GLANVILLE ET AL.: TEACHING RHEUMATOLOGY
37
Third Part
In the third and last part of the course, namely the fifth year, students will go on attachment to district hospitals in the Region and during this time we hope that it will be possible for our colleagues in the district hospitals to give some time to die students and to see that each is allocated two or three patients who have rheumatic and rehabilitation problems. CONCLUSION I have tried to outline briefly the method by which we hope to achieve our objectives, which could perhaps be summarized as follows : (1) To interest students in the aftercare of patients recovering from illness, injury or even the effects of treatment. (2) To develop skills in assessment and in team work with medical, paramedical and non-medical colleagues. (3) To convey some information concerning the services and facilities available for rehabilitation, the work and skills of remedial therapists and the indications for and restrictions of remedial therapy, and (4) How to make use of what is available. It would be nice at this stage to be able to judge the extent of our success or failure but it is too soon. An encouraging sign has been that rehabilitation has had its share of applicants for electives, in spite of the very short exposure so far of students to the subject.
2. THE TEACHING OF PHYSIOTHERAPY TO UNDERGRADUATES MARGARET A. STEWART Principal of School of Physiotherapy and Group Superintendent Physiotherapist, King's Health District (Teaching), London
IN the training syllabus of the Chartered Society of Physiotherapy, rehabilitation is quoted as 'signifying the measures which may be taken to restore optimum function and to be a continuous process from the onset of disability to the point at which the patient achieves his greatest potential. The physiotherapist is a member of the team involved
Downloaded from http://rheumatology.oxfordjournals.org/ at Emory University on August 18, 2015
Employment Scheme and a School for Handicapped Children. Patients are allocated to students who have access to their notes and records and who discuss their progress and treatment with the people giving it, and the students take part in multi-disciplinary discussions at the end of the day and thus experience a rehabilitation service with all its ramifications at work. The second day is spent at Portsmouth, with Drs. Tyler and Nixon who teach on the problems of amputees, limb fitting, wheelchairs and transport for the disabled. They visit the Artificial Limb and Appliance Centre, a magnificent new E.R.U. and a unit for heavily disabled children, with a bias towards medical engineering. This first involvement of regional consultants and their units in teaching rehabilitation will grow as the medical school builds up to its full intake and is in line with the concept of the regional school. For elective studies students can choose almost any subject.
38
RHEUMATOLOGY AND REHABILITATION VOL. XV NO. 1
(/)
Patients with conditions which will be completely cured by treatment or those whose symptoms can be relieved for a significant period of time.
Downloaded from http://rheumatology.oxfordjournals.org/ at Emory University on August 18, 2015
from usually early on in this rehabilitation process, both in the hospital and increasingly in the community'. The physiotherapist will make an assessment of the patient's condition and select appropriate treatment from the methods available. These measures are designed to help patients regain and increase their physical abilities and give them the opportunity to achieve the maximum potential in activities at home, work and leisure. It is important therefore to decide the amount of detailed physiotherapy that should be taught to medical students and to resolve any differences of view about this that may exist between physiotherapists and members of the British Association of Rheumatology and Rehabilitation (B.A.R.R.). One needs to know whether or not the B.A.R.R., as a body, still thinks that 'all too often therapy is prescribed in general terms and important details such as frequency and progression of treatment as well as arranging for attendance at medical review clinics are left to the discretion of the physiotherapist'. This note (HM 62/18, 1962) is still in existence as official guidance though it would seem that many doctors themselves do not agree with it. Tunbridge in his report {Rehabilitation 1972) said too that 'surprisingly few doctors have sufficient experience in the range of modern occupational therapy, physiotherapy and remedial gymnastics to be able to prescribe in detail the most effective treatment, and those who have the necessary experience rarely have time to see the patient sufficiently frequently to vary the treatment as soon as the need arises'. The B.A.R.R., as one body concerned with rehabilitation, should publicize its views as to whether future doctors should be taught this kind of detail or whether it thinks they should be more concerned with principles and objectives of treatment rather than methodology. A physiotherapist is fortunate when she works alongside medical men and is treated by them as a colleague. In this situation knowledgeable doctors, understanding the conditions for which physiotherapy is, or is not, indicated, will discuss diagnosis and prognosis, but will leave the minutiae and management of treatment to the therapist. The experienced physiotherapist of 1975 thinks this a right and proper course of action which should bring about not only effective treatment for the patient but also