10.5826/dpc.1204a189
Introduction: In image interpretation education, many educators have shifted away from traditional methods that involve passive instruction and fragmented learning to interactive ones that promote active engagement and integrated knowledge. By training pattern recognition skills in an effective manner, these interactive approaches provide a promising direction for dermoscopy education.
Objectives: A narrative review of the literature was performed to probe emerging directions in medical image interpretation education that may support dermoscopy education. This article represents the second of a two-part review series.
Methods: To promote innovation in dermoscopy education, the International Skin Imaging Collaboration (ISIC) assembled an Education Working Group that comprises international dermoscopy experts and educational scientists. Based on a preliminary literature review and their experiences as educators, the group developed and refined a list of innovative approaches through multiple rounds of discussion and feedback. For each approach, literature searches were performed for relevant articles.
Results: Through a consensus-based approach, the group identified a number of theory-based approaches, as discussed in the first part of this series. The group also acknowledged the role of motivation, metacognition, and early failures in optimizing the learning process. Other promising teaching tools included gamification, social media, and perceptual and adaptive learning modules (PALMs).
Conclusions: Over the years, many dermoscopy educators may have intuitively adopted these instructional strategies in response to learner feedback, personal observations, and changes in the learning environment. For dermoscopy training, PALMs may be especially valuable in that they provide immediate feedback and adapt the training schedule to the individual’s performance.
text/xml
2160-9381
2243
en
Kelly C. Nelson
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
gamification
Instructional Strategies to Enhance Dermoscopic Image Interpretation Education: A Review of the Literature
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2022-10-31
2021-12-10
2022-10-31
2022-12-02
e2022189
Dermatol Pract Concept
Introduction: In image interpretation education, many educators have shifted away from traditional methods that involve passive instruction and fragmented learning to interactive ones that promote active engagement and integrated knowledge. By training pattern recognition skills in an effective manner, these interactive approaches provide a promising direction for dermoscopy education.
Objectives: A narrative review of the literature was performed to probe emerging directions in medical image interpretation education that may support dermoscopy education. This article represents the second of a two-part review series.
Methods: To promote innovation in dermoscopy education, the International Skin Imaging Collaboration (ISIC) assembled an Education Working Group that comprises international dermoscopy experts and educational scientists. Based on a preliminary literature review and their experiences as educators, the group developed and refined a list of innovative approaches through multiple rounds of discussion and feedback. For each approach, literature searches were performed for relevant articles.
Results: Through a consensus-based approach, the group identified a number of theory-based approaches, as discussed in the first part of this series. The group also acknowledged the role of motivation, metacognition, and early failures in optimizing the learning process. Other promising teaching tools included gamification, social media, and perceptual and adaptive learning modules (PALMs).
Conclusions: Over the years, many dermoscopy educators may have intuitively adopted these instructional strategies in response to learner feedback, personal observations, and changes in the learning environment. For dermoscopy training, PALMs may be especially valuable in that they provide immediate feedback and adapt the training schedule to the individual’s performance.
Kelly C. Nelson
2022/10/31
10.5826/dpc.1204a189
e2022189
Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
2160-9381
gamification
en
e2022189
Dyre L, Tabor A, Ringsted C, Tolsgaard MG. Imperfect practice makes perfect: error management training improves transfer of learning. Med Educ. Feb 2017;51(2):196-206. doi:10.1111/medu.13208
Instructional Strategies to Enhance Dermoscopic Image Interpretation Education: A Review of the Literature
https://dpcj.org/index.php/dpc/article/download/2243/1834
            Instructional Strategies to Enhance
        Dermoscopic Image Interpretation Education:
                 a Review of the Literature
     Tiffaney Tran1, Niels K Ternov2, Jochen Weber3, Catarina Barata4, Elizabeth G Berry5,
         Hung Q Doan1, Ashfaq A Marghoob3, Elizabeth V Seiverling6, Shelly Sinclair7,
      Jennifer A Stein8, Elizabeth R Stoos5, Martin G Tolsgaard9, Maya Wolfensperger10,
                               Ralph P Braun10, Kelly C Nelson1


