Rheumatology curriculum: passport to the future successful handling of the musculoskeletal burden?

L. Goh1, A. Samanta, S. Cavendish2 and D. Heney3

Department of Rheumatology, Leicester Royal Infirmary, 1 Department of Rheumatology, Derriford Hospital, Plymouth, 2 LNR Postgraduate Deanery and 3 Leicester Warwick Medical School, University of Leicester, Leicester, UK

Correspondence to: A. Samanta, Department of Rheumatology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester LE1 5WW, UK. E-mail: ash.samanta{at}uhl-tr.nhs.uk


    Introduction
 Top
 Introduction
 A generic curriculum
 The current position regarding...
 What should be done...
 Conclusion
 References
 
Rheumatic conditions are common in both hospital [1] and community [2] settings. However, this high incidence is not reflected in the coverage of rheumatic disorders in the undergraduate medical school curriculum [3]. Specific training in rheumatology is usually at specialist registrar level and, to a limited extent, in general practitioner vocational training schemes. Consequently, the management of musculoskeletal disease is very dependent on what is learnt as an undergraduate. Undergraduate training, therefore, needs to be sufficiently robust to equip doctors with the necessary competencies to deal with the rheumatic diseases they are likely to encounter in practice. For this paper we have reviewed the literature on undergraduate training across the UK to see how equipped newly qualified doctors might be.

In a survey of medical students who commenced their training in 1981 and 1986, it was found that the practical experiences gained by the students were limited in relation to the musculoskeletal systems [4]. In addition, undergraduate medical school training [5–8] and postgraduate primary care training [9] have been found to suffer from a paucity of appropriate instruction in musculoskeletal medicine. Several years ago we demonstrated in Leicester that a high proportion of referrals to secondary care rheumatology were musculoskeletal complaints that could have been dealt with adequately within primary care [10]. On direct discussion, it became clear that primary care physicians felt less than confident of their ability to examine the locomotor system and to formulate an appropriate management plan. More recently (2002, A. Samanta, unpublished data) we repeated our survey. There has been little change over the last 15 yr. Part of the problem lies in the view taken by medical teachers that examination of the locomotor system is of less importance than that of other systems [11]. This is in sharp contrast to the high frequency of musculoskeletal complaints and the psychological and social impact of such problems, as well as their economic costs [12]. It is not surprising, therefore, that when Ahern looked at 166 medical inpatients and found more than half had musculoskeletal symptoms, rheumatological symptoms had been noted in only 40% and rheumatological examination conducted in only 14% [13]. If physicians have inadequate training in musculoskeletal disorders, they may lack confidence as well as competence in the management of rheumatic diseases [14, 15] which may lead to suboptimal patient management. The aim of this paper is to review the relevant literature regarding the undergraduate rheumatology curriculum in order to determine what is required to produce doctors who are fit for purpose in dealing with common musculoskeletal problems.


    A generic curriculum
 Top
 Introduction
 A generic curriculum
 The current position regarding...
 What should be done...
 Conclusion
 References
 
Concern about the curriculum in medical schools has been addressed to some extent by, for example, the General Medical Council (GMC). The document by the GMC, Tomorrow's Doctors [16], incorporates as a feature a more integrated curriculum. The GMC recommended a reduction in factual load and increased emphasis on the importance of good clinical skills. In addition, they suggested greater consensus on a core curriculum. The New Doctor [17], published by the GMC in 1997, states that the objectives for the pre-registration house officer (PRHO) year are to put into clinical practice the skills acquired during undergraduate years and to illustrate that PRHOs are able to accept the duties of a new doctor. Subsequent to the above recommendations, undergraduate medical teaching in UK medical schools has undergone a change from a traditional preclinical and clinical model to the current more integrated curriculum [18, 19].

