Clin Rheumatol (2015) 34:1157–1163 DOI 10.1007/s10067-015-2984-0
REVIEW ARTICLE
Teaching of clinical anatomy in rheumatology: a review of methodologies Karina D. Torralba 1 & Pablo Villaseñor-Ovies 2 & Christine M. Evelyn 3 & R. Michelle Koolaee 3 & Robert A. Kalish 4
Received: 21 May 2015 / Accepted: 23 May 2015 / Published online: 3 June 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract Clinical anatomy may be defined as anatomy that is applied to the care of the patient. It is the foundation of a wellinformed physical examination that is so important in rheumatologic practice. Unfortunately, there is both documented and observed evidence of a significant deficiency in the teaching and performance of a competent musculoskeletal examination at multiple levels of medical education including in rheumatology trainees. At the Annual Meeting of the American College of Rheumatology in Boston, MA, that took place in November 2014, a Clinical Anatomy Study Group met to share techniques of teaching clinical anatomy to rheumatology fellows, residents, and students. Techniques that were reviewed included traditional anatomic diagrams, hands-on cross-examination, cadaver study, and musculoskeletal ultrasound. The proceedings of the Study Group section are described in this review.
* Robert A. Kalish [email protected] 1
Division of Rheumatology, Department of Medicine, Loma Linda University, Loma Linda, USA
2
Centro de Ciencias de la Salud, Escuela de Medicina, Universidad Autónoma de Baja California, Hospital Angeles de Tijuana, Tijuana, Mexico
3
Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
4
Division of Rheumatology, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St Box 599, Boston, MA 02111, USA
Keywords Clinical anatomy . Medical education . Musculoskeletal ultrasound . Physical examination
Introduction BDoctor, I have never had such a thorough physical examination as this.^ The tone is one of thanks, or maybe surprise or relief. It is rarely voiced as a complaint that the examination was too long or careful. Rheumatologists probably hear this statement more often than other physicians, and it comes as a small but gratifying reward for work that otherwise yields scarce relative financial gain and consumes precious time. Unfortunately, there is abundant evidence that we are falling far short in teaching skills in musculoskeletal examination and rheumatologic clinical anatomy to our trainees at all levels including our fellows [1, 2]. What can we do to make sure this statement is one we continue to hear? We see patients who describe pain and multiple other sensations that only they feel and that we can only strain to comprehend. Is a symptom originating from the joints, the bones, the nerves, or the Bsoft tissues^ around the joints and bones? Or is it a splenic infarct radiating pain to the suprascapular region? As part of trying to figure that out, we relate what we hear from the patient to what we know from our own experiences with pain and that which we have learned from previous patients in whom we eventually were able to correlate a certain symptom with pathology. However, important as a skilled history and nuanced interpretation is in determining the root of a patient’s symptoms, it is a deeper knowledge of clinical anatomy that provides the key additional tool for a more cost-effective and efficient diagnostic plan and a greater chance at uncovering the underlying etiology.
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Clinical anatomy may be defined as anatomy applied to the care of the patient—care that includes not only proper diagnosis and judicious test ordering but also the human connection with the patient. Clinical anatomy is the foundation of a well-informed physical examination. For the rheumatologist, it is a lifeblood. Using knowledge of anatomy as a road map, we examine our patients to understand their symptoms and uncover their pathology. But the touch of the rheumatologist performing a sincere physical examination accomplishes much more. Humans are wired to feel soothed by touch when touch is intended to sooth or heal, with physicians having the potential to do both. Even when touch hurts such as when palpating an inflamed joint, the patient is most often forgiving, knowing that touch is for discovery whose goal is diagnosis and relief. When the patient does not show forgiveness and instead expresses anger or hurt with voice or body language, the physician may be learning key information about that patient’s life experiences and emotional state and should immediately take notice as well as take the cue to stop or move on. The Clinical Anatomy Study Section that took place in Boston in November 2014 during the American College of Rheumatology’s Annual Meeting provided an important initial forum for the sharing of novel methodologies being utilized to teach clinical anatomy to rheumatology fellows and other levels of learners. Three speakers outlined innovative programs for teaching clinical anatomy; their presentations and methods are presented in this published symposium. Dr. Karina Torralba describes a 2-month-long teaching program in clinical anatomy at Loma Linda University that occurs early in the academic year, and integrates physical examination, plain film radiography, and musculoskeletal ultrasound (US). Emphasis is placed on the evidence-based literature pertaining to physical and ultrasound examination of patients with specific conditions. Didactic programs for residents and medical students at Loma Linda are also presented. Dr. Christine Evelyn presents the program which she and Dr. Koolaee supervise and Dr. Torralba helped develop at Los Angeles County—University of Southern California for the rheumatology fellows. This program includes nine lectures focusing on regional anatomy and its importance in clinical diagnosis, monthly fresh cadaver prosection, and instruction on joint injection as well as a weekly ultrasound clinic focusing on the diagnosis and treatment of common conditions seen in the practicing rheumatologist’s office. Lastly, Dr. Pablo Villaseñor-Ovies presents the method of teaching clinical anatomy developed and practiced by members of the Mexican Group for the Advancement of Clinical Anatomy (GMAC). This group, formed and inspired by Dr. Juan Canoso in Mexico City, has implemented workshops in clinical anatomy that have been presented in numerous countries throughout the Americas that feature region by region anatomical teaching using case vignettes, traditional anatomic diagrams, and participant cross-examination.
Clin Rheumatol (2015) 34:1157–1163
In an accompanying editorial [3], Drs. Stavros and Panush eloquently emphasize the central importance of clinical anatomy to the rheumatologist and our patients but also directly challenge us to demonstrate and prove that clinical anatomy leads to the beneficial outcomes we claim. They demand that we try to answer such questions as Bdoes a deeper knowledge of clinical anatomy inform a physical examination that saves money for the health care system, inspire confidence from and connection to the patient, and lead to gratification for the physician?^ Their editorial shakes the ground of selfcongratulations and entitlement that is easy to fall into when one is immersed in one’s own fascination and passion as we are with clinical anatomy. They insist that we go a big step further in proving the value of clinical anatomy to those who may not share this interest and those who must determine what gets paid for. We have not yet met Drs. Stavros’ and Panush’s challenge to prove efficacy and outcomes, but we hope this type of conversation and sharing of teaching methodologies among a group with a common goal and passion for clinical anatomy will lead to increased awareness of the importance of training our fellows to become experts in this area and engender the type of rigorous collaborative medical education and outcome studies that will enable us to accomplish this.
