Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK
Rheumatologists would be expected to agree that competence in the examination of the musculoskeletal system is essential for all medical students at the point of qualification from medical school. Defining that competence and the exact skills required may provoke more disagreement. Teaching a complex and potentially time-consuming examination to medical students is fraught with difficulty. How much should they be taught? How do we get them to take it seriously, to learn the agreed skills to an agreed level of competence and to use these skills in clinical practice?
There are similarities between the neurological and the musculoskeletal examinations. Both are potentially very extensive with many components of the examination likely to be unrewarding in individual patients. Because of this, in practice, experienced clinicians modify their examination according to the history and what they find on their initial examination. The expert clinician has come to this through years of experience, but it should be possible to teach more junior clinicians in a structured way starting with a basic examination and building on to it a more detailed examination that reflects the sort of patients they see and the setting they are in. Musculoskeletal examination, however, also suffers from the added problem that it is not perceived as important by many clinicians. This is not such a problem for neurology where historically examination has been taught, learned and tested [1]. In our own medical school, for example, we have experience of finding that the students have been taught on other topics, such as the cranial nerves, or anaemia [2], when they are time-tabled to be taught joint examination. This may be historical and due to the fact that expansion of rheumatology as a speciality in its own right is relatively recent. It is possible that this may change in the future when the medical teachers come from a generation where rheumatology has been an integral part of their undergraduate and post-graduate training.
There is evidence of neglect of musculoskeletal examination in clinical practice. This occurs in a variety of clinical settings [35], and may have a number of explanations. Teaching of musculoskeletal examination at medical schools has frequently been regarded as poor [1, 610], and there is still a large variation in the amount of time allocated to musculoskeletal subjects in different medical school curricula [1113]. Musculoskeletal examination is poorly described in textbooks [14], which might reinforce negative attitudes and be a further barrier to learning. Consequently, it is not surprising to find that some practising clinicians are not confident in their own musculoskeletal examination skills [15, 16], many wish that they had had more musculoskeletal training [1719] and that some do not regard this as part of their routine medical practice [12]. The General Medical Council in Tomorrow's Doctors [20] emphasized the need for sound clinical skills as a fundamental part of UK undergraduate medical courses. We would argue that this is perhaps even more important for the musculoskeletal system than for others, because of the importance of examination findings in making a diagnosis, and the lack of gold standard diagnostic tests. The view that examination of the musculoskeletal system is of lesser importance than that of other systems is at odds with the frequency of musculoskeletal complaints in clinical practice [21], their place as the most common cause of disability in the community, their contribution to the burden of disease in the population [2225] and the contribution made to the diagnosis of these conditions by clinical examination. Clearly, there is a battle of perception to be won.
A major step forward was made in the 1980s with the development and validation of a screening examination, GALS [26]. This validated screening examination was initially designed for use in primary care and was intended to provide a simple examination tool for the detection of important musculoskeletal abnormalities. A version of the GALS examination is taught in all of the UK medical schools [12]. It is supported by the Arthritis Research Campaign, who publish a widely available booklet containing a description of GALS [27], which is given to medical students at most UK medical schools [12], as well as a video demonstrating its performance. A CD-ROM is being developed (M. Doherty, personal communication). The widespread uptake of the GALS screening examination has demonstrated that a validated, published examination system is acceptable to teachers and students, and that a national approach is possible. We suggest that this widespread agreement about an examination system has facilitated teaching and raised the profile of the musculoskeletal examination to staff and students in many medical schools.
Using GALS, we have the concept of a two level approach to examination of the musculoskeletal system: a screening examination, which distinguishes normality from abnormality, and localizes the presence of an abnormality to a region of the body; and then a targeted, more detailed regional examination if an abnormality is found. It is at the level of the regional examination that we do not have agreement or definition of what should be taught, despite a number of recent recommendations about curriculum requirements for musculoskeletal undergraduate medical education [11, 28, 29]. Leading rheumatology teachers at UK medical schools have expressed a wish for national agreement about core requirements in musculoskeletal undergraduate education [12]. The advantages of such an agreement with respect to regional musculoskeletal examination skills would include the possibility of consistent teaching of these skills across disciplinesstudents all over the country complain that they are taught differently by rheumatologists and orthopaedic surgeons, and differently again in general practiceleading to fairer assessment, increased confidence in the use of these skills and, ultimately, better practice and therefore benefits for patients. We suggest that the definition of an agreed core list of musculoskeletal regional examination skills would take us an important step further in undergraduate teaching. Such a core list would need to be acceptable to rheumatologists, orthopaedic surgeons, general practitioners, medical students, their teachers and deans of medical schools. It would need to be relevant to future practice, evidence-based where possible and relatively concise, without omitting important examination skills. The process of deriving such a core skills set is clearly important. It should use rigorous methodology, involve a variety of professionals from relevant disciplines and settings, be tested and validated, be under the auspices of a recognized body, and be subject to ongoing review and evaluation. Once the content of this skills set has been established, questions can be addressed about appropriate educational methods and materials. Assessment is well known to drive learning, particularly in students, and assessments and examinations can be better defined if the required skills are agreed. Use of these examination skills in clinical practice is likely to be encouraged by increased confidence in the usefulness of clinical examination tests, and by the experience of successful identification of treatable abnormalities. Using the model of GALS, such an improved and defined curriculum would prepare the student for practice at pre-registration level and be a starting point for postgraduate training in their chosen specialty, whether patients with musculoskeletal complaints are a main focus of their career or not. The effects of rheumatology undergraduate training are retained in clinical practice many years later [30, 31] and are influential in later career choice [32], and so it is important that we get it right.
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