There is currently no core curriculum for rheumatology that is accepted worldwide. However, EULAR (European Union League Against Rheumatism) has provided guidelines on the development of a core curriculum in rheumatology. Although this has not been universally accepted or validated in terms of outcomes, it is the first step towards devising a core curriculum in rheumatology. With the establishment of guidelines on core curriculum, the question now arises as to how we should be teaching our undergraduates. Medical students undergo a range of experiences in a variety of learning environments during their training years, such as at the bedside, in clinics, in the lecture room and in the clinical skills centre, and informally through contact with peers. By the end of training, their level of expertise as a newly qualified PRHO will depend, to a large extent, on having had the right teaching methods, the right breadth of knowledge and experience and the right assessment. All this knowledge and these skills then have to be applied in situations that are novel to the new doctor. The importance of active teaching methods that promote deep learning has been well documented in relation to striving towards quality learning outcomes. Zeidler [20] for example, stressed the importance of students playing an active part in learning rheumatology as opposed to traditional methods like lectures, where students are more likely to remain passive. Dacre and Fox [21] advocated teaching methods for rheumatology that included small group teaching, self-directed learning, problem-based learning and portfolio-based learning. These methods, based on adult learning principles, have been found to be effective in delivering university teaching and learning. Nendaz and Bordage [22] found little evidence that teaching of reasoning processes separately from teaching subject content is effective, while Schuwirth [23] concludes that learning of clinical reasoning has to be within its applied setting. Bligh [24] presents a reasoned debate on how students learn, and concludes that ‘structured and organized learning about history taking and identifying clinical problems should take place early and be integrated with learning about disease and illness’. One unanswered question is whether a single generic curriculum is suitable for all speciality areas? Would such a curriculum adequately prepare a student to deal with musculoskeletal problems? There is the issue of how best to learn the different domains that a good doctor needs in order to manage rheumatological and musculoskeletal problems, and how to ensure that these domains all come together in practice. The core curriculum suggested by Doherty and colleagues [25, 26] includes three main domains: competencies in clinical assessment and diagnosis; knowledge of the main characteristics and principles of rehabilitation; and core knowledge supporting diagnosis and management. The main objectives of the curriculum, which are also in line with those suggested by Dequeker [27], are that, by the end of the course, students should be able to take a relevant history and examination of a patient presenting with rheumatological symptoms, state a relevant differential diagnosis, and identify appropriate investigations and a management plan. The British Orthopaedic Association–British Society of Rheumatology musculoskeletal core curriculum [28] identified its key goal as being able to influence training in musculoskeletal disorders in medical schools so as to improve general practitioners’ diagnostic skills and appropriate referral patterns. To date, however, there are no studies to confirm whether such a core curriculum is being followed in medical schools or, if it is, whether new doctors feel that the training in rheumatology is adequate for the disorders they encounter in practice.

However, there is the issue of how best to learn the different domains that a good doctor needs (knowledge of subject content, examination and history-taking skills, diagnostic skills, clinical reasoning and problem solving, communication skills with patients and carers) and how to ensure these different domains all come together in practice. There remains, however, little evidence on the importance of a specific as opposed to a generic teaching approach for the different speciality areas. Without this research, it is difficult to feel confident in the quality of learning in relation to rheumatological conditions, as there are insufficient good-quality studies on evaluation.


    The current position regarding undergraduate rheumatology teaching in the UK
 Top
 Introduction
 A generic curriculum
 The current position regarding...
 What should be done...
 Conclusion
 References
 
Kay and colleagues conducted a survey of undergraduate teaching in rheumatology in the UK [29]. Twenty-three medical schools responded. In 18 medical schools, all medical students were exposed to some rheumatology teaching. However, in five medical schools the curriculum was structured in such a way that 50% of the students might have received no specific training in rheumatology. Furthermore, it was difficult to ascertain from the study the precise details and content of the training which undergraduate students might receive. It would appear that there was no clear link between the training provided and the core curriculum in rheumatology as advocated by Doherty and Woolf [25]. To a large extent, the training delivered in rheumatology lacked a cohesive structure with considerable variation between medical schools.

Only nine medical schools undertook teaching in rheumatology across all the clinical years. In five medical schools this was confined to year 3 and in the other nine it was confined to years 1 and 2. In 20 medical schools, rheumatology was taught as part of another speciality and in only three schools rheumatology teaching had a status independent of other disciplines.

In terms of assessment, 14 medical schools used the traditional approach of assessing through long and short cases, and in the remainder there was an increasing trend towards using objective structured clinical examinations (OSCEs).