The Loma Linda University experience: clinical anatomy and US from medical school, residency, to fellowship Rheumatology fellowship teaching It definitely helps that a review of musculoskeletal clinical anatomy is done early in fellowship training. There seems to be a wide variation in how knowledge in this area is reinforced during residency. For our fellowship program, we conduct within the first 2 months a series of didactic and workshop sessions that integrate physical examination, plain film radiography, and joint-based US (Table 1). We hold evidence-based medicine-formatted conferences to examine the medical literature on the usefulness and limitations of physical examination of particular conditions in specific patient cases especially as it correlates with various radiographic imaging modalities, or to look at the application of US in the evaluation of pathologic anatomic structures in the setting of rheumatic diseases. US clinics at our faculty medical offices focus on joint-based examination to evaluate joint complaints of new patients, to evaluate response of patients with inflammatory arthropathies to treatments, and to do US-guided procedures. Some fellows have participated in the US School of North American Rheumatologists (USSONAR) program [4], particularly in their second year, which we find does enhance the competency of fellows in this modality and appears to give them a more rapid pace of independence. We have found that fellows go on to master anatomy through the use of US and have a better
Clin Rheumatol (2015) 34:1157–1163 Table 1 The LAC-USC and LLU rheumatology fellowship programs have similar educational frameworks on clinical anatomy teaching with radiologic imaging correlations. Described below are the general and
1159 specific tasks expected for fellows for part of the ankle joint anatomy. Cadaveric visualization is encouraged for programs that have access to fresh tissue laboratories
Musculoskeletal anatomy teaching program General tasks • Review relevant anatomy including bones, tendons, and neurovascular structures • Review functions of each structure • Correlate US appearance to plain film/X-ray appearance • Correlate US anatomy to cadaveric anatomy • Understand approaches to palpation-guided injections and US-guided injections • Apply current US definitions of pathology and applications in disease management Medial ankle joint and tibiotalar joint Anatomy to identify Posterior tibialis tendon Flexor digitorum longus tendon Flexor hallucis longus tendon
Posterior tibial artery, vein, and nerve Tibiotalar joint
understanding of the pathophysiology of inflammatory arthropathies and soft tissue pathology. It is important to remember that the goal in incorporating US is not to develop technicians but to enhance the proficiency of rheumatologists by using US as one of the many tools that we use in the evaluation and management of rheumatic diseases [5]. An US probe for a rheumatologist is comparable to that of a stethoscope for a cardiologist. In the context of education theory, US provides a platform for active learning and subsequent potential critical thinking; it also substantially helps learners who have predominantly visual learning styles, instead of using traditional models of learning where memorization has been the standard [6]. Internal medicine resident teaching Our division also holds twice-yearly interactive (IEL) sessions with internal medicine residents with the goal of having residents improve on their rheumatologic physical examination, and palpation-guided joint aspiration and injection techniques. These sessions are done with a mixture of didactics and workshops covering demonstration of these skills, and enhanced with the use of US. For example, the shoulder module can cover a review of vital structures and common joint and soft tissue pathology, physical examination demonstration, and dynamic ultrasonography showing direct relationships between the acromion, humeral head, and intervening soft tissues, followed by an US video of impingement syndrome in a patient [7].
Specific tasks √ Review relevant bony anatomy and tendon location √ Review tendon origins, insertions, and functions √ Review definitions of tendon abnormalities by US √ Visualize by US √ Visualize if possible on cadaver √ Visualize using US √ Visualize if possible on cadaver √ Review bony anatomy relevant to overlying structures √ Identify on cadaver and practice injection (with saline) √ Visualize using US (transverse and longitudinal views) √ Review synovial effusion and synovitis appearance on US
Medical student teaching Loma Linda University School of Medicine (LLUSM) is one of several medical schools in the country that have included US in their curriculum [8]. Rheumatology-related US programs have been successfully implemented in undergraduate curricula to address issues related to teaching normal and abnormal anatomy [9]. Of all student special interest groups at LLUSM the largest is the Ultrasound Student Interest Group, comprised of at least 150 members, advised by Dr. Vi Dinh. Every February, they hold an UltraFest which is a 1-day symposium aimed at introducing medical students to point of care US on many organ systems (Table 2). For the 2015 UltraFest, 200 medical students from various schools had signed up along with over 60 physician instructors from medical schools in California and Tennessee. Hands-on training with live models and specialized simulation models were used. Our division along with one orthopedist spearheaded the Musculoskeletal Module. For almost all of the students, this was their first experience in musculoskeletal US. The primary goal was to have students become familiar with the appearance of musculoskeletal structures on US as it correlates with clinical anatomy and physical examination. We chose to focus on the knee joint to look at tendons, muscles, cartilage, bone, and the volar wrist area to allow examination of the median nerve. A brief 15-min lecture covering US appearances of these structures and corresponding physical exam was followed by a 30-min hands-on live model workshop session with a faculty member (one faculty to two to three students) (Fig. 1).