 1 Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
 2 Department of Plastic Surgery, Herlev Hospital, Herlev, Denmark
 3 Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
 4 Institute for Systems and Robotics; Instituto Superior Técnico, University of Lisbon, Lisbon, Portugal
 5 Department of Dermatology, Oregon Health & Science University, Portland, OR, USA
 6 Division of Dermatology, Maine Medical Center, Portland, ME, USA; Department of Dermatology, Tufts University School of Medicine,
   Boston, MA, USA
 7 Department of Biology, Davidson College, Davidson, NC, USA
 8 The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY, USA
 9 Copenhagen Academy for Medical Education and Simulation; Department of Obstetrics, Copenhagen University Hospital Rigshospitalet,
   Copenhagen, Denmark
10 Department of Dermatology, University Hospital of Zürich, University of Zürich, Zürich, Switzerland



Key words: dermoscopy education, image interpretation education, instructional strategies, educational methods, gamification
Citation: Tran T, Ternov NK, Weber J, et al. Instructional Strategies to Enhance Dermoscopic Image Interpretation Education: A Review of
the Literature. Dermatol Pract Concept. 2022;12(4):e2022189. DOI: https://doi.org/10.5826/dpc.1204a189
Accepted: February 13, 2022; Published: October 2022
Copyright: ©2022 Tran et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Kelly C. Nelson, MD, Department of Dermatology, The University of Texas MD Anderson Cancer Center, 1400
Pressler Street, Unit 1452, Houston, TX 77030, USA, Telephone: 713-745-1113, Fax: 713-745-3597, E-mail: kcnelson1@mdanderson.org




  ABSTRACT             Introduction: In image interpretation education, many educators have shifted away from traditional
                       methods that involve passive instruction and fragmented learning to interactive ones that promote
                       active engagement and integrated knowledge. By training pattern recognition skills in an effective
                       manner, these interactive approaches provide a promising direction for dermoscopy education.
                       Objectives: A narrative review of the literature was performed to probe emerging directions in medi-
                       cal image interpretation education that may support dermoscopy education. This article represents the
                       second of a two-part review series.




Review | Dermatol Pract Concept. 2022;12(4):e2022189                                                                                   1
                       Methods: To promote innovation in dermoscopy education, the International Skin Imaging Collab-
                       orative (ISIC) assembled an Education Working Group that comprises international dermoscopy ex-
                       perts and educational scientists. Based on a preliminary literature review and their experiences as
                       educators, the group developed and refined a list of innovative approaches through multiple rounds of
                       discussion and feedback. For each approach, literature searches were performed for relevant articles.
                       Results: Through a consensus-based approach, the group identified a number of theory-based ap-
                       proaches, as discussed in the first part of this series. The group also acknowledged the role of motiva-
                       tion, metacognition, and early failures in optimizing the learning process. Other promising teaching
                       tools included gamification, social media, and perceptual and adaptive learning modules (PALMs).
                       Conclusions: Over the years, many dermoscopy educators may have intuitively adopted these instruc-
                       tional strategies in response to learner feedback, personal observations, and changes in the learning
                       environment. For dermoscopy training, PALMs may be especially valuable in that they provide imme-
                       diate feedback and adapt the training schedule to the individual’s performance.