The study by Kay and colleagues suggests that currently there are several shortcomings in the UK with regard to undergraduate training in rheumatology. There are at least three areas of concern. First, there are a number of medical students in some medical schools who may complete their undergraduate training never having had any formal training in rheumatology. Furthermore, even in those schools where some formal training is undertaken for all medical students, there is still no consensus as to what is taught. There is a lack of evidence to support the contention that a core curriculum is being followed. Second, in a number of medical schools training in rheumatology is restricted to the first 3 yr. It is difficult to imagine how this could adequately equip the newly qualified doctor with the appropriate competencies to undertake effective clinical musculoskeletal work if there is a long gap between the completion of such training and the actual undertaking of work as a PRHO. However, at present there is a lack of evidence to suggest that time of delivery of rheumatology teaching has any impact on the outcome of competences after qualification. Third, there would appear to be no uniform or consistent objective process that assesses skills pertaining to rheumatology at the end of undergraduate medical training. It would therefore be hard to evaluate with confidence on a national basis the effectiveness of undergraduate medical training in rheumatology.

These findings, taken in totality, cause concern and would suggest that even now the quality of training in rheumatology that an undergraduate medical student might receive is very much a matter of chance. It is well recognized that the effects of undergraduate training in rheumatology are retained in clinical practice in the long term [30, 31]. It has already been emphasized that there is a large musculoskeletal workload in clinical practice, both in primary and secondary care. If the doctors of tomorrow are to be able to successfully handle this, then it is imperative that undergraduate medical students should receive high-quality training in rheumatology that is consistently and uniformly delivered across all medical schools.


    What should be done regarding undergraduate teaching in rheumatology?
 Top
 Introduction
 A generic curriculum
 The current position regarding...
 What should be done...
 Conclusion
 References
 
The aim of undergraduate medical training is that the student should be able to put into practice the key skills they have learnt and the knowledge they have gained, and to be able to demonstrate that he or she is ready to accept the duties and responsibilities of a fully registered doctor [17]. Applying this to rheumatology, a student should have acquired core knowledge and key skills about the locomotor system and should be able to put this into practice in regard to clinical musculoskeletal work. The 1999 EULAR standing committee on education and training [20] stated that at the end of the medical course students should be able to assess, by appropriate history and examination (following a problem-orientated approach), an adult patient with locomotor symptoms in terms of descriptive abnormality/impairment, disability and handicap, state a limited differential diagnosis, state relevant investigations, and outline an appropriate management (medical/surgical/rehabilitation) plan. To this, we would like to add a further objective. Many rheumatological and musculoskeletal conditions are long-term and debilitating, and may have an effect on the patient's psychological well-being. Medical professionals involved in the care of such patients require specific skills and attitudes [20, 25]. It is suggested that acquiring these should be an additional objective of undergraduate training in rheumatology. It is believed that rheumatology could offer an excellent model for enhancing the more generic skills necessary for a good doctor–patient relationship.

How can these aims and objectives best be achieved? There is a need for uniformity in core teaching. A core curriculum for rheumatology with three principal domains has already been suggested [25]. There are a number of components within each of these domains that have been listed, and this could provide the basis upon which individual medical schools can build.

There also needs to be agreement on what to teach in examination of the locomotor system. A major step in this direction was made with the development and validation of a screening examination, the GALS (gait, arms, legs, spine) [32]. This screening examination is a valuable and simple tool for the detection of important abnormalities in the locomotor system. It has been suggested by Walker and Kay [33] that there should be a two-level approach to the examination of the locomotor system. The first level would be a GALS screening examination, which distinguishes normal from abnormal and localizes abnormality to a region of the body. This is then followed by a more targeted and detailed regional examination if an abnormality is found. There is a need for agreement as to what should be taught at the level of regional examination. It is helpful to have an agreement in terms of the core curriculum for rheumatology training as well as what should be taught in the examination of the locomotor system. Such an agreement needs to be at national level and should be underpinned by the approval of the GMC and learned professional bodies.

Ideally, the elements of the core curriculum should be spread over the whole undergraduate course. In this way, the learning experience of each year can not only be reinforced, but can also build incrementally upon that of the previous years to promote deeper, and hence more effective, learning [26]. Many of the components of the core curriculum can be taught by teachers other than rheumatologists or orthopaedic surgeons, and there is a shift towards greater community-based locomotor teaching through primary care physicians [26]. To date, there have been no large-scale initiatives involving professions allied to medicine in the teaching of undergraduate medical students in rheumatology, or for the examination of the locomotor system. We would suggest that rheumatology nurse specialists as well as specialist physiotherapists and occupational therapists may provide a valuable pool of teachers. This is an initiative that needs to be explored and has the attraction of improving the ratio of teachers to learners, as well as providing the student with a wider exposure to experiences of health-care delivery that is not restricted by arbitrary professional boundaries.