professional satisfaction for the colleagues. If this kind of working relationship is accepted then it follows that medical undergraduates must know the essential purposes of physiotherapy, i.e. what physiotherapy can do if properly prescribed and properly applied. Physiotherapy can: (1) Prevent deformity and contracture. (2) Initiate a muscle contraction, strengthen a muscle progressively or maintain existing strength in muscles. (3) Maintain joint range or increase joint mobility. (4) Improve respiratory efficiency. (5) Channel all physical measures mentioned towards the achievement of possible function. (6) Relieve pain. This is mentioned last for, though undoubtedly this is most important for the patient, there certainly will be situations in which other methods will be cheaper and as effective. In order to emphasize these points to medical students, a very basic syllabus can be drawn up to illustrate the important situations where physiotherapy is effective and essential. For convenience it can be divided into three categories, showing broad groups of patients who will benefit from physiotherapy:
GLANVILLE ET AL.: TEACHING RHEUMATOLOGY
39
Downloaded from http://rheumatology.oxfordjournals.org/ at Emory University on August 18, 2015
(«) Patients with residual disability which significantly affects their physical capability. («7) So-called 'chest' patients, particularly those who are in-patients. Medical students can then be shown illustrative treatments for patients in category (/) using as models those who have had, for example, traumatic injuries such as fracture, or soft tissue damage. The principles of treatment to be emphasized will be the same whatever the condition chosen—maintenance of range, prevention of stiffness, retardation of atrophy, progressive muscle strengthening and recovery of full function. The need for the early referral of these patients is stressed and the effectiveness of treatment where this is done is contrasted with the likely stiffness and weakness resulting in a 'latestarter'. The second part of a basic syllabus for undergraduates could include the principles of treatment of patients who have heavy residual disabilities. These principles are the same as in category (/), i.e. early referral after onset, prevention of contractures and the need to develop the patient's maximum potential despite his disability. The management of neurological patients will illustrate these points and the early treatment of the 'stroke' patient may be contrasted with the salvage measures necessary when established spasticity and contracture may have produced major rehabilitation problems. The prevention of needless deformity can be shown in the treatment of patients with multiple sclerosis or head injury, and the full re-training of the paraplegic patient following spinal injury will demonstrate the achievement of maximum potential. The treatment of the third main category of patients relates to those with chest conditions. The educational programme should stress the conditions where physiotherapy can help, and advice should be given to students on the avoidance of wasteful physiotherapy which can so often happen with in-patients. Information given might include the demonstration of drainage of secretions from the chest, the effective use of a ventilator and a summary of those activities in which the patient can participate himself. It is the writer's personal view that all rehabilitation (including physiotherapy) should be taught in context and should be closely linked with the students' other instruction in the various branches of medicine. There should be, from the beginning, an association in the student's mind between physiotherapy and all the other aspects of patient care. Thus the physiotherapy for 'stroke' should be included as part of neurological teaching, that for fractures and joint injuries when on the accident/emergency speciality, rheumatoid arthritis with rheumatology, and so on. At the present time, the teaching of physiotherapy to medical students throughout the country is haphazard and follows no common pattern. There may be no instruction at all or the tuition offered may range from single lectures or demonstrations to the participation by the physiotherapist as one of a panel of experts in topic-teaching sessions. Where instruction is formally organized it is usually within the framework of the orthopaedic or rheumatology curriculum. At King's College Hospital there is a joint Orthopaedic and Traumatic Surgery/ Rheumatology and Rehabilitation firm, and once a week teaching time is allocated by the latter consultants to members of the remedial professions. Experienced clinical physiotherapists are enabled to teach and demonstrate on patients within the categories described already. This method seems to have been the most successful of those that have so far been tried, but one acknowledges the disadvantage that, once again, physiotherapy —or rehabilitation—is taught as something on its own. In conclusion, it is suggested that medical students should be taught the main indications and limitations of physiotherapy, and teaching should be within an integrated system so that physiotherapy and rehabilitation are not considered in isolation.
40
RHEUMATOLOGY AND REHABILITATION VOL. XV NO. 1 REFERENCES
HM 62/18 (1962) Note: The Provision of Physiotherapy in Hospitals. Ministry of Health: Central Health Services Council Standing Medical Advisory Committee. Rehabilitation: Report of a Sub-committee of the Standing Medical Advisory Committee (1972) London: H.M.S.O.
