Musculoskeletal assessment of general medical inpatients

S. G. Dubey

Clinical Lecturer in Rheumatology and Medical Education, Academic Unit of Medical Education, Coleridge House, Northern General Hospital, University of Sheffield, Sheffield S5 7AU, UK

Correspondence to: E-mail: s.dubey{at}shef.ac.uk

SIR, I wish to complement Dr Lillicrap and colleagues for a useful study [1], which highlights some of the concerns that musculoskeletal educators and patients with musculoskeletal disorders face every day. I concur with its conclusion that competence in recognition of musculoskeletal disorders has generally improved [2] and that the GALS locomotor screen, developed in 1992 [3], has probably contributed to this. There are two important issues that this study has brought out: competence (or confidence in competence) and performance. It is very worrying that, even in patients where musculoskeletal symptoms were picked up on history, an appropriate examination was not conducted. Indeed, it brings into question the quality assurance process within the NHS. This study also exemplifies the limitations of assessment of competence compared with assessment of performance. Miller's pyramid aptly provides the framework for clinical assessment where performance assessment is at a higher level than competence assessment [4]. I believe that the reasons for this discrepancy between competence and performance are multifactorial. As educators, we recognize the very important role of assessments in driving learning [5]. Currently, there are no work-based assessments in place for junior doctors within the NHS. Also, the example set by the physician as a clinical teacher is the most powerful way for learners to acquire the values, attitudes and behaviour needed for professional and ethical medical practice [6]. I suspect that only a minority of general physicians would regularly perform screening examinations of the musculoskeletal system. This leads to a belief among junior doctors that musculoskeletal examination is not required, even if there are locomotor symptoms. The Royal College of Physicians is currently commencing a research project to gather data on the reliability and feasibility of work-based assessment for junior doctors. If work-based assessments are implemented, perhaps the quality of in-patient assessment will improve.

In Sheffield, we have been teaching GALS for some years. This led to a process where we (led by Dr Snaith, who has retired now) have tried to improve the original version of the GALS, which we have named Sheffield GALS. The concerns we have about the original GALS [3] include the following: (i) in the screening questions, there was no mention of the neck; (ii) we have now come across a number of patients in whom loss of pronation and supination is not the first sign of loss of function at the wrist; and (iii) feedback from students suggested that there were certain signs that students were consistently finding difficult.

The purpose of this exercise is to maintain the central concept of a national screening examination, but to make it more student-friendly and locally applicable. By having some sort of local ownership of this version, we feel that there would be a greater incentive for rheumatologists to teach GALS to their colleagues in medicine, along with junior doctors and medical students. This screening examination was presented and discussed in a national-level conference for musculoskeletal educators held in Castleton in September 2002, named ‘The Changing Curriculum’. The feedback from the various musculoskeletal educators in the country was incorporated and the revised version developed. This is currently being used in this medical school to teach the students, and video clips have been posted on the Networked Learning Environment (NLE) to aid student learning.

The changes we have incorporated in the Sheffield GALS include:

  1. Screening question 1 to read: Do you have any pain or stiffness in your muscles, joints, neck or back?
  2. Exclusion of jaw movements, as we felt rheumatologists do not commonly deal with temporo-mandibular problems.
  3. Increased emphasis on elbow flexion and extension—this is introduced as an extra manoeuvre during examination of the arms as undergraduates find it quite difficult to pick up subtle elbow abnormalities during the initial inspection.
  4. Prayer sign, in addition to pronation and supination of the wrist, as we have now come across a number of patients where loss of pronation and supination is not the first sign of loss of wrist function. Also, students find the prayer sign much more demonstrative.

Most students are soon able to perform this examination within 3–4 min. We believe that this version is easier for people inexperienced in picking up musculoskeletal abnormalities. Encouraged by its face validity and acceptability within the region, I suspect the next step would be to test the content validity of this screening examination.

I would like to thank Dr Snaith for his help and support.

The author has declared no conflicts of interest.

References

  1. Lillicrap MS, Bryne E, Speed CA. Musculoskeletal assessment of general medical in-patients-joints still crying out for attention. Rheumatology 2003;42:951–4.[Abstract/Free Full Text]
  2. Fox RA, Dacre JE, Clark CL, Scotland AD. Impact on medical students of incorporating GALS screen teaching into the medical school curriculum. Ann Rheum Dis 2000;59:668–71.[Abstract/Free Full Text]
  3. Doherty M, Dacre J, Dieppe P, Snaith M. The ‘GALS’ locomotor screen. Ann Rheum Dis 1992;51:1165–9.[Abstract]
  4. Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65:S63–S67.[ISI][Medline]
  5. Newble DI, Jaeger Kerry. The effects of assessments and examinations on the learning of medical students. Med Educ 1983;17:165–71.[ISI][Medline]
  6. Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending-physician role models. N Engl J Med 1998;339:1986–93.[Abstract/Free Full Text]
Accepted 31 October 2003





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