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Table 2 LLU UltraFest 2015 Musculoskeletal Module: educational framework (teaching method, time allocation, goals, and objectives) for this activity Teaching method
Time allocation
Didactic session 10 min Goals The goal of this activity is to have medical students understand (1) the appearance of normal musculoskeletal structures on US and correlate with clinical anatomy, (2) the basic musculoskeletal pathology with clinical and sonographic correlations, and (3) the indications and uses for MSUS scanning. Hands-on live model scanning workshop 40 min Objectives By the end of the module, students are expected to be familiar with the following: 1) Identification of skin and subcutaneous fat 2) Identification of quadriceps muscle 3) Identification of bone: femur and patella 4) Identification of quadriceps and patellar tendons (emphasize anisotropy) 5) Identification of median nerve—anterior wrist longitudinal and transverse views 6) Basic knee evaluation a. Anterior knee (suprapatellar + infrapatellar long): quads tendon, femur, fat pad, and suprapatellar bursa b. Maximal flexion view: transverse and longitudinal femoral cartilage c. Lateral longitudinal: lateral collateral ligament, femur, and fibula d. Medial longitudinal: medial collateral ligament, femur, tibia, medial meniscus, and anserine bursa e. Infrapatellar longitudinal: patellar tendon and fat pad f. Posterior: medial head of gastrocnemius; popliteal artery, nerve, and vein; and Baker’s cyst if present, or at least identify where it should be found
The Los Angeles County—University of Southern California Rheumatology Fellowship Program Rheumatology fellowship programs must present an everexpanding educational menu, during a 2-year fellowship, often leaving little time for the study of MS anatomy. Due to improvement in treatment protocols for gout and rheumatoid
arthritis, current fellows have fewer opportunities to aspirate and inject joints. The use of US, now available in many rheumatology training programs, may be capable of bridging this deficit in anatomic training. At the Los Angeles County—University of Southern California (LAC-USC), anatomy is taught using three broad approaches. This includes classroom didactics, fresh specimen lab sessions using cadavers, and hands-on practice using musculoskeletal US (Table 1). Assessment of fellow knowledge and their satisfaction with their ability to do physical exam and joint-based procedures are asked during the course of the learning process (Table 3). The core curriculum includes several lectures dedicated to reviewing basic musculoskeletal anatomy, along with scenarios of how knowledge of this anatomy is helpful in clinical practice. This information is reinforced during monthly fresh specimen lab sessions, where fellows can identify and review the relevant anatomy, as well as practice intra-articular injections. The US curriculum is robust and consists of a weekly US clinic supervised by two rheumatologists proficient in musculoskeletal US. Fellows are provided with didactic resources (including instructional videos) to review prior to each clinic, which identify relevant anatomy and pathology on US. During this clinic, not only do they have another opportunity to learn anatomy, but fellows have the chance to see firsthand the diagnostic and therapeutic benefits of US. Furthermore, they gain an understanding of how anatomy knowledge is critical for the care of our patients. Lastly, an US workshop is conducted annually (early on in the academic year) for the fellows. This consists of two 4-h sessions and includes a comprehensive review of musculoskeletal anatomy, and reviews this anatomy (as well as pathology) using US. Fellows have ample opportunity during this workshop to practice using the US. This strategy at LAC-USC incorporates both classroom didactics and hands-on practice in order to most effectively teach basic anatomy. Table 3 The following are some ankle anatomy-related questions asked of USC fellows to assess what they have learned in the curriculum. Items 1–5 are asked with a 5-item Likert scale (strongly disagree–strongly agree), while the other questions are free-form questions asked during preceptorship 1. I feel comfortable diagnosing the presence of an ankle effusion. 2. I feel comfortable aspirating or injecting the ankle. 3. I feel comfortable teaching how to aspirate the ankle. 4. I feel comfortable diagnosing subtalar joint dysfunction. 5. I feel comfortable identifying the location of the subtalar joints. 6. Name the structures in the Btarsal tunnel.^
Fig. 1 Loma Linda University Rheumatology Fellows Dr. Chau Nguyen and Dr. Michelle Ngo (both on left, with the former in the foreground) show medical students physical and sonographic examination of the knee at UltraFest 2015
7. Which type of ankle sprain (medial or lateral) is most common? 8. What type of ankle deformity is common in patients with long standing rheumatoid arthritis & what causes it?
Clin Rheumatol (2015) 34:1157–1163
The Mexican Group for the Advancement of Clinical Anatomy Many times in my career have I heard the exhortatory statement Brheumatologists are experts in joint examination,^ yet experience has shown me that most rheumatologists focus their joint examinations on detecting joint effusions and synovitis and pay little consideration to other indispensable elements of the musculoskeletal evaluation. The Bjoint count homunculus^ sums up the anatomy a rheumatologist would need to know if joint synovitis was the only clinical information needed to evaluate patients with rheumatic diseases. All members of the Mexican Group for the Advancement of Clinical Anatomy (GMAC) are practicing rheumatologists convinced that knowing clinical anatomy improves the skills that are needed in the care of rheumatic disease patients. After all, this is what defines clinical anatomy—a science that emphasizes those aspects of structure and function of the human body that aid the practice of medicine [10]. We became an organized group in February of 2009, after Dr. Juan Canoso mesmerized some of us during a series of rheumatologic clinical anatomy workshops that he presented in Mexico in 2007. I was there as a fellow and I still feel very lucky to have received these teachings, as he opened my eyes to a whole new way of examining patients that emphasized a thorough appreciation of the structure and function of the musculoskeletal system. The rheumatic physical exam suddenly became much more than the joint exam. Dr. Canoso made us realize that joints enclose menisci, labra, ligaments, and fat pads, and these are in turn surrounded by tendons, ligaments, bursae and fasciae, all of which may be the anatomical source of discomfort in the rheumatic diseased patient. Some of us desired to learn more about this Bnew^ knowledge and together pressed Juan to create a group in which we could learn and then become teachers. He accepted, and for almost 2 years, we gathered in his dining room for lengthy Saturday morning sessions in which we would learn and practice clinical anatomy. In 2010, our group received a grant from the International League Against Rheumatism (ILAR) which allowed us to give the workshop in different countries. To this date, 34 clinical anatomy seminars have been given in ten Latin American countries, Spain, and the USA, accounting for roughly 900 participants (Table 4). In addition, two short versions of the seminar have been presented at the ACR meetings since 2005 to the present (JC, RAK, and PV-O). Most of the attendees have been practicing rheumatologists, but rheumatology residents and other specialists such as internists, physiatrists, and physical therapists were often present. Along these years, we have received uniformly positive feedback on the seminar, which harmonizes with the results of a qualitative survey that followed the 2007 seminars (Kalish R, Canoso JJ, unpublished data) in which the workshop was considered practical, easy to digest, interactive, dynamic, interesting, and fun.