3. UNDERGRADUATE TEACHING OF RHEUMATOLOGY BY V. WRIGHT
THIS contribution is not a directive on how rheumatology should be taught, but a description of what is done at the University of Leeds and the reasons behind the course. In every Medical School there are constraints that mould the programme, so that one has sympathy for the battered boxer who gasped to his second in between rounds, 'Couldn't we forget the strategy, and just fight for our lives ?' The great constraint is rinding time in an overcrowded curriculum, so that while rheumatology should most properly be taught in the context of general medicine, it may be easier to slot it into the block of orthopaedic teaching. The one other point to emphasize in a time of financial stringency, when Universities are reluctant to spend money on anything other than undergraduate teaching, is that 'he who learns from a teacher not actively engaged in research drinks from a stagnant pond' (Truscott: Red Brick University).
MATERIAL At Leeds, rheumatological teaching is undertaken in the third, fourth and fifth years. In the third year there is an Introductory Lecture beginning with some well chosen remarks on the importance of the subject (such as the fact that it will figure prominently in the Finals Examination), continuing with the prizewinningfilmProblems In Living (demonstrating the impact of rheumatoid arthritis on the lives of individual sufferers), a short television presentation on history-taking and an opportunity for questions. There is also an intensive three weeks of integrated teaching on the locomotor system with rheumatologists, orthopaedic surgeons, anatomists, bioengineers, pathologists, biochemists and remedial staff members. The organization of the course bows down at the shrine of integrated teaching, and helps to dispel the illusion that a University is a series of departments held together by either a central heating system or a common grievance over parking. Some of the results from a questionnaire given to the students at the conclusion of the course are shown in Table I. It will be seen that while students appreciated the integration of the material, they did not favour the integration of the participants. To run a successful integrated course in which more than one staff member is present at each session demands so much time before and during the course that I do not think the gains are worth the pains. In the fourth year the students are taught for the final 10 days of an orthopaedic block infirmsof up to 12 members. This is the crucial period and will be discussed in more detail. In the fifth year, tutorials on the ward are conducted once a week throughout the year, and students must attend two of those in rheumatology—no more than 12 students being taken at any one time (first come, first served). During an elective period of two months, rheumatology may be selected for all or part of this time. The students become
Downloaded from http://rheumatology.oxfordjournals.org/ at Emory University on August 18, 2015
Professor of Rheumatology, University of Leeds, Leeds LS2 9JT
37
Third Part
In the third and last part of the course, namely the fifth year, students will go on attachment to district hospitals in the Region and during this time we hope that it will be possible for our colleagues in the district hospitals to give some time to die students and to see that each is allocated two or three patients who have rheumatic and rehabilitation problems. CONCLUSION I have tried to outline briefly the method by which we hope to achieve our objectives, which could perhaps be summarized as follows : (1) To interest students in the aftercare of patients recovering from illness, injury or even the effects of treatment. (2) To develop skills in assessment and in team work with medical, paramedical and non-medical colleagues. (3) To convey some information concerning the services and facilities available for rehabilitation, the work and skills of remedial therapists and the indications for and restrictions of remedial therapy, and (4) How to make use of what is available. It would be nice at this stage to be able to judge the extent of our success or failure but it is too soon. An encouraging sign has been that rehabilitation has had its share of applicants for electives, in spite of the very short exposure so far of students to the subject.
2. THE TEACHING OF PHYSIOTHERAPY TO UNDERGRADUATES MARGARET A. STEWART Principal of School of Physiotherapy and Group Superintendent Physiotherapist, King's Health District (Teaching), London
IN the training syllabus of the Chartered Society of Physiotherapy, rehabilitation is quoted as 'signifying the measures which may be taken to restore optimum function and to be a continuous process from the onset of disability to the point at which the patient achieves his greatest potential. The physiotherapist is a member of the team involved
Downloaded from http://rheumatology.oxfordjournals.org/ at Emory University on August 18, 2015
Employment Scheme and a School for Handicapped Children. Patients are allocated to students who have access to their notes and records and who discuss their progress and treatment with the people giving it, and the students take part in multi-disciplinary discussions at the end of the day and thus experience a rehabilitation service with all its ramifications at work. The second day is spent at Portsmouth, with Drs. Tyler and Nixon who teach on the problems of amputees, limb fitting, wheelchairs and transport for the disabled. They visit the Artificial Limb and Appliance Centre, a magnificent new E.R.U. and a unit for heavily disabled children, with a bias towards medical engineering. This first involvement of regional consultants and their units in teaching rehabilitation will grow as the medical school builds up to its full intake and is in line with the concept of the regional school. For elective studies students can choose almost any subject.
