Let's be clear on the proper place of photographs in teaching dermatology

Dear Sir

I read with a degree of interest the letter by Amri et al. (2012) on the proper place of digital photographs in teaching dermatology. They undertook a study to compare student learning from either a session of ‘traditional clinical teaching’ on five patients, or what one must infer was a similarly facilitated teaching session based on images of these patients. They found no statistical difference in outcomes of diagnostic ability. However, even allowing that the report is in succinct correspondence form, there appear to be important limitations of methodology and reporting such as unclear hypothesis, small sample size with no power calculation, no comments on efforts to reduce confounding, such as by preventing students from each group from meeting during the study and no assessment of whether some students did any further study of the subject prior to their evaluation. Whatever doubt this may cast on the reliability of their results, I was rather astounded to read that, ‘The majority of students agreed or strongly agreed that digital photograph teaching is better than the traditional clinical teaching, as well it encouraged them [sic] to learn more about the discussed conditions’. This runs starkly counter to my experience of teaching dermatology to hundreds of medical students. The highlight for most is the chance to interact with real patients with real disease. This is particularly important in dermatology, as the psychosocial impact of skin disease is often a major source of morbidity and this cannot be gauged from photographs. Some skin disease presents with very subtle findings that are difficult to capture by photography and palpation is often required as part of the skin examination. Without question, clinical photographs have an important role in dermatology education – classical presentations can be shown, rarer or acute diseases can be illustrated, assessment of large numbers of students can be enhanced – but their proper place is certainly as an adjunct to clinical exposure to actual patients. Amri et al. may need to reflect on how effectively they deliver their traditional clinical teaching.