Introduction                                                        interpretation represents a complex skill since learners must
                                                                    apply their knowledge of anatomy and pathology and their
Curricular requirements for medical education empha-                problem-solving skills to assess each image and reach a di-
size the importance of teaching students how to apply ac-           agnosis or conclusion [5]. In addition to absorbing relevant
quired knowledge in solving problems and exercising critical        declarative knowledge, learners must restructure and adapt
judgment [1].1 The ability to manipulate knowledge in this          their knowledge for each new image [4]. In radiology ed-
­manner is difficult if declarative concepts (e.g., key terms and   ucation, traditional teaching methods have been gradually
definitions) are rigid and decontextualized. In the preclinical     replaced by more interactive approaches, such as case-based
phase of medical education, learning often entailed attending       instruction [6]. Here learners are engaged as problem solv-
organized lectures and memorizing isolated facts specific to        ers, actively processing and integrating information [6].
the organ systems under study [2]. In light of the evolving ed-        As with radiology education, pathology education has
ucational environment, this traditional structure is being sup-     also demonstrated similar shifts away from conventional ap-
planted as educators incorporate classroom technology tools         proaches in favor of more interactive ones [4,5]. Through
and experiment with different approaches (eg group discus-          an integrated pathology curriculum, learners become more
sions, case presentations, patient contact experiences) [2].        active in their own learning, and pathology more integrated
    These emerging approaches aim to integrate knowledge            with other medical subjects [7]. As a result, acquired knowl-
across different specialties while improving long-term re-          edge is more flexible and primed for application across mul-
tention and preparing learners for real-world practice. In          tiple different contexts.
medical education, an instructional approach that promotes             Similar educational methods that confer conceptual un-
integrated knowledge is the illness script theory, derived          derstanding and train pattern recognition through real-life
from schema theory. In psychology, “schemas” are bundles            cases represent a promising new direction for dermoscopy
of pre-existing knowledge structures in long-term memory,           education. Combined with developments in technology,
where information is stored indefinitely, and “scripts” refer       these reflect contemporary trends in teaching strategies in
to those knowledge structures representing generic event se-        medical education. This review seeks to explore an array of
quences that can be retrieved from long-term memory and             emerging instructional strategies in image interpretation ed-
activated in the appropriate real-world context. For instance,      ucation that could meaningfully support dermoscopy train-
conceptual knowledge pertaining to a specific illness can be        ing programs.
quickly retrieved upon recognition of associated triggers,
such as a set of symptoms [3]. In contrast with the container
                                                                    Objectives
model introduced in the first part of this series, the illness
script theory promotes integration of declarative knowledge         This article represents the second part of a two-part review
and pattern recognition and reinforces the development of           series on instructional approaches in image interpretation
clinical reasoning skills [3].                                      education that may translate to dermoscopy education. The
    In image interpretation education, recent shifts away           first part of this series discussed limitations of traditional ap-
from the container model as the dominant instructional ap-          proaches based on the container model and considered con-
proach have occurred in radiology education [4]. Radiograph         temporary learning theories including whole-task learning,



2                                                                               Review | Dermatol Pract Concept. 2022;12(4):e2022189
microlearning, perceptual learning, and adaptive learning.         representations of the player progress, and badges are em-
In this second part, we will explore instructional strategies      blems of achievements that can be earned and collected. For
and methods—such as gamification, social media, perceptual         instance, a player may earn a badge for reaching a specified
and adaptive learning (PALMs), metacognition, and produc-          number of points or completing activities. Both points and
tive failure—that may also support dermoscopy education.           badges provide immediate feedback and function as rewards.
While these strategies and methods could apply to general          Finally, performance graphs display a player performance
dermatology education, the scope of this series is limited to      over time, focusing on improvements.
dermoscopy education.                                                 Each of the above elements are highly personalized as-
                                                                   pects of the player experience that serve to sustain learner
                                                                   motivation [13]. By providing clear feedback, many of the
Methods
                                                                   elements may also enhance self-regulated learning in which
The methods employed for our literature review are de-             learners control their own learning process and monitor
scribed in detail in the first part of this series [8]. This ar-   their own performance. The performance data generated by
ticle presents additional instructional strategies identified      player activity enables educators to analyze learner perfor-
during the group consensus and literature search processes         mance in order to optimize the educational program.
of this study. The instructional strategies presented in this
                                                                   Applications in Dermoscopy Education
second part include: gamification, social media, perceptual
                                                                   In dermoscopy education, educational applications (or
and adaptive learning modules (PALMs), metacognition, and
                                                                   “apps”) such as YouDermoscopy (developed by Meeter
productive failure.
                                                                   Congressi in Italy), DermaChallenge (developed by a team
                                                                   from the Medical University of Vienna in Austria), and Diag-
Results                                                            nosUs (developed by Centaur Labs in the U.S.) have all em-
                                                                   braced a gamified approach [14-16]. The YouDermoscopy
Gamification
                                                                   app divides dermoscopic cases into different levels that can
Overview
                                                                   be unlocked and provides feedback on learner performance,
In gamification, principles of game design are strategically
                                                                   such as through point rewards [14]. Targeted towards der-
applied to the learning environment to enhance motivation
                                                                   matologists, DermaChallenge features quizzes containing
and engagement. This strategy is derived from motivation
                                                                   dermosopic images, and for each image, players select the
theory, which emphasizes the importance of individual mo-
                                                                   corresponding diagnosis from choices representing common
tivation in the learning process [9]. Motivation is defined as
                                                                   dermoscopic diagnoses [15]. If incorrect, players receive
the process by which goal-directed activities are initiated and
                                                                   immediate feedback and review the correct answer. Quiz-
sustained [10]. In games, factors shown to enhance player
                                                                   zes are similarly organized into multiple levels that players
motivation include challenge, curiosity, autonomy, fantasy,
                                                                   may unlock.
competition, collaboration, and recognition [10]. Conve-
                                                                      More broadly, the DiagnosUs app allows players to prac-
niently, many of these factors may be incorporated into edu-
                                                                   tice image interpretation for dermoscopy in addition to other
cational games to make the learning process more engaging.
                                                                   specialties, such as radiology, ophthalmology (retinography),
   By taking advantage of familiar game mechanics and dy-
                                                                   and obstetrics/gynecology (ultrasonography) [16]. While
namics, games in the educational setting induce goal-directed
                                                                   the app contains other noteworthy features such as crowd-
activity in an artificial social context, producing quantifiable
                                                                   based labeling, its educational component is mainly geared
outcomes [11]. The pursuit of clearly defined goals in games
                                                                   towards medical learners, and the dermoscopy section pri-
has been associated with increased affective measures and
                                                                   marily covers melanoma detection training [16]. Quizzes,
decreased cognitive load [12]. In other words, students have
                                                                   called “missions,” may contain dermoscopic images of nevi
more fun when learning in a gamified environment, where
                                                                   that players classify as benign or malignant. Once players
they also benefit from the ability to control their own learn-
                                                                   submit their answer, they can review the correct answer, see
ing process.
                                                                   the number of users who answered correctly or incorrectly,
Game Design Elements                                               and participate in the discussion forum for that case [16].
To invoke a sense of challenge and novelty among learners,
educators may incorporate the following classical elements         Social Media
of game design: avatars, points, badges, performance graphs,       Overview
and leaderboards [11]. Avatars are digital representations of      With the pervasiveness of social media in daily life, educa-
the player within the game and may be as simple as a cus-          tors are also seeking to leverage social media platforms to
tomizable icon chosen by the player. Points are numerical          enhance curriculum design, promoting classroom interaction



