Academic Department of Musculoskeletal Disease, University of Leeds, Leeds, 1Academic Rheumatology, University of Bristol, Bristol, 2Rheumatology Department, University of Newcastle upon Tyne, Newcastle upon Tyne, 3Academic Centre for Medical Education, University College London, London, UK.
Correspondence to: D. A. Coady. E-mail: d.a.coady{at}ncl.ac.uk
Medical education is an essential component of clinical practice and is a principal aim of the General Medical Council [1]. Todays doctors must therefore be educators as well as clinicians. They must educate their peers and juniors, medical students, patients and also themselves.
We should prepare medical students for clinical practice by the most efficient, enjoyable, and evidence-based methods devised. Medical students of the 21st century are demanding. Our students rightly expect high-quality targeted teaching. Traditional medical courses relied heavily upon non-clinicians to educate students in the first 2 yr of the medical degree and upon the good nature of practising doctors to provide students with their clinical training. Times have changed. The modern NHS imposes targets and initiatives on its workforce. For the majority of clinicians, there is less time to devote to teaching students than there seemed even a decade ago. This is likely to become more of a problem. By 2005, English medical schools alone will take nearly 6000 new students each year (an increase of approximately 50% since 1997) and teaching will be taking place in a wider variety of settings.
Once trained, doctors are expected to maintain and develop their skills and expertise enabling them to deliver high-quality healthcare to patients within a medical setting (in which the shelf-life of specific knowledge is forever shortening). Members of the allied health professions face the same issues. Furthermore there is a need to educate patients about their disease and its management. Patient education is especially important in specialities which manage a high proportion of patients with chronic illness, such as rheumatology.
In this world of increasing demands it is clear that medical education initiatives should be evidence-based. Despite this, many of the assessment tools we use to determine the benefits of education remain blunt.
The Arthritis Research Campaign (arc) has traditionally been the main organization that has supported educational initiatives in rheumatology in the UK. They provide financial sponsorship of educational research projects and publish booklets and information sheets for patients with arthritis and educational material for general practitioners, hospital doctors, allied health professionals and medical students. A committee framework has been established within the arc organizational structure to facilitate educational research with the designation of a specific education subcommittee of the scientific coordinating committee.
arcs remit is to promote high-quality educational research in arthritis and musculoskeletal disease. They do this by recommending the award of educational project grants, educational research fellowships (ERFs) and allied health professional postgraduate training and educational travel/training bursaries via an external peer review process. ERFs are a relatively recent addition to the grant portfolio and were introduced in 1999 in order to encourage educational research and the development of educational research skills by individuals rather than by institutions via the project grant scheme. In much the same way as fellowships have been available to scientists as part of a career path to develop academic rheumatologists, ERFs are likely to develop a similar cadre of people with a major interest in education [2].
The aim of these ERFs is [2]:
to encourage clinicians (including GPs), allied healthcare professionals and non-clinicians to undertake research into educational methodology and/or medical education with the aim of improving the general standard of education in arthritis and musculoskeletal disease relating either to medical or patient education.
ERFs are generally awarded for 2 to 3 yr (full or part time) and candidates are expected to register for a higher degree (MD, MSc or PhD). Since 2000, arc have awarded four ERFs, all to trainee rheumatologists. These fellowship projects have involved aspects of undergraduate and postgraduate medical education and include subjects such as musculoskeletal ultrasonography, clinical examination skills and patient management problems.
This editorial aims to present an outline of the current ERF projects, describe some of the more common educational research techniques employed, discuss some of the challenges of undertaking educational research and offer some practical advice for those considering applying for an ERF.
Current ERF projects
The development of a programme of education and competency assessment for rheumatologists performing musculoskeletal ultrasonography (A. Brown)
Musculoskeletal ultrasonography is being performed by an increasing number of rheumatologists as part of their routine clinical practice. This presents a number of educational challenges, particularly with regard to training and assessment. The aim of this project is to address these issues and develop a structured outcome-based curriculum including a system of competency assessment for rheumatologists performing this imaging technique. This ongoing project has involved a number of stages. Initially a situational analysis was undertaken in order to assess current evidence and practice, training and assessment experiences and opinions regarding the role of rheumatologists. This was achieved by literature review, individual and focus group interview and a cross-sectional questionnaire survey of ultrasonography experts, and generated a large volume of useful preliminary data which provided endorsement of the project aims and informed the subsequent study [3, 4]. The second phase sought to establish consensus agreement about the role of a rheumatologist ultrasonographer by determining the appropriate indications, knowledge and skills that they require. Delphi methodology, encompassing four stages and two iterative rounds and a panel of international experts, was used to accomplish this and has led to the formulation of a set of best practice guidelines specifically for rheumatologists performing ultrasonography [5]. The third stage involved the development of a competency-based model. The expert panel was presented with the preceding data and asked to rate the relative importance of competency items according to specific criteria. This allowed determination of competency standards and the development of specific learning outcomes, which have formed the basis for a rheumatology ultrasound curriculum. The next stage of this study involves the implementation of this curriculum framework and a thorough period of evaluation in order to ensure its effectiveness and efficiency and suitability for use throughout those in the field of rheumatology.
