Centre for Rheumatology, Department of Medicine, University College London, Arthur Stanley House, 4050 Tottenham Street, London W1T 4NJ, 1Jubilee Street Practice, Commercial Road, London E1, 2Barnsley District General Hospital, Barnsley S75 2EP and 3Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK
Correspondence to: A. Rahman. E-mail: anisur.rahman{at}ucl.ac.uk
The General Medical Council (GMC) report Tomorrow's doctors, published in 1993 [1] and updated in 2002 [2], specified that undergraduate medical courses should devote a significant proportion of time to courses in which students could choose between different options. These courses would be separate from the core material that should be taught to every student, and would allow each student to engage in deeper study of topics that particularly interested them. The student-selected courses were originally called special study modules (SSMs) but are now known as student-selected components (SSCs). This editorial will explore the reasons why rheumatologists might consider organizing SSCs for medical students, and describes ways in which this can be done successfully.
What are SSCs?
Tomorrow's doctors 2002 is important because the GMC has statutory powers to advise on the content of the medical curriculum and to inspect teaching at medical schools. The report suggests that each medical school should have between 25 and 33% of its curriculum available for SSCs over a medical course that lasts 5 years [2]. At least two-thirds of these SSCs must be directly related to medicine, though not necessarily wholly clinical in content. SSCs based on basic science or the humanities as related to medicine are acceptable. At Newcastle, for example, there are SSCs in complementary medicine, on medicine in classical civilizations and on ethics in medicine. SSCs at both the Royal Free and University College London Medical School and at Leeds Medical School allow students to study another language.
The structure and duration of SSCs can vary widely from one medical school to another or between different years of the course. Some SSCs are full-time blocks lasting 2 to 8 weeks, whereas others may consist of one afternoon a week spread over a period of several weeks. The specified aims of SSCs, according to the GMC, include the development of students skills in research and self-directed learning, ability to study areas outside the core curriculum in depth, development of confidence in their own skills and abilities and the opportunity to present the results of their work in both written and verbal form. SSCs are also thought to be an opportunity for students to consider future career paths.
It is therefore very important for anyone who organizes an SSC to consider whether these areas are covered and particularly to ensure that assessment of the students addresses their progress in at least some of these areas.
Why should SSCs in rheumatology be offered?
Since SSCs are an important part of the GMC requirements for medical curricula, it is clear that every medical school must take steps to provide them. One might therefore argue that departments of rheumatology within medical schools should take their share of this responsibility. Within hospitals, however, no protected time or extra funding may be available for provision of SSCs (though this is likely to vary between medical schools). This may be a serious disincentive, particularly where teaching time is restricted by increasing service commitments. It is possible for medical schools simply to demand that each department takes a certain number of medical students and offers them teaching which is labelled an SSC, but this policy is unlikely to lead to motivated teachers, satisfied students or well-organized SSCs. If possible, it is better to ask for volunteers to organize SSCs in subjects that they really want to teach.
Why should rheumatologists volunteer to teach SSCs? The best reason is that it gives us the opportunity to engage students with our specialty. Most rheumatologists would agree that the short period of time devoted to musculoskeletal disorders within the core curriculum is inadequate [35]. This is particularly evident when one considers the high prevalence of rheumatological conditions in everyday clinical practice. For example, it is estimated that 1115% of all consultations with general practitioners relate to musculoskeletal problems [6, 7].
Providing SSCs is one possible answer to the perceived deficiency in musculoskeletal teaching in the current curriculum. SSCs provide an opportunity to expand the curriculum time available for rheumatology and to demonstrate to students the breadth and depth of our specialty. SSCs in rheumatology are also well-suited to emphasizing the links between research and clinical practice and the importance of communication skills and multidisciplinary teaching.
Teaching SSCs can be particularly rewarding, because the students have often specifically chosen your SSC owing to a pre-existing interest or positive view of the teaching provided by the department. Such students are highly motivated and likely to interact well with each other and with the teacher. It is often possible to teach SSC students in smaller groups than would be usual in the core curriculum and to cover subjects not regarded as core material, such as your own particular research interest, in greater detail. This may stimulate the interest of the students sufficiently that they seek to work with you in the future, for example on an intercalated BSc project. A positive experience of rheumatology as an undergraduate may also influence future career choices [8].
It is also possible, however, that you may be allocated a group of students who did not particularly want to do your SSC, but were sent to you as a second or third choice. This is unusual, in our experience, and the best way to avoid it is to make your SSC popular and interesting enough that there is no shortage of first-choice applicants.
Where should SSCs in rheumatology take place?
An attractive feature of SSCs is the flexibility of the format. The teaching can be centred in out-patient clinics, science laboratories, or in primary care, working in partnership with GPs. Some SSCs consist of a series of well-defined sessions. Tables 1 and 2 show examples of such SSCs that the authors (AR and SA) have organized. Table 1 shows a science-based SSC entitled Autoantibodies in rheumatological diseases run at Royal Free and University College Medical School, whereas Table 2 shows an SSC based mainly in primary care, entitled Arthritis and disability in the community, run at Barts and the London Medical School.
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Although the SSCs described above are very different, they are all relevant to the practice of rheumatology in a variety of settings. In each case, we recruited a variety of different teachers. We encouraged the teaching of subjects that are not routinely covered in the core curriculum of the medical school, but in which the teachers had a special interest or expertise.
A very important strength of the SSC format is that its flexibility allows course organizers to recruit teachers from many different disciplines. This broadens the experience of medical students and allows them to look at clinical problems from different viewpoints. For example, the SSC on Arthritis and disability in the community included a session with a nurse practitioner about drug monitoring and counselling. SSCs at Newcastle include sessions with the paediatric multidisciplinary team (specialist physiotherapist, occupational therapist and nurses) to understand the importance of the multidisciplinary team in the care of children with rheumatic disease.