Review | Dermatol Pract Concept. 2022;12(4):e2022189                                                                             3
and facilitating peer-to-peer learning [17]. Educators may       opinions for cases (eg dermoscopic features, dermoscopic
use these platforms to either deliver or complement curricu-     diagnoses, treatment plans) and provide their rationale,
lum delivery. As active participants, learners may contribute    sometimes supported by references. By facilitating academic
discussion points and comments and collaborate with peers        discussion, the forum allows users to learn from each other
via group chats. These interactions may occur in either a syn-   and enables new ideas to emerge. Similarly, the IDS Face-
chronous fashion with real-time responses or an asynchro-        book group offers another virtual space for users to network
nous fashion with delayed responses.                             and discuss interesting cases [23].
                                                                    On Instagram, a popular photo- and video-sharing app,
Applications in Medical Education                                the handle for the most popular dermoscopy account is
In a study in China, investigators evaluated the feasibility     “@dermoscopy_.”24 Managed by a team of dermatologists
of a social networking platform called Microblog among           in Brazil, the account boasts over 40,000 followers. The
pharmacotherapy students [18]. Learners completed phar-          content producers frequently post short educational videos
macotherapy case studies through Microblog, and the end-         and dermoscopic images with the diagnoses or answers in
of-course survey results indicated that a majority of learners   the captions. Many dermatology residency programs also
agreed that the platform enhanced their learning experience      employ group text messaging apps such as WhatsApp and
by increasing their active engagement in the course. Some        GroupMe. In these virtual spaces, trainees may share inter-
shared that compared to meeting face-to-face, meeting on-        esting de-identified dermoscopic cases from their training
line was more convenient, allowing team members to collab-       experiences and solicit ideas from attending physicians and
orate from any location “with a simple click”[18] However,       other trainees.
some still expressed a preference for face-to-face commu-           Many educational apps that incorporate elements of
nication, citing issues such as delayed responses and online     game design also benefit from social media features. These
chatter. Instructors needed to balance between maintaining       apps may present cases in a game-like format and then in-
a discreet online presence to promote student participation      corporate a forum for users to discuss the cases. For exam-
and monitoring discussion threads for potential issues (eg       ple, the “Play Live” function on the YouDermoscopy app
wrong/misleading information, repetitive comments).              allows players to provide an opinion or request assistance
    Ideally, social media platforms in the educational setting   from others in real time [14]. The DiagnosUs app also has a
create opportunities for students to share ideas and learn       discussion forum for each case that players may use to ask
from peers [19]. An example in radiology education is a          clarifying questions and share their findings [16].
de novo social media platform called Collective Minds Ra-           While the advantages of social media include increased
diology (developed by a team in Sweden) [20]. Available to       learner engagement through opportunities for collaboration,
download as a smartphone app, this platform enables users        its incorporation into the learning environment may require
to share their expertise and collaborate on challenging ra-      administrative training and technical support [17,25]. To en-
diology cases [20].                                              sure a high-quality learning experience, administrative staff
    While the development of these platforms de novo may         may need to routinely monitor online activity to ensure accu-
be time-consuming and labor-intensive, the incorporation of      racy of information and provide further guidance as needed.
existing platforms into the learning environment represents
an alternative route. For example, an online research meth-      Perceptual and Adaptive Learning
odology course implemented a collaborative space on the          Modules (PALMs)
Twitter platform to enhance student engagement [21]. In          Overview
this course, students discussed topics of interest on Twitter    Perceptual and adaptive learning modules (PALMs) repre-
through tweets (text-based posts constrained by 140-280          sent a novel teaching tool in medical education that com-
characters) and course-specific hashtags (indexed keywords       bines the strengths of both perceptual learning and adaptive
or phrases preceded by the “#” symbol). A significant ma-        learning in order to accelerate expertise [26]. As discussed in
jority of learners in this study agreed that the collaborative   the first part of this series, the perceptual learning technique
groupwork via the social media platform positively contrib-      is an interactive approach that introduces a specific visual
uted to their learning.                                          feature and then exposes learners to numerous examples so
                                                                 that learners can quickly and accurately identify that fea-
Applications in Dermoscopy Education                             ture in new cases [27]. The adaptive learning technique op-
As an online platform for dermatologists to discuss inter-       timizes learning outcomes through continuous performance
esting dermoscopic cases, the International Dermoscopy           tracking and personalized modifications [28]. This method
Society (IDS) forum represents an example of social media        equates low response times and high accuracy rates with
in dermoscopy education [22]. Here users can share their         content mastery [28].