The SHEEP project: a novel (patient centred) instrument to help general practitioners (GPs) manage common musculoskeletal presentations (S. Clarke)
This ERF aims to produce educational material to help GPs manage shoulder and knee pain more effectively. The drivers behind this have been the lack of formalized training for GPs in the management of musculoskeletal disorders and their consequent lack of confidence in treating such patients effectively. The project has involved a series of in-depth interviews with GPs and focus groups with patients. The focus groups with patients involved volunteers with current knee or shoulder pain. Aspects of their care (what they liked and what they didnt like) were discussed and extracted from the verbatim transcripts. These care items were used to define the content of a patient satisfaction questionnaire. It is intended to use this questionnaire to determine how GPs are performing in relation to their patients expectations. This technique allows the team to accommodate GPs needs, patient-centred information and published evidence into a training package. It is planned to produce a two-part package, delivered 1 month apart, into individual GP practices. The facilitator delivering this package will encourage discussion regarding the management of specific patient cases. The practice will be asked to put together their own checklist of diagnostic and therapeutic manoeuvres. Over the following month the patient satisfaction questionnaires will be distributed amongst patients with knee and shoulder pain attending the practice. The outcomes from the questionnaire can then be presented to the practice along with their own checklist embedded in a dedicated website to which the practice has access. The learning outcomes from this intervention will be assessed.
Which musculoskeletal clinical skills should medical students learn? (D. Coady)
It is clear that medical students are taught a wide variety of clinical tests in musculoskeletal examination and that there is a lack of consistency in the teaching they receive across specialties [6]. The primary aim of this study has been to determine the core set of regional musculoskeletal examination skills for medical students to learn in addition to the now widely accepted GALS screening examination [7]. The development of a detailed regional examination, once an abnormality has been identified on the initial history and screening examination, has not previously been described. It is proposed that a standardized core skills set will improve medical students confidence and ability in performing a musculoskeletal examination. Focus groups were used in the development of a national questionnaire. This questionnaire asked all consultant rheumatologists, orthopaedic surgeons, geriatricians and a selection of general practitioner trainers to score musculoskeletal clinical skills for medical students on a five-point scale ranging from definitely not required to essential. Results from the focus groups and national questionnaire were then weighted by a group nominative technique to arrive at an agreed core skills set for medical students. Educational materials including a video demonstrating the core skills have been produced and are currently being evaluated. An updated handbook Introduction to the musculoskeletal system for medical students, incorporating these core skills will also soon be available through arc.
A needs-based training programme in primary care (I. Haq)
Primary care training in rheumatology has traditionally been extremely variable. Studies have shown that up to 20% of primary care visits are due to musculoskeletal complaints [8]. It is understandable that GPs often may not feel confident in the management of these problems. The aims of this ERF project are to devise a needs-based training programme in rheumatology and assess the effect on confidence and skills. Focus group interviews have been used to find out what local GPs think of their postgraduate training in rheumatology and what their current learning needs are. The interviews were carried out in small groups of five or six and were audio- and videotaped. The interviews were semi-structured and continued until no new themes emerged in the discussion. The tapes were then transcribed and analysed for emerging themes. This has enabled a course to be developed that addresses the learning needs of the local GPs. The course includes a mixture of teaching techniques from lectures, small group work, problem solving and practical skill sessions. We are also involving patient partners (PPs) in this project. These PPs were trained to teach medical students about back pain, and they now feel confident enough to work with rheumatologists and GPs in order to discuss optimal treatment of back pain in the community. The effect of the training programme on the confidence, skills and referral patterns of GPs will be assessed using further questionnaire and interviews. Rheumatologists will be surveyed nationally to help define a consensus on the gold standard for referral letters from primary to secondary care using the Delphi technique.