1161 Table 4 GMAC seminars 2009–2014
Country Argentina Brazil Chile Colombia El Salvador Ecuador Honduras México Uruguay USA Panama Spain Total
Number of seminars 4 5 1 1 1 1 3 7 2 3 1 1 30
Objectives of GMAC Our primary goal is to promote the study of clinical anatomy among rheumatologists. The specific goals that have steered our group’s activities in the last 5 years are (1) to learn and teach clinical anatomy, (2) to perform research in clinical anatomy, (3) to promote our view that rheumatology training programs should have a clinical anatomist on staff, (4) to participate in musculoskeletal US courses, (5) to foster friendship among colleagues from different countries, and (6) to nurture humanism in rheumatology. The workshop Our educational method was developed by Robert A. Kalish and Juan J. Canoso and has been refined for over a decade [11]. It represents the fusion of regular case discussions, a case-centered anatomical analysis, and the demonstration, by cross-examination between participants and instructors, of the relevant anatomical items. Our seminars deal primarily with regional limb anatomy. The discussed cases are familiar conditions such as a trigger finger, rheumatoid tenosynovitis, or carpal tunnel syndrome. Regardless of their complexity, every case summarizes a real patient we have seen in our practices, so they always represent rheumatic conditions or their mimics and reflect reality. Emphasis is placed on the soft tissues rather than the joints or bones. Skin creases, the superficial and deep fascia, and specialized dense connective tissues such as pulleys, muscles, tendons, ligaments, and bursae receive detailed attention. Injection techniques, while not the main topic in the workshop, are often discussed to enhance the interest of the participants. Here is an example: Step 1 Case presentation: A woman with long-lasting rheumatoid arthritis presents with intermittent tingling and numbness on her right thumb, index, and middle fingers. Step 2 Anatomical illustrations are shown on the screen that depict the sensory innervation of the hand, the position of the median nerve in the forearm, and its relation to the tendons of
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palmaris longus and flexor carpi radialis, the bone insertions of the transverse carpal ligament, as well as the elements enclosed in the carpal tunnel. Step 3 Participants and instructors identify by crossexamination the discussed structures in their own arms and on their partners. This is done in groups with a participant to instructor ratio no larger than 10:1. In reference to the carpal tunnel syndrome, we describe and identify the muscles involved in the movements of the thumb while we remind the attendees which of these are innervated by the median nerve; we then emphasize and identify the bone attachments of the transverse carpal ligament: the pisiform and scaphoid tubercle, the crest of the trapezium, and the hook of the hamate. We then move to touch the tendons in the distal forearm: flexor carpi ulnaris, flexor digitorum superficialis and profundus, palmaris longus, and flexor carpi radialis, as we depict the closeness of the median nerve to the latter two. Step 4 A simulated injection for carpal tunnel syndrome via the ulnar bursa is shown, emphasizing relevant superficial landmarks. This exercise is participative rather than theoretical and differs greatly from the traditional teaching of anatomy. We shy away from complex clinical discussions and in particular the discussion of therapies, many of which are controversial in the regional pain syndromes. The focus is always the anatomy. We encourage participants to bring loose casual clothing and sandals as the instructors do, so that everyone, teachers and attendees, becomes a model for others. While this close interaction brings to reality the all-important issue of anatomical variation, it also makes the workshop both light and fun. It could not be otherwise; these are lengthy sessions that usually extend no less than 7–8 h. Research projects and future perspectives We initially focused on determining the degree of practical clinical anatomy knowledge among rheumatologists and rheumatology residents. A pre-workshop evaluation was held on 170 participants from six of our seminars in Latin America plus one in the USA. The evaluation tool consisted of the identification or demonstration of action of key anatomical elements in the examiners’ and participants’ own bodies. These exams took place on a one to one basis. This study showed that among those evaluated, there is a significant lack of knowledge of basic clinical anatomy which is of central importance in rheumatologic assessment and diagnosis, particularly in the regional pain syndromes [2]. Additionally, our workshop appeared to increase self-assessed competence in musculoskeletal evaluation according to an online survey that was completed by 76.4 % of the participants [12]. We are currently analyzing the results of a study in which we evaluated the impact of our workshop, as an educational intervention, on the competence in musculoskeletal examination among rheumatology and orthopedic residents in Mexico City. Several additional
Clin Rheumatol (2015) 34:1157–1163
investigations are in different phases of completion, all in the field of anatomy as it applies to rheumatology. In summary, 6 years after its creation, GMAC has become a solid group of friends that love and teach clinical rheumatology. We have promoted in several countries, among many people, our view that clinical anatomy is a core foundation of the expertly performed rheumatologic physical examination. The enthusiasm of the participants has been striking and uniform. We have received consistent feedback from participants after completion of the workshop that they consider an improved knowledge of clinical anatomy important and necessary. Beyond the fact that clinical anatomy is an essential precursor for those interested in learning musculoskeletal ultrasound, we have endorsed the view that interlacing clinical anatomy with musculoskeletal ultrasonography potentiates the capacity of this diagnostic tool. In the spirit of this being one of several methods presented in this publication, GMAC looks forward to persisting in its quest to positively impact others' attitudes and knowledge of clinical anatomy while at the same time learning from and collaborating with others who teach clinical anatomy and musculoskeletal US.
Disclosures None.
References 1.
Freedman KB, Bernstein J (2002) Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am 84A:604–8 2. Navarro-Zarza J, Hernández-Díaz C, Saavedra M, AlvarezNemegyei J, Kalish R, Canoso JJ, Villaeñor-Ovies P (2014) Preworkshop knowledge of musculoskeletal anatomy of rheumatology fellows and rheumatologists of seven North, Central and South American countries. Arthritis Care Res 66:270–6. doi:10. 1002/acr.22114 3. Savvas S, Panush RS (2015) Should all rheumatologists study musculoskeletal anatomy? Clin Rheumatol, http://link.springer.com/ journal/10067. Accessed 26 April 2015. doi:10.1007/s10067-0152944-8 4. Kissin EY, Niu J, Balint P, Bong D, Evangelisto A, Goyal J, Higgs J, Malone D, Nishio MJ, Pineda C, Schmidt WA, Thiele RG, Torralba KD, Kaeley GS (2013) Musculoskeletal US training and competency assessment program for rheumatology fellows. J US Med 32(10):1735–43. doi:10.7863/ultra.32.10.1735 5. Cannella AC, Kissin EY, Torralba KD, Higgs JB, Kaeley G (2014) Evolution of musculoskeletal US in the United States: implementation and practice in rheumatology. Arthritis Care Res 55(1):7–13 6. Craig M, Craig M (2006) Essentials of sonography in patient care. Saunders, St Louis, pp 31–37 7. Bureau NJ, Beauchamp M, Cardinal E, Brassard P (2006) Dynamic sonography evaluation of shoulder impingement syndrome. AJR 187(1):216–20 8. Baltarowich OH, Di Salvo DN, Scoutt LM, Brown DL, Cox CW, DiPietro MA, Glazer DI, Hampter UM, Manning MA, Nazarian LN, Neutze JA, Rombero M, Stephenson JW, Dubinsky TJ (2014) National US curriculum for medical students. US Quarterly 30:13–19
Clin Rheumatol (2015) 34:1157–1163 9.