4                                                                           Review | Dermatol Pract Concept. 2022;12(4):e2022189
   The combination of these two approaches in PALMs has            images in terms of learning outcomes [33]. While an exten-
the potential to transform education in medical fields that        sive number of unique example images may thus not be nec-
rely on pattern recognition skills. Learners using PALMs           essary for PALMs, components that seem essential include
may be asked to classify a number of images from a train-          opportunities for immediate feedback and repetitive practice.
ing library after being introduced to a specific visual feature.
Adaptive algorithms analyze their individual performance —         Metacognition
as assessed in terms of response time and accuracy — and           Overview
make personalized modifications to their future training           Metacognition, a term originally coined in the 1970s, refers
[29]. Learners continue training until they achieve content        to the awareness of one’s own cognitive processes, or cog-
mastery, demonstrated by their fulfillment of the objective        nition about cognition [34]. In medical education, learners
learning criteria. Through this training method, learners de-      who apply metacognition reflect on their study strategies
velop expert-level pattern recognition skills in an efficient      and learning outcomes and correct errors in order to im-
manner while learning how to perform relevant clinical             prove performance [35]. In becoming more aware of their
tasks. While the perceptual learning and adaptive learning         learning processes, students may strategically allocate their
approaches can be applied individually, learning outcomes          learning efforts and simultaneously reduce their cognitive
seem to be optimized when they are strategically combined.         load. As medical knowledge and healthcare systems continue
                                                                   to evolve, providers must be able to continually assess their
Applications in Medical Education
                                                                   own knowledge, performance, and possible biases to main-
In transesophageal echocardiography (TEE) and electro-             tain good clinical practice in a rapidly changing world [36].
cardiography (EKG) interpretation education, PALMs have
enabled learners to develop pattern recognition skills com-        Applications in Medical Education
parable to those of experts. In a non-randomized controlled        While metacognitive processes may be difficult to measure
study on TEE interpretation, anesthesiology residents com-         given their complexities, researchers have developed various in-
pleted PALMs that showed about 180 video clips, provided           struments to evaluate metacognition and self-regulation, the lat-
feedback, and measured response time and accuracy [30].            ter referring to the ability to control one own learning through
Compared to both their baseline and the control group,             planning, monitoring, and evaluation [36]. In the literature, the
learners in the PALM group performed significantly better          following methods have been adopted for medical education:
in terms of accuracy and fluency after six months. In an-
other before-and-after study on EKG interpretation, learners       1. The Metacognitive Awareness Inventory (MAI) measures
used PALMs containing over 400 unique EKG tracings and                two broad categories of metacognition, knowledge of
similarly retained accuracy and fluency gains after one year          cognition and regulation of cognition [37].
compared to their baseline [31].                                   2. The Inventory of Learning Styles (ILS) measures aspects
   In dermatology education, PALMs have also been suc-                of self-regulation, external regulation, and lack of reg-
cessful in training pattern recognition, as demonstrated in a         ulation [38]. The self-regulation scale measures the de-
before-and-after study among medical students [32]. For dif-          gree to which students reflect on their learning processes,
ferent visual features, the PALMs presented example images            identify the cause of their learning problems, and man-
in a flashcard style and measured response time and accuracy.         age their efforts in achieving their own learning objec-
As learner performance improved, images from that category            tives. The external regulation scale measures the degree
were spaced further apart to assess long-term retention.              to which students rely on didactic aids, such as formal
                                                                      learning objectives, and external support, such as feed-
Applications in Dermoscopy Education                                  back and assignments from instructors. The lack of regu-
PALMs may be developed for dermoscopy education in                    lation scale concerns the inability of students to regulate
which educators teach key dermoscopic features for common             learning and the perceived lack of external support.
dermatologic diagnoses and then expose learners to numer-          3. The Self-Regulated Learning Perception Scale (SRLPS)
ous example images for each feature. Learners practice iden-          measures motivation and action to learning; planning
tifying features on new images and receive feedback, while            and goal setting; strategies for learning and assessment;
adaptive algorithms measure response times and accuracy               and lack of self-directedness [39].
rates and retire specific learning concepts based on objective
mastery criteria. To promote optimal learning, the number             The above instruments may be employed on a routine
of example images required for these modules remains to be         basis to gain further insight into metacognitive processes
explored. A study on radiograph interpretation found that          and learning experiences. For example, a study on metacog-
reusing images was similarly effective to only using unique        nition across four medical schools employed both the MAI