Having discussed objectives and method in the educational process, the third stage we must now address is assessment. In 1990 George Miller, a psychologist, proposed a very useful framework for the assessment of clinical competence [34]. In Miller's pyramid, the lowest level is ‘knows’, followed by ‘knows how’, then ‘shows how’ and finally ‘does’. These four levels of the pyramid correspond broadly to knowledge base, skills, competence and performance. Miller specifically distinguished between the higher and lower levels. The higher levels focus on what actually happens in practice rather than what happens in an artificial testing situation. Work-based assessment methods target the higher levels whereas the two lower levels are targeted mainly by the more conventional forms of assessment. In a model in which undergraduate rheumatological training is a single longitudinal programme, it is expected that in the early years the student might focus on a knowledge base which could be assessed using multiple-choice questions or the short answer question format. As teaching progresses through the years, clinical skills are expected to be developed and the student will need to demonstrate that they know what to do and how to do it. OSCEs [35, 36] and objective structured long examination records (OSLERs) [37] should feature much more prominently in this sort of assessment. Towards the end of the training and as a junior doctor, the learner will need to be assessed against competence: ‘can they do it?’. For an established practitioner the assessment is against performance: ‘is it actually done?’. A discussion of performance assessment in rheumatology is beyond the scope of the present paper.

There is a subtle, but important difference between skills and competence. Skill is the ability to do something. Competence is the ability to do something effectively and well. The crucial difference lies in the word ‘effectively’. The relevance of this in clinical practice is that a skill may be learned by rote and repeated practice. However, competence requires the addition of attitudes, behaviour and responsiveness to the application of a skill in a particular clinical situation. A useful definition of competence has been provided by Epstein and Hundert as ‘the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and the community being served’ [38]. Competence is an integrative function that builds on the foundation of basic clinical skills and scientific knowledge. It requires the use of knowledge, moral development, effective communication with patients and colleagues and the willingness and emotional awareness to use such skills judiciously and humanely in order to solve real-life problems.

The assessment of competence is a complex process and requires an assessment of knowledge, technical skills, problem-solving, understanding attitudes and ethics [39]. We suggest that one possible approach to competency-based assessment in rheumatology would be direct observation of the consultation. The clinical consultation in rheumatology is an essential unit of practice, and the subsequent management of the patient derives from it. Direct observation of the consultation would reliably assess whether the competencies that derive from the components of the core curriculum in rheumatology have been successfully achieved. Crucial to the assessment of the consultation is that an appropriate instrument is used. A possible tool that could be used for evaluating the consultation is the Leicester Assessment Package (LAP). The LAP was developed in Leicester and designed for both formative and summative purposes. There are seven prioritized categories of consultation competence with a number of individual components in each category. The LAP has been used in general practice, in the postgraduate setting in ENT surgery, and for the assessment of medical students at the Leicester Warwick Medical School for the intermediate clinical examinations and the final clinical examinations. It is suggested that using the LAP for direct observation of the consultation would be a useful tool to assess whether the student has successfully acquired the necessary competencies expected at the end of an undergraduate training in rheumatology. The seven categories include history-taking, physical examination, patient management, problem-solving, relationship with patients, anticipatory care and record-keeping. It is suggested that using the LAP or another direct observation assessment method would allow assessment of whether the student has successfully acquired the necessary competencies and also address the more complex psychosocial and attitudinal issues involved in a rheumatology consultation [40].

Another emerging tool in assessing performance includes 360-degree evaluation [41]. This method is extremely helpful in assessing professionalism and communication. The lack of sufficient training in skills requiring the assessment and diagnosis of musculoskelatal problems is not restricted to this country. Opinion from North America [42], Latin America [43], South Africa [44], several Asian Pacific countries [45] and Australia [13] indicates that it is not uncommon for medical students to qualify without being able to make a general assessment of the musculoskeletal system.