Wright SA, Bell AL (2008) Enhancement of undergraduate rheumatology teaching through the use of musculoskeletal US. Rheumatology 47:1564–6 10. Kalish RA, Canoso JJ (2007) Clinical anatomy: an unmet agenda in rheumatology training. J Rheumatol 34:1208–11 11. Kalish RA, Canoso JJ (2012) Development of the seminar. Reumatología Clínica 8:10–12
1163 12.
Saavedra MÁ, Navarro-Zarza JE, Alvarez-Nemegyei J, Canoso JJ, Kalish RA, Villaseñor-Ovies P, Hernández-Díaz C (2014) Selfassessed efficacy of a clinical musculoskeletal anatomy workshop: a preliminary survey. Reumatol Clin. doi:10.1016/j.reuma.2014.11. 003
REVIEW ARTICLE
Teaching of clinical anatomy in rheumatology: a review of methodologies Karina D. Torralba 1 & Pablo Villaseñor-Ovies 2 & Christine M. Evelyn 3 & R. Michelle Koolaee 3 & Robert A. Kalish 4
Received: 21 May 2015 / Accepted: 23 May 2015 / Published online: 3 June 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract Clinical anatomy may be defined as anatomy that is applied to the care of the patient. It is the foundation of a wellinformed physical examination that is so important in rheumatologic practice. Unfortunately, there is both documented and observed evidence of a significant deficiency in the teaching and performance of a competent musculoskeletal examination at multiple levels of medical education including in rheumatology trainees. At the Annual Meeting of the American College of Rheumatology in Boston, MA, that took place in November 2014, a Clinical Anatomy Study Group met to share techniques of teaching clinical anatomy to rheumatology fellows, residents, and students. Techniques that were reviewed included traditional anatomic diagrams, hands-on cross-examination, cadaver study, and musculoskeletal ultrasound. The proceedings of the Study Group section are described in this review.
* Robert A. Kalish [email protected] 1
Division of Rheumatology, Department of Medicine, Loma Linda University, Loma Linda, USA
2
Centro de Ciencias de la Salud, Escuela de Medicina, Universidad Autónoma de Baja California, Hospital Angeles de Tijuana, Tijuana, Mexico
3
Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA
4
Division of Rheumatology, Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St Box 599, Boston, MA 02111, USA
Keywords Clinical anatomy . Medical education . Musculoskeletal ultrasound . Physical examination
Introduction BDoctor, I have never had such a thorough physical examination as this.^ The tone is one of thanks, or maybe surprise or relief. It is rarely voiced as a complaint that the examination was too long or careful. Rheumatologists probably hear this statement more often than other physicians, and it comes as a small but gratifying reward for work that otherwise yields scarce relative financial gain and consumes precious time. Unfortunately, there is abundant evidence that we are falling far short in teaching skills in musculoskeletal examination and rheumatologic clinical anatomy to our trainees at all levels including our fellows [1, 2]. What can we do to make sure this statement is one we continue to hear? We see patients who describe pain and multiple other sensations that only they feel and that we can only strain to comprehend. Is a symptom originating from the joints, the bones, the nerves, or the Bsoft tissues^ around the joints and bones? Or is it a splenic infarct radiating pain to the suprascapular region? As part of trying to figure that out, we relate what we hear from the patient to what we know from our own experiences with pain and that which we have learned from previous patients in whom we eventually were able to correlate a certain symptom with pathology. However, important as a skilled history and nuanced interpretation is in determining the root of a patient’s symptoms, it is a deeper knowledge of clinical anatomy that provides the key additional tool for a more cost-effective and efficient diagnostic plan and a greater chance at uncovering the underlying etiology.
1158
Clinical anatomy may be defined as anatomy applied to the care of the patient—care that includes not only proper diagnosis and judicious test ordering but also the human connection with the patient. Clinical anatomy is the foundation of a well-informed physical examination. For the rheumatologist, it is a lifeblood. Using knowledge of anatomy as a road map, we examine our patients to understand their symptoms and uncover their pathology. But the touch of the rheumatologist performing a sincere physical examination accomplishes much more. Humans are wired to feel soothed by touch when touch is intended to sooth or heal, with physicians having the potential to do both. Even when touch hurts such as when palpating an inflamed joint, the patient is most often forgiving, knowing that touch is for discovery whose goal is diagnosis and relief. When the patient does not show forgiveness and instead expresses anger or hurt with voice or body language, the physician may be learning key information about that patient’s life experiences and emotional state and should immediately take notice as well as take the cue to stop or move on. The Clinical Anatomy Study Section that took place in Boston in November 2014 during the American College of Rheumatology’s Annual Meeting provided an important initial forum for the sharing of novel methodologies being utilized to teach clinical anatomy to rheumatology fellows and other levels of learners. Three speakers outlined innovative programs for teaching clinical anatomy; their presentations and methods are presented in this published symposium. Dr. Karina Torralba describes a 2-month-long teaching program in clinical anatomy at Loma Linda University that occurs early in the academic year, and integrates physical examination, plain film radiography, and musculoskeletal ultrasound (US). Emphasis is placed on the evidence-based literature pertaining to physical and ultrasound examination of patients with specific conditions. Didactic programs for residents and medical students at Loma Linda are also presented. Dr. Christine Evelyn presents the program which she and Dr. Koolaee supervise and Dr. Torralba helped develop at Los Angeles County—University of Southern California for the rheumatology fellows. This program includes nine lectures focusing on regional anatomy and its importance in clinical diagnosis, monthly fresh cadaver prosection, and instruction on joint injection as well as a weekly ultrasound clinic focusing on the diagnosis and treatment of common conditions seen in the practicing rheumatologist’s office. Lastly, Dr. Pablo Villaseñor-Ovies presents the method of teaching clinical anatomy developed and practiced by members of the Mexican Group for the Advancement of Clinical Anatomy (GMAC). This group, formed and inspired by Dr. Juan Canoso in Mexico City, has implemented workshops in clinical anatomy that have been presented in numerous countries throughout the Americas that feature region by region anatomical teaching using case vignettes, traditional anatomic diagrams, and participant cross-examination.