Review | Dermatol Pract Concept. 2022;12(4):e2022189                                                                              5
and SRLPS and found that students in the clinical phase of           Productive Failure
their training demonstrated higher levels of metacognition,          Overview
especially in terms of planning and goal setting, compared           Productive failure is a relatively novel concept in education
to those in the preclinical phase [39]. Students enrolled at         that uses early failures to activate retrieval of prior knowl-
schools that applied learner-centered teaching methods, such         edge and promote problem-solving skills [43]. It plays on
as problem-based learning, also displayed higher levels of           the proverbial wisdom of failing before succeeding and en-
metacognition compared those learning via conventional               courages creative risk-taking [44]. This method is conceptu-
methods [39]. Similar scales may be employed in dermos-              alized as a two-phase process [43]. In the first phase, learners
copy education to assess changes in metacognitive awareness          are given a challenging problem to solve on their own or in
over the course of a training program.                               groups prior to any, or minimal, didactic training (Genera-
                                                                     tion and Exploration). After struggling to generate their own
Applications in Dermoscopy Education
                                                                     solutions to the challenging problem, learners are provided
A proposed strategy to prime metacognitive awareness in der-         formal training (Consolidation and Knowledge Assembly).
moscopy learners involves prospective judgments of learning          The learner initial struggle with the challenging problem
(JOLs) in which learners rate how likely they would remem-           may facilitate conceptual understanding and meaningful
ber an item on a test [40]. The act of making JOLs has been          future learning [45]. Learners who are prepared for future
shown to enhance long-term memory and improve learning               learning demonstrate the ability to apply key learning con-
performance on cued recall tests [41]. In dermoscopy educa-          cepts in solving new problems [45].
tion, this strategy may be applied by prompting learners to             By inducing early failures within a safe learning envi-
rate their level of confidence in answering a question, such         ronment, productive failure may create conditions in which
as whether a dermoscopic image contains a specific feature.          learners become more motivated to obtain and retain a solu-
Learners may track changes in their performance as well as           tion to the problem given the effort already invested into
changes in their confidence throughout the training program          solving it [46]. This phenomenon is known as the endow-
in order to better understand their strengths and weaknesses.        ment effect: once learners endow a problem with resources,
    Metacognition allows learners to more actively engage            such as time and effort, it may become more emotionally
in their own learning as they consider their knowledge, per-         valuable to know and learn the solution [46].
sonal abilities, and learning strategies [42]. To better un-            In a testing-oriented learning environment, instructional de-
derstand their strengths and weaknesses for metacognitive            sign that incorporates productive failure may also benefit from
processes, learners require some form of feedback on their           the testing effect, which refers to the positive effects of test-­
performance. Digital solutions, such as mobile apps, may             taking on long-term memory and knowledge retention [47].
facilitate metacognitive awareness through auto-­generated           While the challenging problem is not necessarily presented as
displays of performance data, encouraging proactive ad-              a test, students may perceive it as a form of assessment as they
justments of learning strategies. In incorporating elements          practice retrieving their prior knowledge. Though these diffi-
of game design, the process of reflecting on learning prog-          cult exercises may hamper learning performance in the short
ress may become more engaging for both learners and                  run, they may improve learning outcomes in the long run [48].
educators.
    Beyond the classroom setting, learners may also contem-          Applications in Medical Education
plate instances of cognitive error in real-life clinical practice.   In implementing the productive failure approach, it is im-
Cognitive errors specific to skin cancer diagnosis include           portant that students actively generate mistakes themselves
inattentional blindness (overlooking a melanoma) and di-             rather than observe the mistakes of others [49]. Yet, the pro-
agnostic error (evaluating a melanoma but incorrectly di-            ductive failure approach may be uncomfortable for learn-
agnosing it as a benign skin growth). When presented with            ers with strong aversion to failure. To minimize negative
feedback and performance data, learners may reflect upon             psychological consequences of failure, instructors may ap-
errors in their learning strategies and adjust accordingly.          ply a classroom strategy called error management training
    In real-life clinical practice, most expert dermoscopists        in which errors are framed as “positive” occurrences and
describe systematically capturing dermoscopic images of all          natural byproducts of the learning process [50]. In a ran-
biopsied lesions and then reviewing those images when their          domized study, medical students assigned to error manage-
clinical diagnosis is discordant with the histopathologic di-        ment training were encouraged to probe freely, make errors
agnosis. In reviewing the images, overlooked clues may be            during ultrasound practice, and reflect on their errors [50].
identified, improving the provider proficiency. Metacognitive        In a ­simulation-based test conducted a week later with real
awareness thus has the potential to improve performance              patients, students in the error management arm performed
and long-term learning outcomes in the clinical setting.             better than those in the error avoidance arm.



