Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 11-15
Published Online November 2013 (
Open Access JCDSA
Dermatology Resident Generated Textbook Questions as a
Resident-Centered Educational Strategy
Nathan A. Davis, Kimberly Cooper, Erica B. Kelly, Sharon S. Raimer, Richard F. Wagner*
The University of Texas Medical Branch, Galveston, USA.
Email: *
Received August 13th, 2013; revised September 11th, 2013; accepted September 18th, 2013
Copyright © 2013 Nathan A. Davis et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background: Textbook conferences are widely used by dermatology residency programs in the United States to pro-
vide educational ex posure to the sp ecialty. Typically an entire textbook is reviewed each academic year. However, resi-
dents may be uncertain about mastery of the assigned readings. Since most dermatology textbooks do not provide ques-
tions about the material presented at the end of each chapter, an innovative senior resident from our program wrote
questions about each chapter and offered them to the other residents prior to scheduled discussions of the assigned ma-
terials. Methods: A pilot study for resident generated quizzes about assigned textbook reading in general dermatology
was developed, implemented, and assessed by anonymous completion of a Likert Scale by participants. Results: Par-
ticipants indicated that quizzes better prepared them for the annual dermatology in-service examination and they
thought that the additional creation of quiz materials in the subspecialty areas of dermatopathology and dermatologic
surgery would be useful. Conclusion: Resident generated quizzes are a novel approach to the learning environment
during dermatology residency for residency programs and may be useful for other residency programs that utilize text-
book conferences. Additional research is needed.
Keywords: Dermatology; Residency; Accreditation; Self-Assessment; Textbook; Quiz
1. Introduction
Learning in medical education is assessed by many dif-
ferent tools. Each modality facilitates learners’ ability to
obtain, process, and understand materials provided. Ac-
cording to the Accreditation Council for Graduate Medi-
cal Education (ACGME) requirements (IV.A.5.b). (3) for
dermatology, residents “···should be trained, throughout
the residency, with a various combinations of lectures,
conferences, seminars, demonstrations, individual or group
study of color transparencies or images and histological
slides, clinical rounds, chart and record reviews, fac-
ulty-trainee sessions in small groups and one-to-one set-
tings, book and journal reviews···” [1]. While much
resident training occurs in the clinical setting, textbook
reading remains an essential part of medical education
for many dermatology programs. However, since it is
recognized that physicians have a limited ability to accu-
rately self-assess [2], it would be useful for them to have
objective self-assessment tools available to measure le arn -
ing. Self-assessment of learning has been studied in other
contexts. Al-Kadri et al. found that feedback fro m others
was an essential element of self-assessment for medical
students [3]. In another study, psychology students who
created at least three questions about course work im-
proved their exam scores [4].
2. Background
Simply reading a text may make it difficult for partici-
pants to assess their level of competency. While some
board review materials used in preparation for the com-
prehensive certification examination administered annu-
ally by the American Board of Dermatology provide a
question bank for self-assessment, few textbooks offer
similar chapter review questions to assess comprehension .
Our objective was to create a self-assessment tool that
dermatology residents might use as a means of testing
their understa n din g of the material read in each chapter.
3. Materials and Methods
In accordance with ACGME guidelines, each academic
*Corresponding author.
Dermatology Resident Generated Textbook Questions as a Resident-Centered Educational Strategy
year all dermatology residents in our program complete
reading assignments. These readings include various as-
pects of clinical dermatology, pediatric dermatology, der-
matopathology, and dermatologic surgery. Reading sched-
ules are determined annually by the chief dermatology
residents with approval by the program director. The
reading requirements are typically completed in a six to
eight month time course each year. Internal departmental
educational activities are exempted from Institutional
Review Board review.
For the academic year of 2011-2012, Andrews Dis-
eases of the Skin: Clinical Dermatology, tenth edition,
was chosen as the clinical dermatology text for our 9
resident program. This 38 chapter text was divided into
23 reading assignments. Prior to each review conference,
residents were expected to have read the assigned chap-
ters. In order to enhance resident understanding and com-
prehension of each reading assignment, a written quiz
was implemented. Prior to the group discussion, a self-
assessment quiz consisting of 17 - 33 questions (closed-
book format) was given to each resident except for the
chief resident who created the quiz (NAD). Question
types consisted of multiple choice, fill-in-the-blanks,
true/false, and matching. Following quiz completion,
answer sheets were distributed and the reading assign-
ment was summarized by a chief resident. Emphasis was
placed on key concepts from the chapter. Faculty mem-
bers were present for additional commentary.
