Undergraduate rheumatology teaching in the UK: a survey of current practice and changes since 1990

L. J. Kay, C. M. Deighton1, D. J. Walker and E. M. Hay2 on behalf of the Arthritis Research Campaign Undergraduate Working Party of the ARC Education Sub-committee

Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne,
1 Department of Rheumatology, City Hospital, Nottingham,
2 Staffordshire Rheumatology Centre, The Haywood, Stoke on Trent, UK


    Introduction
 Top
 Introduction
 Methods
 Results
 Conclusions
 References
 
Undergraduate medical teaching is important in a number of respects: it lays the foundation for future practice, skills and attitudes, forms a basis for lifelong learning and in some cases the quality of undergraduate teaching may determine career choices later in life [1]. Medical undergraduate teaching in the UK was reviewed extensively in 1993 and far-reaching recommendations were made in the General Medical Council (GMC) document Tomorrow's doctors[2]. These recommendations particularly focused on training in clinical skills and emphasized the importance of integration both vertically with the basic sciences and horizontally with other specialty areas. There was also an increased emphasis on social and psychological aspects of disease and disability, and a primary care viewpoint. Similar recommendations about rheumatology undergraduate education were made by a working party representing the UK rheumatology education bodies, the British Society for Rheumatology (BSR) and the Arthritis Research Campaign (ARC) [3]. The provision and methods of undergraduate rheumatology teaching in the UK were last reviewed in 1990 [4] 3 yr before these recommendations were made. It is therefore timely to reappraise the situation and to assess the impact, if any, of the recommendations of the GMC, the BSR and the ARC on undergraduate rheumatology education in the UK. Change proceeds slowly in most large institutions, so we felt that 4 yr after these important reports was an appropriate time to assess medical schools' responses.


    Methods
 Top
 Introduction
 Methods
 Results
 Conclusions
 References
 
A three-page questionnaire, previously used in 1990 [4] was sent in December 1997 to the lead rheumatology teacher at each of the 26 medical schools in the UK. The questionnaire contained both closed and open questions, allowing free text responses. Questions related to the structure, setting and time allocation of rheumatology teaching, as well as teaching and assessment methods used. Direct questions about change in the rheumatology curriculum were asked. One mailing only was used and the results were compared with those from 1990. Data were analysed with EPI-INFO version 6, using the {chi}2-test where appropriate with significance set at the 5% level.


    Results
 Top
 Introduction
 Methods
 Results
 Conclusions
 References
 
Questionnaires were returned from 23 of the 26 medical schools. The 1990 questionnaire had a 100% response rate.

Exposure to rheumatology teaching
All medical schools included rheumatology as part of their undergraduate curriculum. In 18/23 (78%) schools, all medical students were exposed to clinical rheumatology teaching. Between 50 and 75% of students were taught clinical skills in the remaining five schools. In 1990, 92% of schools taught clinical skills to all students, with 30 and 90% of students receiving such teaching in the other two universities. The proportion of medical schools at which all students were taught locomotor system clinical skills was significantly higher in 1990 than 1997 (P = 0.006).

Setting and timing of teaching
Nine of the 23 schools (39%) offered clinical rheumatology teaching to students in their first 2 yr, compared with 37% in 1990. Only five medical schools confined their clinical teaching to one academic year, most commonly the third (Fig. 1Go), compared with 17 schools in 1990. In the remainder, teaching was spread across the clinical years, with students receiving rheumatology teaching in all 5 yr at one school and in all three clinical years at five schools.



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FIG. 1. Timing of rheumatology teaching to medical students.

 
Only three schools taught rheumatology in isolation. Rheumatology was taught in combination with a variety of subjects at the other 20 schools, most commonly orthopaedics (18), general medicine (10) and rehabilitation medicine (six). Other combinations included primary care (two), neurology (two) and health care of the elderly, anatomy, cardiology, immunology and accident and emergency medicine (one each).

Rheumatology teaching contact time
The questionnaire asked for details of the duration of rheumatology teaching in terms of a main rheumatology module, and any other contact time. Nineteen schools had a main rheumatology module of median duration 6 weeks (range 2–32). Other schools had more fragmented teaching, with sessions integrated within other disciplines. If a week is assumed to comprise 30 h of teaching time, then the median overall teaching time for rheumatology was 69 h (range 6–510). For comparison, the median teaching time in 1990 was 4 weeks (range 0–8), i.e. 120 h.

