British Journal of Rheumatology 1992;31:279-280
REPORT OF A CONFERENCE OF ORTHOPAEDIC PROFESSORS University of Liverpool 17 and 18 November 1991
UNDERGRADUATE EDUCATION IN MUSCULOSKELETAL DISEASES BY V. WRIGHT* AND P. S. HELLIWELLf * University Department of Clinical Medicine, General Infirmary at Leeds; fRoyal Infirmary, Huddersfield
GENERAL PRACTITIONERS' VIEW The need for the musculoskeletal system being part of the curriculum was obvious. Dr A. Forbes had surveyed the general practitioners of Liverpool and found only 5% had received training in rheumatology, despite the large percentage of their workload being concerned with locomotor disease. She showed the lack of confidence that GPs had concerning rheumatic problems, the inappropriateness of many referrals, and the less than ideal management of these patients. She deplored the failure of the Royal College of General Practitioners to make any commitment to teaching in musculoskeletal diseases. Dr Doherty cited a survey of 80 general practitioners, 53% of whom felt the need for further rheumatic training; 30% had done a rheumatology attachment in their vocational training schemes, but 71% felt they had received inadequate teaching in the subject. He has clearly shown the absence or inadequacy of joint examination among general medical patients. Prof. Duckworth was concerned about the large number of rheumatic patients whom neither rheumatologists nor orthopaedic surgeons wished to see— those previously seen by physical medicine specialists; that is an indictment of both groups of doctors. At Guy's Hospital the orthopaedic surgeons and rheumatologists are now looking at their referrals conjointly, to direct the patient to the appropriate department.
THE DEAN'S VIEW The General Medical Council, Professor Shaw said, was pressing for an integrated curriculum to help accomplish appropriate educational objectives. He felt that the current curriculum tends to quash curiosity— but it has to be said that this educational approach occurs long before students arrive at medical school. Jack Stevens, Emeritus Professor of Orthopaedic Surgery at Newcastle (introduced by Professor Gregg as a man with strong views—but which orthopaedic surgeon hasn't?), endorsed this wholeheartedly from his extensive experience in England and in the USA, where he gained the Golden Apple award for the outstanding teacher of the year at North Western University. His radical solution was to teach clinical medicine and basic science in parallel from the start. On day 1 students would see patients in the NHS. On day 2 they would be taught how to use the library. On day 3 these would be reviewed. He would decrease the medical course to 4 years, and give students a maximum of 4 weeks holiday annually. The shortened curriculum is employed in the USA and recently at the University of Sydney, but it should be noted that these Medical Schools only take graduates. Professor Shaw felt that decreasing the length of undergraduate courses would increase the length of postgraduate training, with no net gain in time. To achieve the aims of the General Medical Council, the days of the Professorial robber barons would have to be terminated, said Prof. Harris, Dean at Leicester. Gone are the times when medicine and surgery could have large chunks of time entirely to themselves. This found favour with Dr Wood, Professor of Anatomy at
CLINICAL TEACHERS' VIEW The rheumatic diseases are a superb model for the teaching of knowledge, attitudes and skill. Prof. Galasko discussed aims at some length. If we aim at nothing we will certainly hit it. Prof. Duthie expanded these and saw the aims of the teacher as stimulating intellectual creativity, refining critical judgement, firing imagination, ensuring correct values, developing social consciousness, encouraging a good grasp of the mother tongue, and appreciating the scientific method. The student must grasp the truth enunciated by T. S.
Submitted 17 December; accepted 23 December 1991. Correspondence to Prof. V. Wright, Rheumatology and Rehabilitation Research Unit, 36 Clarendon Road, Leeds LS2 9NZ. 279
Downloaded from http://rheumatology.oxfordjournals.org/ at Cornell University Library on July 12, 2015
Liverpool, who characterized good teachers of anatomy by competence, enthusiasm, emphasis on functional anatomy, and efficiency. Professor Walton was keen to see teaching of the musculoskeletal system placed firmly within the 12point Edinburgh Declaration of the European Medical Students Association. In particular he emphasized health promotion and disease prevention. Prof. Woodrow was dubious about how much we had to contribute at the moment in that area; he was far from convinced that instruction about posture and exercises would reap prophylactic benefits.
THE main complaint of medical students is that the curriculum is overloaded. At the same time medical teachers are worried that educational objectives (viz. that the student's mind is not a vessel to befilledbut a flame to be ignited) have been lost in conveying a great mass of information. Changes in the NHS and medical practice are forcing medical schools to rethink the way students gain their clinical experience. These and other pressures are heightening the level of debate and creating unprecedented opportunities for innovation in medical education. A meeting of the Association of Orthopaedic Professors, organized in Liverpool by Professor Klenerman, to which a number of rheumatologists, general practitioners, and two medical students were invited, discussed undergraduate education in the locomotor system.