At the completion of our annual textbook reading,
each resident was asked to complete an anonymous
evaluation regarding their educational experience in this
activity. The evaluation consisted of seven statements
that residents rated using a five-point Likert Scale (Table
1). A score of 1 represented “completely disagree” and a
score of 5 represented “completely agree”. In addition,
there was a question to assess what quiz format was pre-
ferred. Resident comments were also solicited about th eir
learning experience during this process.
4. Results
All eight dermatology residents completed the 23 session
reading schedule and weekly quizzes. Evaluations were
collected from all residents except the chief resident who
created the quizzes, and are summarized in Table 1. All
residents preferred a combination of multiple choice, fill-
in-the-blanks, true/false, and matching. Residents fa-
vored creation of additional quiz materials for the sub-
specialty areas of dermatopathology and dermatologic
surgery. Resident qualitative comments reflected interest
in additional multiple choice questions about the reading
material, possibly reflecting the format of the annual
dermatology in-training examination. The resident who
created the questions (NAD) thought that this process
increased his comprehension of the reading materials.
5. Conclusions
Learning occurs in a variety of ways. A particular chal-
lenge for dermatology residents is the huge body of
knowledge they are expected to master during the three-
year programs. At our institution, didactic teaching is
done through a v ariety of modalities. These include text-
book conferences, grand rounds, lectures, dermatopathol-
ogy unknown slide conferences, kodachrome confer-
ences, board review, journal club, and interdisciplinary
conferences. In addition to these scheduled group activi-
ties, assigned textbook reading is an integral part of resi-
dency training. Through the use of quizzes, residents
were provided with immediate feedback about their re-
call of the assigned reading.
Previous research supports the educational utility of
providing quiz materials to residents, although the opti-
mal use of quizzes in this setting requires further inves-
tigation. Neurology residents scored significantly higher
on neuroanatomy that was tested on their residency in-
service training examination (RITE) when they partici-
pated in team based oral quizzes [5]. However, written
Table 1. Dermatology resident evaluation (five-point Likert Scale).
Statement Not
Applicable “1 - 3” Likert
Responses “4” Likert
Responses “5” Likert
Responses Mean Likert
My knowledge of clinical dermatology has improved 0 0 1 7 4.9
I feel better prepared for the Dermatology In-Training Exam this ye ar3 0 1 4 4.8
I am likely to use these questions to complement my studying
for the In-Training Exam 0 0 2 6 4.8
I am likely to use these quest io ns ne xt year to supplement our
clinical dermatology reading 2 0 0 6 5
I think questions that correlate to our dermatopa t ho l og y reading
would be helpful 0 0 2 6 4.8
I think questions that correlate to our dermatologic surgery rea d i ng
would be helpful 0 0 1 7 4.9
Overall, the weekly questions related to our clinical dermatology
reading was a good experience 0 0 0 8 5
1 = completely disagree, 5 = comple tely agree.
Open Access JCDSA
Dermatology Resident Generated Textbook Questions as a Resident-Centered Educational Strategy 13
quizzes about neuropharmacology did not improve RITE
performance compared to controls [5]. In another educa-
tional study, radiology residents using an audience re-
sponse system during lectures demonstrated significantly
more learning and long-term retention [6].
The incorporation of resident generated quiz questions
for assigned textbook reading assignments was high-
lighted in our most recent Specialty Specific Program
Information Form (PIF) for the Dermatology Residency
Review Committee. In response to a question about Prac-
tice-Based Learning and Improvement (PR IV.A.5.c), our
program was asked to:
“Describe one learning activity in which residents en-
gage to identify strength s, deficiencies, and limits in their
knowledge and expertise (self-reflection and self-assess-
ment); set learning and improvement goals; identify and
perform appropriate learning activities to achieve self-
identified goals (life-long learning).”
Our response to this question highlighted the adoption
of this new educational process in to our program:
“An example of this type of le arning is when the PG Y4
dermatology chief residents organize assigned textbook
readings from Andrews’ during each academic year, with
the goal of completing this textbook in time for the an-
nual in-service examination. This activity permits our
residents to identify strengths, deficiencies, and limits in
their knowledge and expertise (self-reflection and self-
assessment) and set learning and improvement goals for
themselves through appropriate learning activities in or-
der to achieve self-identified goals such as life-long
learning and critical thinking. These assigned readings
are supervised by dermatology faculty (Dr. E. Kelly). All
the residents read the assignment, and the reading is re-
viewed by a PGY4 resident, with faculty adding per-
spective. This comprehensive reading program is used by
residents at all levels to identify the strengths, deficien-
cies, limits and areas of expertise and areas of special
interest. One of the current PGY4 chiefs, Dr. N. Davis,
has supplemented the assigned readings this year with
short quizzes that he creates based on the readings that
all the residents take prior to discussion as a method of
self-assessment. Residents take the quiz prior to the dis-
cussion and then discover the correct answers during
discussion of the reading by PGY4 residents. This type
of supportive learning environment creates a learning
environment of inquiry and problem solving that helps
residents set learning and improving goals and focus on
the type of learning activities that will help them achieve
their goal of life-long learning and discovery. Dr. E.
