Faculty of Medicine, Kuwait University, Kuwait
SIR, We have followed with interest recent write-ups on teaching and training in rheumatology [111]. Here we share our experience in the undergraduate teaching of rheumatology at the Faculty of Medicine, Kuwait University (FOM-KU). The first batch of medical students was taken in at this institution in 1976, making FOM-KU one of the oldest medical schools in the Gulf region (after Saudi Arabia) [12]. The course offers a 7-yr programme after high school (12 years of formal education) culminating in the BM, BCh degree. It begins with six semesters of essential sciences (physics, chemistry, biology and mathematics) and an English language course, followed by eight semesters of the actual medical curriculum. The first batch of BM, BCh students graduated in 1983. A British-trained rheumatologist was appointed to the faculty of the department of medicine in 1982. During the first few years, diseases of the musculoskeletal (MSK) system were taught by the rheumatologist as part of a series of lectures and bedside clinical teaching sessions in internal medicine during the first and third clinical years (i.e. the fifth and seventh years of the 7-yr BM, BCh course). Patients with common rheumatological problems were presented and discussed during the clinical sessions. In 1984 an integrated systems course (ISC) was introduced in the first clinical year (fifth year of the BM, BCh course). It starts with a core course followed by a series of organ system blocks. The chief coordinator of the ISC has always been the chairman of the department of medicine. He appoints coordinators for the core course and the ISC. The core course gives an introduction and orientation to the clinical years, and is followed by an introduction to the basic tools for making a diagnosis. There is then an introduction to the most important manifestations of the diseases of the different systems. From the beginning of the ISC in 1984, there has been provision in the core course for a full lecture on the epidemiology and presenting complaints related to diseases of the MSK system. This provision has been on a par with that for the other vital organ systems of the body. Simultaneously, whereas the didactic teaching is scheduled for the afternoons, the students spend the mornings in hospital wards, where tutors give them hands-on sessions on history-taking, general examination of patients and examination of the different body systems. Again, examination of the MSK system is the subject of one of the full, separate clinical sessions. During the ISC, a separate block of 40 h, spread over a period of 5 weeks, is devoted to the MSK system. From its inception in 1984, this course has been coordinated by a trained rheumatologist on the faculty of the department of medicine. Coordinators are co-opted from the departments of orthopaedic surgery, microbiology (including clinical immunology), radiology, pathology, community medicine, pharmacology and nuclear medicine. At the end of this MSK block there is a written (multiple-choice format, 80% of the total marks) and a laboratory practical (objective examination by pathology department, 20% of the total marks) examination. There are nine such systems course blocks. Results of the examinations for these nine blocks count towards the final examination at the end of the first clinical year. Thus, to be awarded a pass, the student must get a minimum mark of 60% in the aggregate of all nine examinations. Failing this, the student has to repeat the full year. This provides great motivation to the students to do well in each of the systems courses, including the MSK system.
The MSK system course has three components: medical, surgicalorthopaedic and physiatry (physical medicine and rehabilitation). The course has didactic lectures (20 h), multidisciplinary seminars (MDS, 4 h), case studies (8 h) and pathology practicals (8 h). The lecture topics include the following: introduction and epidemiology; the burden of MSK diseases on society and the MSK syndromes; inflammatory, degenerative, crystal-deposition and infectious arthropathies; connective tissue diseases and vasculitides; regional pain syndromes; soft-tissue rheumatism; pain-amplification syndromes; acute rheumatological emergencies; basic laboratory investigations; the role of imaging; injury-related problems; bone diseases; developmental abnormalities of the MSK system; and the basic principles of therapeutics. The topics in the MDS include inflammatory polyarthritis with rheumatoid arthritis as the prototype, and bone tumours. Case studies include inflammatory polyarthritis, connective tissue disease, injury-related problems of the MSK system, and bone and joint infections. Over the past 5 yr the MSK system course has been modified to some extent, its aims and objectives have been defined, lecture contents have been restructured, and efforts have been made to make the course more problem-oriented.
The undergraduate course given at this university compares favourably with the recommendations of the EULAR Standing Committee [9] except for the under-representation or complete omission of the following: (1) assessment of disability, handicap and disadvantage; (2) neck and back pain; (3) strategies for the primary prevention of locomotor diseases; (4) rehabilitative aspects of MSK diseases. Osteoporosis and osteomalacia are not included under rheumatology, as these topics are covered in the course on endocrine and metabolic diseases. Similarly, the paediatric department teaches paediatric rheumatology separately. Therefore, details about it are not included in this communication. The course does encompass the epidemiological, community and rehabilitative aspects that have been emphasized in the General Medical Council's recommendations on undergraduate medical education [13]. Similarly, self-learning exercises with emphasis on enquiry and the exploration of knowledge (through case studies) have been introduced recently. Most importantly, in view of the recommendations regarding the gross overcrowding of the undergraduate curriculum, last year the MSK course was further shortened by 4 h (by dropping eight didactic lectures and replacing them with two case studies) and made more relevant to the needs of the community. The unrealistic degree of completeness of the earlier course has been pruned to give a course that leaves scope for factual learning in preparation for later stages of training [13].
Some of the major problems that are still to be resolved include (1) the coordination of hospital posting with the topics being covered in the rheumatology block; (2) the non-utilization of the rheumatology out-patient clinic for teaching purpose; and (3) the shortage of trained persons for teaching history-taking and the examination of the MSK system to multiple small batches of students simultaneously. It is hoped that, over a period of time, these problems will resolved.
The MSK system course has motivated three past students of this medical school to take up the specialty of rheumatology and one student to take up physiatry as their professional career. These persons have already reached the level of consultant or faculty member in the department of medicine.
We believe that a good beginning has been made. It must evolve further in order to provide, in addition, advanced postgraduate education in rheumatology.
We express our sincere thanks to Professor K. V. Johny, Chairman, Department of Medicine and Chief Co-ordinator, fifth year Core Lecture Course and the Systems Course, Faculty of Medicine, Kuwait University, Kuwait.
Notes
Correspondence to: A. N. Malaviya, Department of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait.
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