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In an accompanying editorial [3], Drs. Stavros and Panush eloquently emphasize the central importance of clinical anatomy to the rheumatologist and our patients but also directly challenge us to demonstrate and prove that clinical anatomy leads to the beneficial outcomes we claim. They demand that we try to answer such questions as Bdoes a deeper knowledge of clinical anatomy inform a physical examination that saves money for the health care system, inspire confidence from and connection to the patient, and lead to gratification for the physician?^ Their editorial shakes the ground of selfcongratulations and entitlement that is easy to fall into when one is immersed in one’s own fascination and passion as we are with clinical anatomy. They insist that we go a big step further in proving the value of clinical anatomy to those who may not share this interest and those who must determine what gets paid for. We have not yet met Drs. Stavros’ and Panush’s challenge to prove efficacy and outcomes, but we hope this type of conversation and sharing of teaching methodologies among a group with a common goal and passion for clinical anatomy will lead to increased awareness of the importance of training our fellows to become experts in this area and engender the type of rigorous collaborative medical education and outcome studies that will enable us to accomplish this.
The Loma Linda University experience: clinical anatomy and US from medical school, residency, to fellowship Rheumatology fellowship teaching It definitely helps that a review of musculoskeletal clinical anatomy is done early in fellowship training. There seems to be a wide variation in how knowledge in this area is reinforced during residency. For our fellowship program, we conduct within the first 2 months a series of didactic and workshop sessions that integrate physical examination, plain film radiography, and joint-based US (Table 1). We hold evidence-based medicine-formatted conferences to examine the medical literature on the usefulness and limitations of physical examination of particular conditions in specific patient cases especially as it correlates with various radiographic imaging modalities, or to look at the application of US in the evaluation of pathologic anatomic structures in the setting of rheumatic diseases. US clinics at our faculty medical offices focus on joint-based examination to evaluate joint complaints of new patients, to evaluate response of patients with inflammatory arthropathies to treatments, and to do US-guided procedures. Some fellows have participated in the US School of North American Rheumatologists (USSONAR) program [4], particularly in their second year, which we find does enhance the competency of fellows in this modality and appears to give them a more rapid pace of independence. We have found that fellows go on to master anatomy through the use of US and have a better
Clin Rheumatol (2015) 34:1157–1163 Table 1 The LAC-USC and LLU rheumatology fellowship programs have similar educational frameworks on clinical anatomy teaching with radiologic imaging correlations. Described below are the general and
1159 specific tasks expected for fellows for part of the ankle joint anatomy. Cadaveric visualization is encouraged for programs that have access to fresh tissue laboratories
Musculoskeletal anatomy teaching program General tasks • Review relevant anatomy including bones, tendons, and neurovascular structures • Review functions of each structure • Correlate US appearance to plain film/X-ray appearance • Correlate US anatomy to cadaveric anatomy • Understand approaches to palpation-guided injections and US-guided injections • Apply current US definitions of pathology and applications in disease management Medial ankle joint and tibiotalar joint Anatomy to identify Posterior tibialis tendon Flexor digitorum longus tendon Flexor hallucis longus tendon
Posterior tibial artery, vein, and nerve Tibiotalar joint
understanding of the pathophysiology of inflammatory arthropathies and soft tissue pathology. It is important to remember that the goal in incorporating US is not to develop technicians but to enhance the proficiency of rheumatologists by using US as one of the many tools that we use in the evaluation and management of rheumatic diseases [5]. An US probe for a rheumatologist is comparable to that of a stethoscope for a cardiologist. In the context of education theory, US provides a platform for active learning and subsequent potential critical thinking; it also substantially helps learners who have predominantly visual learning styles, instead of using traditional models of learning where memorization has been the standard [6]. Internal medicine resident teaching Our division also holds twice-yearly interactive (IEL) sessions with internal medicine residents with the goal of having residents improve on their rheumatologic physical examination, and palpation-guided joint aspiration and injection techniques. These sessions are done with a mixture of didactics and workshops covering demonstration of these skills, and enhanced with the use of US. For example, the shoulder module can cover a review of vital structures and common joint and soft tissue pathology, physical examination demonstration, and dynamic ultrasonography showing direct relationships between the acromion, humeral head, and intervening soft tissues, followed by an US video of impingement syndrome in a patient [7].
Specific tasks √ Review relevant bony anatomy and tendon location √ Review tendon origins, insertions, and functions √ Review definitions of tendon abnormalities by US √ Visualize by US √ Visualize if possible on cadaver √ Visualize using US √ Visualize if possible on cadaver √ Review bony anatomy relevant to overlying structures √ Identify on cadaver and practice injection (with saline) √ Visualize using US (transverse and longitudinal views) √ Review synovial effusion and synovitis appearance on US
Medical student teaching Loma Linda University School of Medicine (LLUSM) is one of several medical schools in the country that have included US in their curriculum [8]. Rheumatology-related US programs have been successfully implemented in undergraduate curricula to address issues related to teaching normal and abnormal anatomy [9]. Of all student special interest groups at LLUSM the largest is the Ultrasound Student Interest Group, comprised of at least 150 members, advised by Dr. Vi Dinh. Every February, they hold an UltraFest which is a 1-day symposium aimed at introducing medical students to point of care US on many organ systems (Table 2). For the 2015 UltraFest, 200 medical students from various schools had signed up along with over 60 physician instructors from medical schools in California and Tennessee. Hands-on training with live models and specialized simulation models were used. Our division along with one orthopedist spearheaded the Musculoskeletal Module. For almost all of the students, this was their first experience in musculoskeletal US. The primary goal was to have students become familiar with the appearance of musculoskeletal structures on US as it correlates with clinical anatomy and physical examination. We chose to focus on the knee joint to look at tendons, muscles, cartilage, bone, and the volar wrist area to allow examination of the median nerve. A brief 15-min lecture covering US appearances of these structures and corresponding physical exam was followed by a 30-min hands-on live model workshop session with a faculty member (one faculty to two to three students) (Fig. 1).