How might SSCs in rheumatology be run?
SSCs are so flexible that no single pattern is preferred. However, some general principles may be helpful.
First, keep things simple in case you have to change your arrangements at short notice. An SSC that involves the use of expensive equipment or booking multiple outside speakers may represent wasted effort if no students actually select it.
Second, try not to do everything yourself or to rely too heavily on the efforts of one individual. SSCs usually represent extra work. Though GPs can be remunerated for this work, hospital staff are not usually remunerated directly. People are often willing to provide one or two sessions on subjects they enjoy, but less keen to commit to more than this.
Third, use the untapped teaching resources in your department. There are often people who do not normally get the chance to teach, but who would enjoy doing so if asked. For example, the session with the nurse practitioner in Arthritis and disability in the community was especially popular with the students. You could also consider using patients as teachers, particularly where students visit the patients in their own homes.
Fourth, allow sufficient time in the SSC for self-directed learning. This is a particular aim of SSCs and also reduces the amount of taught sessions you have to provide. One of the most convenient ways to arrange this is to discuss with each student a project or topic that they would like to study, point them in the direction of some source materials and allow them one or two sessions of free time to research the project and produce an essay and/or a verbal presentation. Students produced excellent projects of this kind in all the SSCs described above.
Fifth, allow a degree of flexibility to tailor the SSC to the interests of individual students. Perhaps the easiest way to do this is to make part of the SSC a project on a subject chosen by the student, but relevant to the general objectives of the SSC.
Finally, make sure that the learning objectives for each student and the criteria for assessment are clear at the outset. We prefer to assess a mixture of verbal presentations and written work. Questions that test the ability of students to put into practice the information taught in each session may be particularly useful. For example, the session on the principles of ELISA assays in Table 1 was followed by a question asking the students to design their own assay to resolve a particular clinical problem.
How should we assess learning outcomes of SSCs in rheumatology?
A major difficulty in analysing the success or impact of education using the SSC format is the diversity of SSCs in different medical schools. Each SSC at each school may be selected by only a relatively small number of students each year. Published feedback about such SSCs is therefore based on small samples of students and relies heavily on qualitative interpretations. For example, innovative SSCs in hospital management [11], literature in medicine [12], the arts in medicine [13] and medical informatics [14] have been described in the literature, but these reports describe the experiences of two, eight, 24 and 59 students, respectively.
A possible way in which organizations such as the British Society for Rheumatology (BSR) or Arthritis Research Campaign (arc) could address this problem is to provide a forum for teachers in universities to collaborate in developing generic templates for SSCs. This might produce a series of teaching and learning materials for particular sessions, which could be used as off-the-shelf resources to deliver either single modules or whole SSCs. Such modules could comprise statements of required pre-course knowledge, learning outcomes for the session and suggested teaching methods, including support materials such as slides, videos or paper cases, and assessment tools. These generic SSCs could then be delivered by teachers in different medical schools. For example, the template shown in Table 2 could be reproduced anywhere that rheumatologists and GPs are prepared to work together. Using course materials and handouts generated centrally via the BSR or arc, the main responsibility of the local SSC organizer would be to recruit suitable teachers for each of the sessions. This would make it easier for busy clinicians to offer SSCs, since it would remove the initial burden of designing the programme and course materials, and assessments could be shared.
A wide variety of teaching skills can be used in SSCs and many clinicians may not be familiar with techniques such as problem-based learning or small group teaching. BSR/arc could also help out with training teachers if additional or different teaching skills are required.
Evaluation of the SSCs could also be undertaken collaboratively. Standardized assessments, such as Objective Structured Clinical Examination (OSCE) stations [15] and extended matching questions can be developed and used across medical schools to evaluate the effectiveness of these modules in teaching skills and knowledge. As well as these summative assessments, formative assessments of generic skill development may be useful. Acceptability to students and staff can be assessed using open questionnaires or rating scales for specific points [13].
Such common assessment methods might allow for comparison of performance across different schools, and gives a potential avenue for research to compare the effectiveness of different teaching methods or materials. Recognizing the importance of educational research, the arc has already established a scheme for educational project grants and research fellowships.
A potential difficulty in sharing an SSC outline across different medical schools is the variability of SSC formats. Provided that the total number of taught sessions is the same in the different schools, however, this need not be a major obstacle. Alternatively, schools could share a bank of separate sessions which could be used independently in different SSC outlines. Each SSC would need to have defined pre-session knowledge and learning outcomes but could then be delivered as off-the-shelf sessions. It would have been quite possible to run the SSC described in Table 2 as a day-release course over 8 weeks rather than a full-time course over a fortnight. However, it is important that students from the same year of the course undertake the SSC in each centre, if comparisons between centres are to be made.
The principles outlined in this editorial may also be applicable to teaching of rheumatology in other countries, though the variation between medical curricula worldwide is such that this has not been discussed in any detail.
Conclusion
First promoted by the GMC 10 years ago, SSCs are now part of the bedrock of medical undergraduate education in the UK. Although they can be considered an extra burden of work for hard-pressed clinicians, it is also possible to see SSCs as an opportunity for rheumatologists to collaborate with colleagues in other disciplines, to extend the range of rheumatology teaching available to students, to take a lead in the development of British medical education and to attract bright and able doctors to our specialty.
Acknowledgments
The authors would like to thank Dr David Bender for his support and advice. We would also like to thank all our colleagues who taught on these SSCs. LK and AA are members of the arc Education Sub-committee.
There was no funding for this paper and there were no conflicts of interest for the authors.
References
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