If you want to dive straight into the meat of this book, feel free to skip the section below, and go directly to the Introduction, where I provide a summary of skincancer909 and how to get the most from it. What follows is the story behind why I wrote skincancer909.
For around twenty years I researched into the genetics of skin cancer. From work on the somatic genetics of skin cancer, including p53, through to the identification of the gene for red hair (melanocortin 1 receptor, MC1R). Along the way this involved studies of sun sensitivity, freckling, and the evolution of skin colour. Interesting, and well received, though this work was, particularly the work on the evolution of skin colour, it was of limited relevance to either my clinical work — seeing, diagnosing, and advising patients with skin cancer — and teaching medical students.
Around 2004-2006 I began to think hard about clinical skills, and how the perceptual skills that underpin dermatology could be taught to medical students. Although I had always thought of myself as an enthusiastic teacher, it was clear that our teaching — like much, if not most medical education — was based on little more than habit or prejudice. The more I have thought about this topic, the more I believe medical schools are out of tune with the present, let alone the future. Worse still, attempts at reform are usually infected with an infatuation with the latest fads or fashions. The criticism of medical educationalists as being akin to those people ‘ooing and aahing’ close to the catwalks in the Milan or London fashions shows each year, is well made.
Around this time, I began a collaboration with Bob Fisher, a Professor of Computer Vision, here in Edinburgh. We set out to try to develop a semi-automated system for skin cancer diagnosis that layered human perception on top of classical computer vision machine learning approaches (Dermofit). We were more successful in the latter than the former, published widely, and commercialised a small component of the work. Frustratingly, we were not able to raise the finance we needed to develop what I thought was the most interesting aspect of the work: an attempt to use software to meld human perceptual abilities and computer vision in an interactive two-way fashion. A genuine cyborg, remained beyond our grasp (and recent research suggests that alternative approaches, that do not rely on humans at all, may be more fruitful).
There were however other more tangible outcomes, too. The Wellcome Trust had funded the science, and had allowed us to collect a large library of high quality digital images that could be used by other researchers, but which also had full consent for use on the Web, and which I quickly integrated into our teaching. The collaboration also allowed me to think much harder about teaching and learning in dermatology. In particular, IMHO, student textbooks remain stuck in a past age, where publishers make scarce what is not scarce, and where new technology — such as web images and videos — are viewed as a danger to profits, rather than an opportunity to help people learn. The Web and the resulting ability to reproduce large numbers of images at almost zero cost should be revolutionary, and yet it was clear from talking to students, that their needs were still not being met [1]. There is something scary here, too. I actually think that a combination of regulation, and impoverishment of clinical academic units has meant that we are in a worse position in our use of technology than when I was a student (when programming was something I did on a mainframe….).
I take a more nuanced view than many on the value of Open Educational Resources (OER) versus the offerings from commercial publishers. Whilst I think there are real opportunities for producing large-scale collaborative clinical content, that is rigorously designed and executed, such projects will require substantial budgets, and universities or groups of universities seem unable to realise that they face increasing irrelevance if they do not seize such opportunities [2,3]. Dull PowerPoint presentations or worse still, videos of dull PowerPoint presentations are not the way forward, but content matters!
For large enrolment subjects, such as business studies, or introductory science courses, change could come sooner rather than later. For more niche domains — like skin cancer — change will take longer. Skincancer909 is meant to fill the gap. Until there is something better.
Who is skincancer909 designed for?
There is a simple answer to this. I wrote the first version of skincancer909 in 2011 because I thought my students at the University of Edinburgh would find it useful. The response was gratifying, not just from them, but from medical students at other universities. However, it is clear that a lot of other people have used the site and become interested enough to write to me about it. This first version was very much a ‘paper book’ on the web, whereas this 2017 version takes advantage of what the WWW can deliver. There are important limitations to keep in mind, however.
First, skincancer909 is primarily geared towards medical students, based on my experience of medical students in the UK. It emphasises the union of science and perceptual skills involved in recognition, and whilst it provides an introduction to therapeutics, it is not sufficient to guide unsupervised clinical practice. It is more education, than professional certification.
Second, clinical practice is not uniform in different parts of the world. Many parts of the world provide more high level expertise in dermatology out with hospital than the UK is willing to offer. The availability of therapies, and even access to dermatologists varies considerably. Attitudes to skin cancer screening, mole checking, follow up, or even ‘routine checks’ all vary considerably across Europe, let alone the rest of the world.
Third, there are other groups of people who have found skincancer909 useful. These range from those who are just curious about the topic, through to podiatrists, dentists, nurses and other health care related staff. I am sure I cannot meet all their needs, but I hope they continue to find skincancer909 helpful.
Finally, I acknowledge elsewhere the major contributions Dr Lisa Naysmith has made to this text.
Jonathan Rees, Edinburgh, (updated December 2022).
[1] For a paper expanding on this see: Dermatology undergraduate skin cancer training: a disconnect between recommendations, clinical exposure and competence.
[2] On this topic, see this interesting article by Woodie Flowers from MIT: A contrararian view of MITx: What are we doing?
[3] A classic early paper published in Science on what might happen, from Eli Noam. Electronics and the Dim Future of the University. E. M. Noam. Science 1995. DOI: 10.1126/science.270.5234.24
Skincancer909 by Jonathan Rees is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Where different rights apply for any figures, this is indicated in the text.