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:
Most students are soon able to perform this examination within 34 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.
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