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Table 2 LLU UltraFest 2015 Musculoskeletal Module: educational framework (teaching method, time allocation, goals, and objectives) for this activity Teaching method
Time allocation
Didactic session 10 min Goals The goal of this activity is to have medical students understand (1) the appearance of normal musculoskeletal structures on US and correlate with clinical anatomy, (2) the basic musculoskeletal pathology with clinical and sonographic correlations, and (3) the indications and uses for MSUS scanning. Hands-on live model scanning workshop 40 min Objectives By the end of the module, students are expected to be familiar with the following: 1) Identification of skin and subcutaneous fat 2) Identification of quadriceps muscle 3) Identification of bone: femur and patella 4) Identification of quadriceps and patellar tendons (emphasize anisotropy) 5) Identification of median nerve—anterior wrist longitudinal and transverse views 6) Basic knee evaluation a. Anterior knee (suprapatellar + infrapatellar long): quads tendon, femur, fat pad, and suprapatellar bursa b. Maximal flexion view: transverse and longitudinal femoral cartilage c. Lateral longitudinal: lateral collateral ligament, femur, and fibula d. Medial longitudinal: medial collateral ligament, femur, tibia, medial meniscus, and anserine bursa e. Infrapatellar longitudinal: patellar tendon and fat pad f. Posterior: medial head of gastrocnemius; popliteal artery, nerve, and vein; and Baker’s cyst if present, or at least identify where it should be found
The Los Angeles County—University of Southern California Rheumatology Fellowship Program Rheumatology fellowship programs must present an everexpanding educational menu, during a 2-year fellowship, often leaving little time for the study of MS anatomy. Due to improvement in treatment protocols for gout and rheumatoid
arthritis, current fellows have fewer opportunities to aspirate and inject joints. The use of US, now available in many rheumatology training programs, may be capable of bridging this deficit in anatomic training. At the Los Angeles County—University of Southern California (LAC-USC), anatomy is taught using three broad approaches. This includes classroom didactics, fresh specimen lab sessions using cadavers, and hands-on practice using musculoskeletal US (Table 1). Assessment of fellow knowledge and their satisfaction with their ability to do physical exam and joint-based procedures are asked during the course of the learning process (Table 3). The core curriculum includes several lectures dedicated to reviewing basic musculoskeletal anatomy, along with scenarios of how knowledge of this anatomy is helpful in clinical practice. This information is reinforced during monthly fresh specimen lab sessions, where fellows can identify and review the relevant anatomy, as well as practice intra-articular injections. The US curriculum is robust and consists of a weekly US clinic supervised by two rheumatologists proficient in musculoskeletal US. Fellows are provided with didactic resources (including instructional videos) to review prior to each clinic, which identify relevant anatomy and pathology on US. During this clinic, not only do they have another opportunity to learn anatomy, but fellows have the chance to see firsthand the diagnostic and therapeutic benefits of US. Furthermore, they gain an understanding of how anatomy knowledge is critical for the care of our patients. Lastly, an US workshop is conducted annually (early on in the academic year) for the fellows. This consists of two 4-h sessions and includes a comprehensive review of musculoskeletal anatomy, and reviews this anatomy (as well as pathology) using US. Fellows have ample opportunity during this workshop to practice using the US. This strategy at LAC-USC incorporates both classroom didactics and hands-on practice in order to most effectively teach basic anatomy. Table 3 The following are some ankle anatomy-related questions asked of USC fellows to assess what they have learned in the curriculum. Items 1–5 are asked with a 5-item Likert scale (strongly disagree–strongly agree), while the other questions are free-form questions asked during preceptorship 1. I feel comfortable diagnosing the presence of an ankle effusion. 2. I feel comfortable aspirating or injecting the ankle. 3. I feel comfortable teaching how to aspirate the ankle. 4. I feel comfortable diagnosing subtalar joint dysfunction. 5. I feel comfortable identifying the location of the subtalar joints. 6. Name the structures in the Btarsal tunnel.^
Fig. 1 Loma Linda University Rheumatology Fellows Dr. Chau Nguyen and Dr. Michelle Ngo (both on left, with the former in the foreground) show medical students physical and sonographic examination of the knee at UltraFest 2015
7. Which type of ankle sprain (medial or lateral) is most common? 8. What type of ankle deformity is common in patients with long standing rheumatoid arthritis & what causes it?
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The Mexican Group for the Advancement of Clinical Anatomy Many times in my career have I heard the exhortatory statement Brheumatologists are experts in joint examination,^ yet experience has shown me that most rheumatologists focus their joint examinations on detecting joint effusions and synovitis and pay little consideration to other indispensable elements of the musculoskeletal evaluation. The Bjoint count homunculus^ sums up the anatomy a rheumatologist would need to know if joint synovitis was the only clinical information needed to evaluate patients with rheumatic diseases. All members of the Mexican Group for the Advancement of Clinical Anatomy (GMAC) are practicing rheumatologists convinced that knowing clinical anatomy improves the skills that are needed in the care of rheumatic disease patients. After all, this is what defines clinical anatomy—a science that emphasizes those aspects of structure and function of the human body that aid the practice of medicine [10]. We became an organized group in February of 2009, after Dr. Juan Canoso mesmerized some of us during a series of rheumatologic clinical anatomy workshops that he presented in Mexico in 2007. I was there as a fellow and I still feel very lucky to have received these teachings, as he opened my eyes to a whole new way of examining patients that emphasized a thorough appreciation of the structure and function of the musculoskeletal system. The rheumatic physical exam suddenly became much more than the joint exam. Dr. Canoso made us realize that joints enclose menisci, labra, ligaments, and fat pads, and these are in turn surrounded by tendons, ligaments, bursae and fasciae, all of which may be the anatomical source of discomfort in the rheumatic diseased patient. Some of us desired to learn more about this Bnew^ knowledge and together pressed Juan to create a group in which we could learn and then become teachers. He accepted, and for almost 2 years, we gathered in his dining room for lengthy Saturday morning sessions in which we would learn and practice clinical anatomy. In 2010, our group received a grant from the International League Against Rheumatism (ILAR) which allowed us to give the workshop in different countries. To this date, 34 clinical anatomy seminars have been given in ten Latin American countries, Spain, and the USA, accounting for roughly 900 participants (Table 4). In addition, two short versions of the seminar have been presented at the ACR meetings since 2005 to the present (JC, RAK, and PV-O). Most of the attendees have been practicing rheumatologists, but rheumatology residents and other specialists such as internists, physiatrists, and physical therapists were often present. Along these years, we have received uniformly positive feedback on the seminar, which harmonizes with the results of a qualitative survey that followed the 2007 seminars (Kalish R, Canoso JJ, unpublished data) in which the workshop was considered practical, easy to digest, interactive, dynamic, interesting, and fun.
