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

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 More recently (2002, A. Samanta, unpublished data) we repeated our survey.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. 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. 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. 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]. 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