6                                                                                Review | Dermatol Pract Concept. 2022;12(4):e2022189
   Technology tools may also ease learners aversion to             Conclusions
failure by creating a low-stakes learning environment, al-
lowing students to explore new problems in a safe and              A summary of the instructional strategies and methods ex-
non-threatening setting. The use of technology enables             plored in the second part of this review series is included in
small failures to be “contained and managed” within an             Tables 1 and 2. Over the years, many dermoscopy educators
external system [44].                                              may have intuitively adopted these approaches in response
                                                                   to learner feedback, personal observations, and changes in
Applications in Dermoscopy Education
                                                                   the learning environment. In dermoscopy education, the
Productive failure recognizes the inherent value of mis-           strategic integration of these emerging approaches may sup-
takes and the educational utility of errors. By inducing early     port the development of pattern recognition skills, such as
failures within a safe learning environment and activating         global interpretation and holistic processing.
the problem-solving process, productive failure can be an              In light of our review, we envision a hypothetical der-
effective teaching tool. In dermoscopy education, produc-          moscopy training program with active learning strategies in-
tive failure can be implemented by providing challenging           formed by contemporary learning theories. In this program,
cases before each module, followed by feedback and guid-           learning concepts, such as a specific diagnosis, could be or-
ance. This will help activate a shift towards planning and         ganized as their own unit, and each unit could be prefaced
goal-setting and probe metacognitive awareness of potential        by a challenging problem that simulates productive failure
weaknesses. Incorporation of technology tools may also help        and activates problem-solving processes. For each diagno-
establish a safe learning environment that permits learners to     sis, learners could learn and review educational content us-
make mistakes and understand their mistakes, spurring them         ing PALMs that teach key diagnostic features and expose
towards later success in their learning journey.