Kelly uses this learning activity to promote resident
learning and evaluate the PGY4 residents, especially in
relationship to their ability to communicate and teach
their fellow residents about dermatology topics and their
medical knowledge of these topics.”
This pilot study suggests that resident generated ques-
tions about assigned textbook reading for the purpose of
self-assessment may be applicable to other postgraduate
residency programs outside of dermatology that have re-
quired textbook conferences. Another variation of this
process with potential educational impact might be to
engage all participants in question-generation [7]. Further
exploratory studies with the goal to enhance this aspect
of resident education should be considered. This educa-
tional experience is reported from one intermediate sized
dermatology program, and it may not be directly appli-
cable to smaller or larger programs in the same or dif-
ferent specialties. There was no control group. Question
validity and reliability, as well as questionnaire validity
have not yet been evaluated.
This preliminary educational research indicated that
dermatology residents were receptive to resident-gener-
ated quizzes about assigned textbook readings. Although
additional research which is needed in this area before
any conclusion about the educational value of this activ-
ity can be made, our experience seems to indicate that
this approach may be useful for resident education.
[1] Accreditation Council for Graduate Medical Education,
“ACGME Program Requirements for Graduate Medical
Education in Dermatology,” 2013.
[2] D. A. Davis, P. E. Mazmanian, M. Fordis, R. Van Harri-
son, K. E. Thorpe and L. Perrier, “Accuracy of Physician
Self-Assessment Compared with Observed Measures of
Competence: A Systematic Review,” JAMA, Vol. 296,
No. 9, 2006, pp. 1094-1102.
[3] H. M. Al-Kadri, M. S. Al-Moamary, H. Al-Takroni, C.
Roberts and C. P. van der Vleuten, “Self-Assessment and
Students’ Study Strategies in a Community of Clinical
Practice: A Qualitative Study,” Medical Education, Vol.
17, 2012, Article ID: 11204.
[4] J. W. Berry and S. L. Chew, “Improving Learning through
Interventions of Stude nt-Generated Questions and Conc ept
Maps,” Teaching of Psychology, Vol. 35, No. 4, 2008, pp.
[5] L. Schuh, D. E. Burdette, L. Schultz and B. Silver, “Two
Prospective Educational Interventions in a Neurology Resi-
dency: Effect on RITE Performance,” Neurologist, Vol.
13, No. 2, 2007, pp. 79-82.
[6] E. I. Rubio, M. J. Bassignani, M. A. White and W. E. Brant,
“Effect of an Audience Response System on Resident
Learning and Retention of Lecture Material,” American
Journal of Roentgenology, Vol. 190, No. 6, 2008, pp.
[7] R. Ahn and M. Class, “Student-Centered Pedagogy: Co-
Construction of Knowledge through Student-Generated
Midterm Exams,” International Journal of Teaching and
Learning in Higher Education, Vol. 23, No. 2, 2011, pp.
Open Access JCDSA
Dermatology Resident Generated Textbook Questions as a Resident-Centered Educational Strategy
Appendix 1
Andrews’ Questions (Chapter 27)
1) What is the most common extracutaneous manifes-
tation of Incontinentia pigmenti? __________________.
2) All of the following are associated with Naegeli-
Franceschetti-Jadassohn syndrome EXCEPT:
a) hyperhidrosis;
b) toothlessness;
c) perioral and periorbital reticulate pigmentation;
d) absent dermatoglyphics;
e) congenital malalignment of the great toes.
3) In patients with Chondrodysplasia punctata, the
classic x-ray finding is _____________________ ____.
CP is caused by a mutation in ______ __________
important in the cholesterol biosynthesis pathway.
4) Turner syndrome (XO) is associated with an in-
creased risk of:
a) angiomyolipomas;
b) periungual fibromas;
c) SCC;
d) pulmonary stenosis;
e) melanoma.
5) Name 2 syndromes caused by a mutation in
PTPN11: __________________, _________________.
What is the common cardiovascular abnormality
seen in both? _____________________________.