Teaching methods and materials
Rheumatologists used a wide variety of teaching methods (Table 1Go). Traditional teaching styles such as large and small groups were common (18 and 23 schools, respectively), but more innovative methods such as problem-based and self-directed learning were also frequently used. Four schools described their teaching as lecture-based, with a further four having partly lecture-based teaching. Computers, models and videos were widely used, as were ARC publications (see below).


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TABLE 1. Teaching and learning methods used in rheumatology courses at UK medical schools

 

Assessment
Nineteen schools specifically tested rheumatological knowledge in one or more examination (Table 2Go). In 13 schools the examination counted towards the final degree, and in 13 these examinations had to be passed in order to progress to finals. According to the questionnaire responses, in five medical schools students could progress to or pass finals without any examination that included rheumatology. Medical schools used a wide variety of assessment methods. A multiple-choice format was still the most common [15/23 (65%) schools compared with 78% in 1990; P = 0.32]. Clinical skills were tested using traditional long and short case examinations in 14 schools and objective structured clinical examinations (OSCE) [5] in 12. Seven schools set written examinations in rheumatology. Clinical skills were tested using at least one method in 14 schools (64%) compared with 22% of schools in 1990 (P < 0.001).


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TABLE 2. Examination of rheumatological skills and knowledge in UK medical schools in 1990 and 1997

 

Curriculum changes since 1990
Sixteen schools had already implemented a new curriculum in response to the recommendations of the GMC [2]. Five others planned to implement changes in 1998. Free text comments identified a number of common themes in these changes, for example:

The role of the ARC
Resources currently provided by the ARC to support teaching were widely used: 18 schools used the ARC collected reports, 20 the ‘Introduction to the musculoskeletal system’ [6] and one the slide collection. One each mentioned the patient information booklets, the posters and a skeleton purchased with ARC funding. The lead teachers suggested many ways in which the ARC could provide assistance to undergraduate rheumatology teaching (Table 3Go). These included help with the development and dissemination of teaching materials, support, funding and training for clinical teachers and central support for the place of rheumatology in the medical school curriculum.


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TABLE 3. Suggested assistance that the ARC could provide to medical schools for the teaching of undergraduate rheumatology

 


    Conclusions
 Top
 Introduction
 Methods
 Results
 Conclusions
 References
 
The majority of schools include rheumatology clinical skills teaching in the curriculum for all of their students, but in five schools (three more than in 1990) up to half the students may receive no clinical rheumatology teaching at all. There has been no significant change in the number of schools including clinical rheumatology in their pre-clinical or early years. In 1990 the majority of schools taught rheumatology in the third year only, whereas in 1997 the spread of rheumatology teaching throughout the clinical years had broadened quite strikingly. The time allocated to rheumatology teaching is difficult to compare with that in 1990, as timetabled teaching appears to have become more fragmented, but overall time may have fallen from a median of 4 to just over 2 weeks. Taken with the additional medical schools where only a proportion of students were taught rheumatological clinical skills, this may suggest that rheumatology has been seen as an elective rather than a core component of the curriculum in some schools. This is clearly a matter of concern given the high rate of consultation for musculoskeletal conditions in primary care [7] and the lack of confidence expressed by general practitioners in their rheumatological examination skills [8, 9].

Rheumatology was generally taught in conjunction with other specialties. In many schools this appeared to be as a common musculoskeletal option with orthopaedics, whereas in other schools rheumatology was perceived as a medical subspecialty and therefore taught with general medicine. Combined teaching with primary care occurred in only two medical schools. The setting of rheumatology teaching appears to be increasing in its diversity, which may lead to new insights into the strengths and limitations of different teaching collaborations.

Lectures appear to have diminished as the main form of rheumatology teaching: a wide variety of methods was reported in this study. There was almost universal use of ARC teaching materials, suggesting that tutors found their style and content appropriate. This suggests that such materials may be highly influential and that the development of teaching materials may be efficiently and effectively co-ordinated by the ARC.

The rate of assessment of clinical skills has risen 3-fold since 1990, most commonly by traditional long and short case methods, but also by means of an OSCE examination. Some form of examination of rheumatological knowledge or skills was a requirement for reaching or passing the final examination in all but five medical schools. This was a significant change from the 1990 survey and accords well with the recommendations of the GMC [2] and of the joint report of the ARC and the BSR [3]. This increased inclusion of clinical rheumatology skills in examinations may perhaps be the most effective way of ensuring medical students' appreciation of their importance.