1161 Table 4 GMAC seminars 2009–2014
Country Argentina Brazil Chile Colombia El Salvador Ecuador Honduras México Uruguay USA Panama Spain Total
Number of seminars 4 5 1 1 1 1 3 7 2 3 1 1 30
Objectives of GMAC Our primary goal is to promote the study of clinical anatomy among rheumatologists. The specific goals that have steered our group’s activities in the last 5 years are (1) to learn and teach clinical anatomy, (2) to perform research in clinical anatomy, (3) to promote our view that rheumatology training programs should have a clinical anatomist on staff, (4) to participate in musculoskeletal US courses, (5) to foster friendship among colleagues from different countries, and (6) to nurture humanism in rheumatology. The workshop Our educational method was developed by Robert A. Kalish and Juan J. Canoso and has been refined for over a decade [11]. It represents the fusion of regular case discussions, a case-centered anatomical analysis, and the demonstration, by cross-examination between participants and instructors, of the relevant anatomical items. Our seminars deal primarily with regional limb anatomy. The discussed cases are familiar conditions such as a trigger finger, rheumatoid tenosynovitis, or carpal tunnel syndrome. Regardless of their complexity, every case summarizes a real patient we have seen in our practices, so they always represent rheumatic conditions or their mimics and reflect reality. Emphasis is placed on the soft tissues rather than the joints or bones. Skin creases, the superficial and deep fascia, and specialized dense connective tissues such as pulleys, muscles, tendons, ligaments, and bursae receive detailed attention. Injection techniques, while not the main topic in the workshop, are often discussed to enhance the interest of the participants. Here is an example: Step 1 Case presentation: A woman with long-lasting rheumatoid arthritis presents with intermittent tingling and numbness on her right thumb, index, and middle fingers. Step 2 Anatomical illustrations are shown on the screen that depict the sensory innervation of the hand, the position of the median nerve in the forearm, and its relation to the tendons of
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palmaris longus and flexor carpi radialis, the bone insertions of the transverse carpal ligament, as well as the elements enclosed in the carpal tunnel. Step 3 Participants and instructors identify by crossexamination the discussed structures in their own arms and on their partners. This is done in groups with a participant to instructor ratio no larger than 10:1. In reference to the carpal tunnel syndrome, we describe and identify the muscles involved in the movements of the thumb while we remind the attendees which of these are innervated by the median nerve; we then emphasize and identify the bone attachments of the transverse carpal ligament: the pisiform and scaphoid tubercle, the crest of the trapezium, and the hook of the hamate. We then move to touch the tendons in the distal forearm: flexor carpi ulnaris, flexor digitorum superficialis and profundus, palmaris longus, and flexor carpi radialis, as we depict the closeness of the median nerve to the latter two. Step 4 A simulated injection for carpal tunnel syndrome via the ulnar bursa is shown, emphasizing relevant superficial landmarks. This exercise is participative rather than theoretical and differs greatly from the traditional teaching of anatomy. We shy away from complex clinical discussions and in particular the discussion of therapies, many of which are controversial in the regional pain syndromes. The focus is always the anatomy. We encourage participants to bring loose casual clothing and sandals as the instructors do, so that everyone, teachers and attendees, becomes a model for others. While this close interaction brings to reality the all-important issue of anatomical variation, it also makes the workshop both light and fun. It could not be otherwise; these are lengthy sessions that usually extend no less than 7–8 h. Research projects and future perspectives We initially focused on determining the degree of practical clinical anatomy knowledge among rheumatologists and rheumatology residents. A pre-workshop evaluation was held on 170 participants from six of our seminars in Latin America plus one in the USA. The evaluation tool consisted of the identification or demonstration of action of key anatomical elements in the examiners’ and participants’ own bodies. These exams took place on a one to one basis. This study showed that among those evaluated, there is a significant lack of knowledge of basic clinical anatomy which is of central importance in rheumatologic assessment and diagnosis, particularly in the regional pain syndromes [2]. Additionally, our workshop appeared to increase self-assessed competence in musculoskeletal evaluation according to an online survey that was completed by 76.4 % of the participants [12]. We are currently analyzing the results of a study in which we evaluated the impact of our workshop, as an educational intervention, on the competence in musculoskeletal examination among rheumatology and orthopedic residents in Mexico City. Several additional
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investigations are in different phases of completion, all in the field of anatomy as it applies to rheumatology. In summary, 6 years after its creation, GMAC has become a solid group of friends that love and teach clinical rheumatology. We have promoted in several countries, among many people, our view that clinical anatomy is a core foundation of the expertly performed rheumatologic physical examination. The enthusiasm of the participants has been striking and uniform. We have received consistent feedback from participants after completion of the workshop that they consider an improved knowledge of clinical anatomy important and necessary. Beyond the fact that clinical anatomy is an essential precursor for those interested in learning musculoskeletal ultrasound, we have endorsed the view that interlacing clinical anatomy with musculoskeletal ultrasonography potentiates the capacity of this diagnostic tool. In the spirit of this being one of several methods presented in this publication, GMAC looks forward to persisting in its quest to positively impact others' attitudes and knowledge of clinical anatomy while at the same time learning from and collaborating with others who teach clinical anatomy and musculoskeletal US.
Disclosures None.
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