There is growing consensus worldwide that, in order to truly address this issue, it is important to have an integrated musculoskeletal curriculum in order that experts from various specialties may work together closely and develop a common approach for the assessment and treatment of these disorders, thereby pulling together the existing disparate threads [46]. The task that lies ahead is a large one. It is imperative that clearly defined outcomes need to be established in assessing the competence of future doctors and their ability to deal with musculoskeletal conditions. This would best be done through a world-wide network, ensuring that there is a framework for globally accepted standards, which may then be adapted to local needs. At the undergraduate level, the emphasis should be on acquiring clinical skills and knowledge of common musculoskeletal conditions. In addition, the focus should be on developing an attitude that is appropriate for treating patients with such conditions, especially as they may have long-term chronic pain. Undergraduate medical students need to develop a minimum level of competence in evaluating patients, and this needs to be combined with basic knowledge of the locomotor system, which should include cell biology and the anatomy, physiology and pathology of bones, joints and muscles. It is envisaged that the content of the curriculum would contain certain common conditions that are universal, such as trauma, low back pain, osteoarthritis, rheumatoid arthritis, infections and gout, but there would be a further development of the curriculum dependent upon local needs. Clinical skills are usually best acquired in out-patient clinics, specialist wards, emergency services, primary care and clinical skills centres. However, this needs to be combined with formal instruction, and problem-based learning may be a useful adjunct, especially for more complex problems and those that have a large social aspect to their management. Assessment should be by the use of reliable and validated tests, and the desired competence should include the acquisition not only of the skills necessary for the assessment and diagnosis of musculoskeletal conditions but also of an appropriate attitude in managing patients with chronic conditions. An integrated musculoskeletal core curriculum in the undergraduate years could provide a powerful tool to achieve this [46].


    Conclusion
 Top
 Introduction
 A generic curriculum
 The current position regarding...
 What should be done...
 Conclusion
 References
 
It is well recognized that rheumatic conditions are common, both in primary and secondary care. However, the overall coverage of rheumatic disorders, as well as training for rheumatology and musculoskeletal disease, in the undergraduate medical school curriculum is not proportional to the workload in actual practice. Current evidence would suggest that there are a number of shortcomings in undergraduate rheumatology training, in terms of the content, how this is delivered and how it is assessed. There would appear to be considerable variation across medical schools in the UK.

The EULAR standing committee on education and training has provided a very useful framework for what ought to be a core curriculum in rheumatology during undergraduate medical training. The objectives are that, at the end of training, students should be able to provide a description of locomotor abnormality and impairment, a description of disability and handicap, state a limited differential diagnosis, state relevant investigations, and outline an appropriate management plan. To this we would add that students should also be able to develop the specific attitude required for the management of patients who have long-term debilitating conditions.

Undergraduate training in rheumatology should be a longitudinal integrated process spread across all the years and built upon incrementally in each successive year rather than in isolated and disjointed units. Teachers other than rheumatologists or orthopaedic surgeons can teach many of the components of the core curriculum, and much teaching can be carried out in primary care. An as-yet untapped resource of teachers lies in professions allied to medicine, and we would suggest that this is an avenue that needs to be seriously considered. The advantage of including other health professionals would be an improvement in the teacher/learner ratio as well as exposure to a wide spectrum of experience that crosses the more traditional professional boundaries. Mires et al. demonstrated that multiprofessional teaching can be an effective educational strategy when the intended educational objectives are clearly defined [47].

The assessment of teaching in rheumatology needs to be more competency-based towards the end of the medical curriculum. We would suggest that the competencies that are to be acquired through the undergraduate core curriculum can be assessed using the Leicester Assessment Package, by involving direct observation of the consultation process.

Both PRHO and senior house officer (SHO) training is under review within the UK. The Department of Health has issued a document (‘Modernising medical careers’) indicating that a 2-yr foundation programme will be introduced for SHOs [48]. There will be a need to ensure that undergraduate programmes lead naturally into postgraduate programmes and that they provide continuity in training.

As Walker and Kay have said, ‘There is a battle of perception to be won’ [33]. There is a need to recognize and prioritize rheumatology teaching within the undergraduate curriculum and to have agreement between medical schools in this country about a core curriculum as well as the method of its delivery and assessment.

We recognize that effecting improvement in the teaching and assessment of rheumatology is an arduous task. However, there are many benefits to be gained from doing so, not only for direct patient care but also in terms of more effective delivery of services in a health-care system that is already strained.


    Acknowledgments
 
We are grateful to Anthony D. Woolf, Professor of Rheumatology, Peninsula Medical School, Royal Cornwall Hospital, Truro, for his helpful comments on an earlier draft of this paper.

The authors have declared no conflicts of interest.


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 Introduction
 A generic curriculum
 The current position regarding...
 What should be done...
 Conclusion
 References
 

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Submitted 28 December 2003; Accepted 28 June 2004