Twenty-one of the 26 medical schools had planned or implemented a new curriculum since 1990. Curriculum changes have been broadly in line with national recommendations [2, 3] as follows: increased priority has been given to the teaching and assessment of clinical skills; teaching of rheumatology appears to be more integrated both horizontally, as evidenced by the increasing diversity of specialties with which rheumatology is now taught and by the decline in the separate rheumatology ‘module’, and vertically as shown by the increased spread of rheumatology teaching across the undergraduate years. From this questionnaire survey, however, there is little evidence that there has been more emphasis on the primary care aspects of rheumatological disease, although it is possible that this is a limitation of the study method.

This questionnaire survey has given a picture of change and increasing diversity in rheumatology undergraduate curricula in UK medical schools. Alterations appear to reflect the recommendations for change both from the GMC [2] and from the rheumatology education bodies [3], with changes in course structure, delivery and assessment. The increased diversity gives an enhanced opportunity to share experience and compare strategies used, for the benefit of future rheumatology undergraduate education in the UK and elsewhere. We are concerned that, despite the importance and frequency of musculoskeletal complaints in everyday medicine, rheumatology appears to be losing its status as a core specialty in some medical school curricula. This is contrary to the spirit of the GMC's recommendation [2] and is of particular concern in view of the impending demographic changes. The burden of musculoskeletal disease will rise markedly with the projected increase in the older population of 25% in the next 15 yr [10], at which time the students who entered medical school at the time of this survey will be consultants and general practitioners. Their musculoskeletal clinical skills and knowledge of rheumatology, wherever they practise, will be more and not less relevant than those of current doctors. It is the responsibility of rheumatologists and our representative bodies to maintain the standard of teaching in medical schools and to ensure that adequate priority is given to rheumatology teaching in the undergraduate curriculum. The GMC's recent publication, The doctor as teacher [11], emphasizes the doctor's professional obligation to contribute to medical students' education, and to develop and maintain the skills of a competent teacher. As rheumatologists we should consider an added obligation: that medical students in our medical schools receive adequate training in the essential components of rheumatology that they and their future patients will need.


    Acknowledgments
 
This work has been funded by the Education Committee of the Arthritis Research Campaign, and L. J. K. is an ARC Clinical Lecturer in Rheumatology. We thank the rheumatologists who participated in this survey.


    Notes
 
Correspondence to: L. J. Kay, Department of Rheumatology, The Medical School, University of Newcastle, Framlington Place, Newcastle upon Tyne NE2 4HH, UK. Back


    References
 Top
 Introduction
 Methods
 Results
 Conclusions
 References
 

  1. Lambert TW, Goldacre MJ, Edwards C, Parkhouse J. Career preferences of doctors who qualified in the United Kingdom in 1993 compared with those of doctors qualifying in 1974, 1977, 1980 and 1983. Br Med J1996;313:19–24.[Abstract/Free Full Text]
  2. General Medical Council. Tomorrow's doctors: recommendations on undergraduate medical education. London: General Medical Council, 1993.
  3. Doherty M, Dawes P. Guidelines on undergraduate curriculum in the UK. Br J Rheumatol1992;31:409–12.[ISI][Medline]
  4. Jones A, Maddison P, Doherty M. Teaching rheumatology to medical students: current practice and future aims. J R Coll Physicians Lond1992;26(1):41–3.[ISI][Medline]
  5. Harden RM, Gleeson FA. ssessment of clinical competence using an objective structured clinical examination. Med Educ1979;13:41–54.[ISI][Medline]
  6. Arthritis Research Campaign (formerly Arthritis & Rheumatism Council). An introduction to the musculoskeletal system. Derbyshire: ARC, 1991.
  7. Dieppe P, Paine T. Referral guidelines for general practitioners—which patients with limb joint arthritis should be sent to a rheumatologist? ARC Report on Rheumatic Diseases, January 1994:1.
  8. Hettle M, Braddom RL. Curriculum needs in physical medicine and rehabilitation for primary care physicians. Results of a survey. Am J Phys Med Rehabil1995;74:271–5.[ISI][Medline]
  9. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ, Buchbinder R. Determinants of physician confidence in the management of musculoskeletal disorders. J Rheumatol1996;23:351–6.[ISI][Medline]
  10. Meenan R, Callahan LF, Helmick CG. The National Arthritis action plan: a public health strategy for a looming epidemic. Arthritis Care Res1999;12:79–81.[ISI][Medline]
  11. General Medical Council. The doctor as teacher. London: General Medical Council, 1999.
Submitted 17 August 1999; revised version accepted 10 January 2000.