Commonly employed educational research techniques
Most educational research relies on qualitative research methods. Qualitative methodology was developed in the social sciences arena and has only recently become popular in medical research. A useful overview of qualitative research methods has been published by the Department of Health [9]. There are several differences between qualitative and quantitative research [10]. In the former, words rather than numbers are the unit of analysis, and work is more descriptive and interpretive. Qualitative studies are generally smaller in scale and the research design emerges from data obtained rather than being pre-determined. Commonly used qualitative research methods include in-depth (individual) and small group (focus group) interviews, questionnaire surveys and consensus building processes such as the Delphi and group nominative techniques.
Interviews and focus groups are a useful means of data collection but hold their own challenges. Generally they are audiotaped and transcribed. A variety of methods for analysing the text are available and the choice of method often depends on the primary research question [9]. Scientific journals publishing qualitative work require high standards and it is essential that a rigorous and acceptable approach is adopted to ensure high levels of validity.
Questionnaire surveys are practical instruments used to canvass opinion from a large number of individuals. They can be used to explore issues of interest raised during interviews or focus group discussions but unless questioning is specific, can be poor at providing detailed information. The design of the questionnaire and attention to detail is important to maximize the information gathered and to ensure validity. Guides to designing questionnaires and maximizing response rates from postal questionnaires are available and prove to be a useful resource [12, 13]. Pilot testing is recommended to assess the function of the questionnaire in order to exclude any comprehension or wording difficulties, ensure a user-friendly format and assess the feasibility of administration and response rate.
The Delphi technique is a structured multistage process involving a series of iterative rounds and aims to combine expert opinion to establish a group consensus on a given subject. It can be usefully applied to areas of controversy or areas in which published data are inadequate, and involves a series of questionnaires interspersed with controlled feedback [1315]. This approach has been widely used in various areas of healthcare research, including the development of guidelines for best practice and content of curricula and in the definition of professional roles and clinical protocols [16, 17]. This method is particularly useful in situations where practical constraints, such as a large widely dispersed group, prevent round-table discussion and also avoids individual dominance, which can occur in such a setting.
The group nominative technique involves a face-to-face meeting between a group of participants (again generally experts in their field) to achieve a consensus of opinion. Generally ideas are generated by members of the panel and then accepted or rejected through a process of voting. The group nominative technique can also be used to assess data generated from another setting and may be useful in prioritizing results obtained from other areas of a study. In truth it works rather like the Delphi technique but has the advantage of allowing face-to-face interaction and discussion amongst panellists of the issues in question [18].
The challenges of educational research
Research in medical education can be a rewarding undertaking and provides the opportunity to develop new skills and become familiar with new methodological techniques. Unlike the quantitative approaches familiar to most medical practitioners involved in more traditional clinical and laboratory-based studies, educational research employs more qualitative techniques. These can be equally as challenging to master as their quantitative counterparts, and a period of learning and adjustment before becoming fully familiar with these methods is to be expected.
When applying for funding it is important to consider a number of issues that will increase the chances of completing the project and achieving a successful application (see Table 1). It is very easy to generate a lot of repetitive data, which will take a long time to analyse. It is important to remain focused on the research question and use a design that employs a well-structured methodology. It is also prudent to choose a project that is of practical educational utility and is achievable within the designated timeframe and to allow sufficient time for analysis, paper and thesis writing. It is useful to undertake some pilot work before applying for funding as this will encourage familiarity and demonstrate competence with educational research techniques.
|
The learning curve in educational research can be steep but it is a discipline full of promising opportunities. Rewarding teaching experiences and wider future career possibilities are added benefits. The recent expansion in medical student numbers and the creation of new medical schools provides new openings for us all to become involved in teaching and assessment throughout the United Kingdom. Indeed, the increasing requirement for continuing medical education, lifelong learning and revalidation represents a commitment and responsibility for all medical practitioners to recognize the importance of medical education. There is an increasing awareness within the specialty of rheumatology for the need to maintain a high standard of training amongst health professionals. We need to recognize the importance of providing efficient and effective educational programmes and improve our ability to measure accurately the outcome of our interventions.
With more people becoming involved in medical education throughout the UK, the time is right to develop research networks that will allow us to share expertise, foster collaborative studies and deliver a high-quality educational product. Therefore the possibility of becoming involved in educational research at an early stage of ones career should be seen as a unique professional development opportunity. This is reflected in the commitment of arc to the wide variety of ERF projects currently being conducted. This, however, is only a start and there is a large potential for the development of further projects (Table 2). It is vitally important that we develop the knowledge and skills base to be effective teachers and learners and create a robust educational framework in order to achieve this with ownership and leadership from the profession at large. The delivery of high-quality education is fundamental to the existence of an educated profession that will maximize standards of professional practice and ensure the highest levels of patient care.
|
References
|