Table 1. Summary of the instructional methods presented in the second part of this review series plus
             examples of existing or potential applications in dermoscopy education.
 Educational Method                           Description                          Application(s) in Dermoscopy Education
 Gamification              • Factors that contribute to learner motivation       Existing Applications
                             include challenge, curiosity, autonomy, fantasy,    • YouDermoscopy, created and developed by
                             competition, collaboration, and recognition.          Meeter Congressi SRL
                           • In gamification, principles of motivation           • DermaChallenge (Dermonaut), created by
                             theory and elements of game design are                H. Kittler, P. Tschandl, and C. Rinner
                             applied to the educational context to enhance       • DiagnosUs, created and developed by
                             learner engagement and promote goal-directed          Centaur Labs
                             learning.
 PALMs                     • PALMs combine both perceptual learning         Potential Application
                             techniques and adaptive learning algorithms to • dermoscopy PALMs:
                             efficiently train pattern recognition skills.    • educators teach key diagnostic features
                           • Learners classify unique images and receive        and expose learners to numerous example
                             immediate visual feedback, and adaptive            images
                             algorithms determine whether to re-sequence      • learners identify features on new images
                             or retire specific learning concepts.              and receive feedback
                                                                              • adaptive algorithms retire specific learning
                                                                                concepts based on objective mastery
                                                                                criteria
 Social Media              • Social media platforms are leveraged by             Existing Applications
                             educators to increase learner engagement and        • IDS Forum
                             foster peer-to-peer interaction.                    • Facebook pages (e.g., IDS page)
                           • Learners benefit from opportunities for             • Instagram accounts (e.g., @dermoscopy_)
                             collaboration on cases plus the convenience of      • WhatsApp groups (e.g., dermatology trainee
                             a web-based platform.                                 groups)
                           • Disadvantages may include delayed responses,
                             poor quality of interaction, and wrong or
                             misleading information from peers.

IDS = International Dermoscopy Society; PALMs = perceptual and adaptive learning modules.



Review | Dermatol Pract Concept. 2022;12(4):e2022189                                                                           7
     Table 2. Summary of the educational concepts presented in the second part of this review series
              plus examples of existing or potential applications in dermoscopy education.
    Educational Concept                      Description                         Application(s) in Dermoscopy Education
 Metacognition              • Learners who apply metacognition                Potential Application
                              (awareness of one own cognitive                 • JOLs: learners “bet” on whether they will
                              processes) reflect on their learning              remember a given item or rate their level
                              processes and learning outcomes.                  of confidence in answering a question (e.g.,
                            • When presented with visual feedback and           whether a dermoscopic image contains a
                              performance data, learners may identify           specific feature)
                              potential errors in their learning strategies
                              and adjust accordingly.
 Productive Failure         • Learners are given a challenging problem   Potential Applications
                              to solve prior to didactic training        • challenging problem: learners annotate
                              (Exploration). After struggling to           dermoscopic images prior to instruction
                              generate their own solutions, learners     • error management: learners receive instructions
                              are then provided the didactic training      that frame errors as positive occurrences
                              (Consolidation).
                            • The learner initial struggle with the
                              challenging problem facilitates meaningful
                              future learning.

JOLs = judgments of learning.

learners to numerous example images. Learners identify             schedule to the individual’s performance. The development
features on new images and receive feedback, and adaptive          of technology tools that enable the integration of these dif-
algorithms retire specific learning concepts based on objec-       ferent approaches in dermoscopy education will greatly fa-
tive mastery criteria. The PALMs may involve elements of           cilitate endeavors to optimize knowledge acquisition and
game design such as points and badges that enhance learner         skills development.
engagement.
     The program could also be supplemented by group fo-           References
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