndromes) to 7.5 (fungal infections) (Figure 2). Confidence was highest amongst the higher grades. Forty-seven percent were ≥7/10 confident in topical steroid use, with ST6 trainees the most confident (>7/10 confident: ST3 0%, ST4 11%, ST5 55%, ST6 79%). Figure 3 shows the percentage of trainees independently able to perform specific procedures by grade. Overall, 63 and 21% of trainees independently could perform fungal scraping and punch biopsy, respectively. OPEN IN VIEWER

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Figure 3.

Independently able to perform practical procedures by grade.

Seventeen percent rated their GD training very poor/poor, 39% average, 44% good. No trainees rated their GD training excellent. However, 50% of trainees are satisfied with GD training with 69% feeling they will be adequately trained by certificate of completion of training (CCT) (adequately trained by CCT by grade: ST3 80%, ST4 75%, ST5 45%, ST6 78%). Fifty-eight percent would like a formal qualification in GD to be available.

Discussion

A survey conducted in 2009 across UK sexual health services demonstrated that 91% of sexual health clinics manage GD problems in house. The paper concluded that there is no uniform provision of GD across the UK and that training amongst GUM clinicians varied. ¹ A further review of a London sexual health service dermatologist-led GD clinic showed that referring clinicians were not always able to make accurate diagnoses, with 36% diagnoses made by referring clinicians matching that of the dermatologist. ²

The 2010 GUM specialist registrar curriculum states specific learning objectives that trainees should meet by CCT. ³ These include knowledge of specific vulval and penile dermatological conditions. Trainees should be able to perform punch biopsies and fungal scrapings as well as manage simple genital dermatoses. To achieve these learning objectives, trainees are expected to attend dermatology clinics throughout training. A minimum number of clinics (general dermatology and GD) are not stipulated but approximately ten clinics are recommended in the curriculum. Competencies in dermatology should be achieved by the end of ST5.

Our survey shows that training in GD is variable. Most trainees receive GD training through formal lectures or ad hoc clinical teaching, with fewer trainees having access to specialist GD clinics. Access to specialist GD clinics varies across the United Kingdom. There is mixed confidence in diagnosis, use of topical steroids and few trainees are independent of GD practical procedures. By CCT, not all trainees have had access to formal clinical dermatology attachments. Many trainees feel training could be improved with requests for a formalised attachment, formal qualification and greater training in practical procedures.

We recommend that trainees should have regular access to specialist GD clinics from the start of specialist training (led by either GU, dermatology or gynaecology depending on local service provision), even if such clinics are not held in their current trust. A minimum number should be stipulated in the curriculum (e.g. four per year). Training units should encourage and facilitate formal two-week dermatology clinical attachments. These should have been completed by the end of ST5, allowing trainees to benefit from the training prior to CCT. Trainees should be taught and observed performing key practical procedures, such as punch biopsies and fungal scrapings, with supervisors ensuring trainees are independent of these procedures by the end of ST5. These skills will be enabled through attending regular GD clinics and formal dermatology attachments.

Several GD courses are available in the UK. The BASHH GD SIG annual one-day course is planning a reduced rate for GUM trainees from this year (2015) so as to encourage their attendance. The BASHH HPV SIG also organises a Surgical Techniques in GUM course, which includes a lecture on GD and a mini workshop on skin biopsies (we did not survey the number of trainees who have attended this course). In response to this survey, the GD SIG is also planning a practical skills course specifically designed for GU trainees, as well as GD e-learning modules.

There is currently no formal certification in GD available in the UK. The availability of a post-graduate certificate or diploma in GD would improve, standardise and formalise the specialist training in GD for those clinicians (not only trainees) who have a specialist interest in the subject and by default, increase the number of GU clinicians able to train GU specialist registrars.

GD is a common presentation to sexual health clinics. Specialist trainees need standardised training in GD to become competent GU consultants. The results of this survey can likely be extrapolated to non-training GU clinicians, for whom GD training is equally important. We hope this survey has served to raise awareness of GD training and will be used to shape and improve GD training at both local and national levels.