6) In patients with Tuberous sclerosis, adenoma se-
baceum or facial angiofibromas are frequently seen on
the face. These lesions have also been reported in pa-
tients with ___________________.
7) JXG + NF1 = _______.
8) In ataxia-telangiectasia, female carriers are at in-
creased risk for _______________________.
pts can have persistently elevated levels of ______
_____ and _________________.
9) Name the associated epidermolysis bullosa:
a) clumped tonofilaments o n EM _______________ __
b) AD; recurrent bullous eruption of hands and feet __
c) AR; plectin defect __________________________
d) AR; perioral and perinasal hypertrophic granulation
tissue; greatest risk of corneal ulcers _______________.
e) mutation in α6-β4 ______________ _____________
f) mitten-like deformity; high risk of SCC that can
metastasize and cause death _____ _________________.
10) Name the gene defect for familial benign chronic
pemphigus: __________________ _________________.
11) Ichthyosis vulgaris: if you do a biopsy, the granu-
lar layer will be (thickened/reduced).
Epidermal turnover rate is (increased/normal/de-
12) Why are patients with X-linked ichthyosis often
born via C-section? _____________________________.
13) What is the #1 cause of a co llod ion baby? _____ __
14) The mutations causing epidermolytic hyperkerato-
sis are _________________________ _______________.
The mutation causing ichthyosis bullosa of Sie-
mens is ___________________________ ______.
15) The common skin finding which includes migra-
tory annular and polycyclic patches with Netherton syn-
drome is called ____________ ____________________.
Gene defect ______ _______________________.
16) Refsum syndrome is caused by a deficiency of
17) Name the connexin: KID syndrome ___________
EKV __________________________ _________.
Clouston ________________________________.
18) When unilateral epidermal nevi show features of
verruciform xanthoma, ___________ syndrome should
be suspected.
19) Which porokeratosis type has the greatest risk of
malignant tr ansformation? ______ _________________.
20) What AD genodermatosis, characterized by flat
verroucous papules on backs of hands, insteps, knees,
and elbows, is allelic to Darier’ s disease? ____________
21) Matching:
a) Pachyonychia congenital, 1. Benign leukokeratosis
of mucous membranes;
b) Dyskeratosis congenital, 2. Premalignant leu-
22) Hypotrichosis, anodontia, and febrile seizures due
to absent eccrine glands would make you think of:
23) Thyroid disease, Methimazole, and the “hair collar
sign” have been noted with _______________________.
24) Aplasia cutis congenital + CMTC + limb defects =
__________________________ syndrome.
25) Name 3 disorders that are caused by defects in nu-
cleotide excision repair.
26) Which DNA helicase disorder has a particularly
high risk for osteosarcoma of bone? ________________.
27) Atrophodermia vermiculata + multiple BCCs is
associated with what syndrome? ___________________.
Appendix 2
Andrews’ Answers (Cha pter 27)
1) teeth
2) a (perfect criminal = no sweating, no fingerprints,
Open Access JCDSA
Dermatology Resident Generated Textbook Questions as a Resident-Centered Educational Strategy 15
“mask”, no teeth for x-ray id)
3) Calcified stippling of epiphyses; emopamil-binding
4) e
5) Noonan, LEOPARD; pulmonary stenosis (not seen
in Turner)
6) MEN 1
7) CML
8) breast cancer; AFP, CEA
9) a) Dowling Meara (EB herpetiformis
b) We ber -Coc kay ne (L ocal i zed EBS)
c) EBS with muscular dystrophy
d) Herlitz JEB
e) JEB with pyloric atresia
f) Recessive Dystrophic EB (Hallopeau-Siemens)
10) ATP2C 1
11) reduced; normal (retention hyperkeratosis)
12) Failure of labor progression due to placental sulfa-
tase deficiency
13) Nonbullous congenial ichthyosiform erythroderma
14) Keratins 1&10; Keratin 2e
15) Ichthyosis linearis circumflexa; SPINK5 (also re-
member LEKTI)
16) Phytanoyl CoA
17) connexin 26/GJB2; connexin 30.3 and 31/GJB3;
connexin 30/GJB6
19) linear
20) Acrokeratosis verruciformis of Hopf
21) a-1, b-2
22) Hypohidrotic ectodermal dysplasia (aka Christ-
23) Aplasia cutis congenital
24) Adams-Oliver
25) Xeroderma pigmentosum, Cockayne, Trichothio-
26) Rothmund-Thomson (aka poikiloderma congeni-
27) Rombo
Open Access JCDSA