38
RHEUMATOLOGY AND REHABILITATION VOL. XV NO. 1
(/)
Patients with conditions which will be completely cured by treatment or those whose symptoms can be relieved for a significant period of time.
Downloaded from http://rheumatology.oxfordjournals.org/ at Emory University on August 18, 2015
from usually early on in this rehabilitation process, both in the hospital and increasingly in the community'. The physiotherapist will make an assessment of the patient's condition and select appropriate treatment from the methods available. These measures are designed to help patients regain and increase their physical abilities and give them the opportunity to achieve the maximum potential in activities at home, work and leisure. It is important therefore to decide the amount of detailed physiotherapy that should be taught to medical students and to resolve any differences of view about this that may exist between physiotherapists and members of the British Association of Rheumatology and Rehabilitation (B.A.R.R.). One needs to know whether or not the B.A.R.R., as a body, still thinks that 'all too often therapy is prescribed in general terms and important details such as frequency and progression of treatment as well as arranging for attendance at medical review clinics are left to the discretion of the physiotherapist'. This note (HM 62/18, 1962) is still in existence as official guidance though it would seem that many doctors themselves do not agree with it. Tunbridge in his report {Rehabilitation 1972) said too that 'surprisingly few doctors have sufficient experience in the range of modern occupational therapy, physiotherapy and remedial gymnastics to be able to prescribe in detail the most effective treatment, and those who have the necessary experience rarely have time to see the patient sufficiently frequently to vary the treatment as soon as the need arises'. The B.A.R.R., as one body concerned with rehabilitation, should publicize its views as to whether future doctors should be taught this kind of detail or whether it thinks they should be more concerned with principles and objectives of treatment rather than methodology. A physiotherapist is fortunate when she works alongside medical men and is treated by them as a colleague. In this situation knowledgeable doctors, understanding the conditions for which physiotherapy is, or is not, indicated, will discuss diagnosis and prognosis, but will leave the minutiae and management of treatment to the therapist. The experienced physiotherapist of 1975 thinks this a right and proper course of action which should bring about not only effective treatment for the patient but also professional satisfaction for the colleagues. If this kind of working relationship is accepted then it follows that medical undergraduates must know the essential purposes of physiotherapy, i.e. what physiotherapy can do if properly prescribed and properly applied. Physiotherapy can: (1) Prevent deformity and contracture. (2) Initiate a muscle contraction, strengthen a muscle progressively or maintain existing strength in muscles. (3) Maintain joint range or increase joint mobility. (4) Improve respiratory efficiency. (5) Channel all physical measures mentioned towards the achievement of possible function. (6) Relieve pain. This is mentioned last for, though undoubtedly this is most important for the patient, there certainly will be situations in which other methods will be cheaper and as effective. In order to emphasize these points to medical students, a very basic syllabus can be drawn up to illustrate the important situations where physiotherapy is effective and essential. For convenience it can be divided into three categories, showing broad groups of patients who will benefit from physiotherapy:
GLANVILLE ET AL.: TEACHING RHEUMATOLOGY
39
Downloaded from http://rheumatology.oxfordjournals.org/ at Emory University on August 18, 2015
(«) Patients with residual disability which significantly affects their physical capability. («7) So-called 'chest' patients, particularly those who are in-patients. Medical students can then be shown illustrative treatments for patients in category (/) using as models those who have had, for example, traumatic injuries such as fracture, or soft tissue damage. The principles of treatment to be emphasized will be the same whatever the condition chosen—maintenance of range, prevention of stiffness, retardation of atrophy, progressive muscle strengthening and recovery of full function. The need for the early referral of these patients is stressed and the effectiveness of treatment where this is done is contrasted with the likely stiffness and weakness resulting in a 'latestarter'. The second part of a basic syllabus for undergraduates could include the principles of treatment of patients who have heavy residual disabilities. These principles are the same as in category (/), i.e. early referral after onset, prevention of contractures and the need to develop the patient's maximum potential despite his disability. The management of neurological patients will illustrate these points and the early treatment of the 'stroke' patient may be contrasted with the salvage measures necessary when established spasticity and contracture may have produced major rehabilitation problems. The prevention of needless deformity can be shown in the treatment of patients with multiple sclerosis or head injury, and the full re-training of the paraplegic patient following spinal injury will demonstrate the achievement of maximum potential. The treatment of the third main category of patients relates to those with chest conditions. The educational programme should stress the conditions where physiotherapy can help, and advice should be given to students on the avoidance of wasteful physiotherapy which can so often happen with in-patients. Information given might include the demonstration of drainage of secretions from the chest, the effective use of a ventilator and a summary of those activities in which the patient can participate himself. It is the writer's personal view that all rehabilitation (including physiotherapy) should be taught in context and should be closely linked with the students' other instruction in the various branches of medicine. There should be, from the beginning, an association in the student's mind between physiotherapy and all the other aspects of patient care. Thus the physiotherapy for 'stroke' should be included as part of neurological teaching, that for fractures and joint injuries when on the accident/emergency speciality, rheumatoid arthritis with rheumatology, and so on. At the present time, the teaching of physiotherapy to medical students throughout the country is haphazard and follows no common pattern. There may be no instruction at all or the tuition offered may range from single lectures or demonstrations to the participation by the physiotherapist as one of a panel of experts in topic-teaching sessions. Where instruction is formally organized it is usually within the framework of the orthopaedic or rheumatology curriculum. At King's College Hospital there is a joint Orthopaedic and Traumatic Surgery/ Rheumatology and Rehabilitation firm, and once a week teaching time is allocated by the latter consultants to members of the remedial professions. Experienced clinical physiotherapists are enabled to teach and demonstrate on patients within the categories described already. This method seems to have been the most successful of those that have so far been tried, but one acknowledges the disadvantage that, once again, physiotherapy —or rehabilitation—is taught as something on its own. In conclusion, it is suggested that medical students should be taught the main indications and limitations of physiotherapy, and teaching should be within an integrated system so that physiotherapy and rehabilitation are not considered in isolation.
40
RHEUMATOLOGY AND REHABILITATION VOL. XV NO. 1 REFERENCES
HM 62/18 (1962) Note: The Provision of Physiotherapy in Hospitals. Ministry of Health: Central Health Services Council Standing Medical Advisory Committee. Rehabilitation: Report of a Sub-committee of the Standing Medical Advisory Committee (1972) London: H.M.S.O.
3. UNDERGRADUATE TEACHING OF RHEUMATOLOGY BY V. WRIGHT
THIS contribution is not a directive on how rheumatology should be taught, but a description of what is done at the University of Leeds and the reasons behind the course. In every Medical School there are constraints that mould the programme, so that one has sympathy for the battered boxer who gasped to his second in between rounds, 'Couldn't we forget the strategy, and just fight for our lives ?' The great constraint is rinding time in an overcrowded curriculum, so that while rheumatology should most properly be taught in the context of general medicine, it may be easier to slot it into the block of orthopaedic teaching. The one other point to emphasize in a time of financial stringency, when Universities are reluctant to spend money on anything other than undergraduate teaching, is that 'he who learns from a teacher not actively engaged in research drinks from a stagnant pond' (Truscott: Red Brick University).
MATERIAL At Leeds, rheumatological teaching is undertaken in the third, fourth and fifth years. In the third year there is an Introductory Lecture beginning with some well chosen remarks on the importance of the subject (such as the fact that it will figure prominently in the Finals Examination), continuing with the prizewinningfilmProblems In Living (demonstrating the impact of rheumatoid arthritis on the lives of individual sufferers), a short television presentation on history-taking and an opportunity for questions. There is also an intensive three weeks of integrated teaching on the locomotor system with rheumatologists, orthopaedic surgeons, anatomists, bioengineers, pathologists, biochemists and remedial staff members. The organization of the course bows down at the shrine of integrated teaching, and helps to dispel the illusion that a University is a series of departments held together by either a central heating system or a common grievance over parking. Some of the results from a questionnaire given to the students at the conclusion of the course are shown in Table I. It will be seen that while students appreciated the integration of the material, they did not favour the integration of the participants. To run a successful integrated course in which more than one staff member is present at each session demands so much time before and during the course that I do not think the gains are worth the pains. In the fourth year the students are taught for the final 10 days of an orthopaedic block infirmsof up to 12 members. This is the crucial period and will be discussed in more detail. In the fifth year, tutorials on the ward are conducted once a week throughout the year, and students must attend two of those in rheumatology—no more than 12 students being taken at any one time (first come, first served). During an elective period of two months, rheumatology may be selected for all or part of this time. The students become
Downloaded from http://rheumatology.oxfordjournals.org/ at Emory University on August 18, 2015
Professor of Rheumatology, University of Leeds, Leeds LS2 9JT