280
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 4 cation—Student orientation, Problem solving, Integration, Community based, Elective, Systematic in approach. Prof. Porter (Aberdeen) had produced an experimental self-learning programme on back problems. He was sufficiently impressed to develop another programme next year. If teaching methods are to change then we must develop appropriate assessments of outcome; at Dundee they use a questionnaire which measures 'happiness with medical education'. THE STUDENTS' VIEW Finally, two students described their elective experience. Mr Calder had been in Thailand (with high technology in the hospitals and grinding poverty in the community), and Miss Jones had visited Washington, the most violent city in America where a black male has a 1 in 50 chance of being murdered, where 50% of trauma is drug-related (as in England except that our drug is alcohol), and where 50% of their casualties arrive by helicopter, since it has been shown to reduce mortality substantially. The accident team was routinely videoed and their deficiencies discussed later! Miss Jones surveyed the students in her year to find who would wish to go into orthopaedic surgery—six women did (for interest) and three men (for money). The reasons why the other 123 did not wish to do so were that it is surgery, it is too male-dominated, it involves too much hard work, and there is the risk of AIDS. CONCLUSION In conclusion it was agreed that: 1. We must take aboard the conclusions of the General Medical Council. 2. Musculoskeletal diseases must be a core subject in the curriculum. 3. We should abandon the terms 'orthopaedic surgery' and 'rheumatology' for teaching purposes, and develop courses on the musculoskeletal system. 4. Disorders of this system form an excellent model for education in terms of vital knowledge, important skills of examination and differential diagnosis, and the development of attitudes in relation to longterm disease and community care. They also encompass basic science. 5. They should be taught from the beginning of the medical course and not left until the third year. 6. The paper produced by Professor Mollan and the complementary one from the British Society of Rheumatology and the Arthritis and Rheumatism Council are to be welcomed. Those on curriculum committees would like each distilled to a single summary page.
Downloaded from http://rheumatology.oxfordjournals.org/ at Cornell University Library on July 12, 2015
Eliot that difficulties which are unexamined never emerge from the obscurity of prejudice. At Oxford he regularly introduces basic science to the discussion of musculoskeletal problems. Combined courses between rheumatologists and orthopaedic surgeons are being increasingly developed. These were discussed by Prof. Dickson, Prof. Wright and Dr Helliwell (Leeds), Dr Doherty (Nottingham), and Prof. Solomon (Bristol). The Bristol group has an interesting exercise at the beginning and end of their course (the first to interest, the last to examine the student). Twenty stations have demonstrations (e.g. an article from a newspaper, a worn shoe, an X-ray, a patient's hand), with a tutor, who discusses the issue on the first attendance, and asks a single question on the last. Prof. Mollan introduced the draft document from the British Orthopaedic Association, the Royal College of General Practitioners, and the British League Against Rheumatism on musculoskeletal education of the undergraduate. He worries about the incompleteness of the General Medical Council guidelines, believing they will lead to a confused student. The Belfast course certainly has much to commend it, with its emphasis on project work and problem solving. He believes this is successful because it is focused, relevant, cost-time efficient, and motivating intellectually. Much of this approach requires self-learning. The role of textbooks was discussed by Mr Dandy. They must be readable, relevant, and rememberable. Prof. Solomon has analysed their requirements in more depth. He regarded the textbook as a dialogue between the author and the reader's inner self, so that the reader felt in the end he had written the book. Indeed, Solomon favoured leaving two blank pages at the end of each chapter for the student to complete. The illustrations should tell a story—i.e. not a simple picture, but a sequence (e.g. clinical picture, X-ray and diagram in the one frame). Instead of a single X-ray reproduction of the sacroiliac joints, have one with a colostomy. Instead of an X-ray of a Pagetic skull, have one with wires of a hearing aid. These he believed would be more likely to stimulate the student. Indeed, he felt the student would like them. One contributor thought Prof. Solomon would like the student to like them—which is not the same thing. Make the book as short as possible, commented Prof. Duckworth, and think of it for general practitioners, then it would do for students also. At Dundee they have produced self-learning modules in orthopaedic surgery, interspersed with small group tutorials. Mr Dent described these. He also described the principles of SPICES in medical edu-
REPORT OF A CONFERENCE OF ORTHOPAEDIC PROFESSORS University of Liverpool 17 and 18 November 1991
UNDERGRADUATE EDUCATION IN MUSCULOSKELETAL DISEASES BY V. WRIGHT* AND P. S. HELLIWELLf * University Department of Clinical Medicine, General Infirmary at Leeds; fRoyal Infirmary, Huddersfield
GENERAL PRACTITIONERS' VIEW The need for the musculoskeletal system being part of the curriculum was obvious. Dr A. Forbes had surveyed the general practitioners of Liverpool and found only 5% had received training in rheumatology, despite the large percentage of their workload being concerned with locomotor disease. She showed the lack of confidence that GPs had concerning rheumatic problems, the inappropriateness of many referrals, and the less than ideal management of these patients. She deplored the failure of the Royal College of General Practitioners to make any commitment to teaching in musculoskeletal diseases. Dr Doherty cited a survey of 80 general practitioners, 53% of whom felt the need for further rheumatic training; 30% had done a rheumatology attachment in their vocational training schemes, but 71% felt they had received inadequate teaching in the subject. He has clearly shown the absence or inadequacy of joint examination among general medical patients. Prof. Duckworth was concerned about the large number of rheumatic patients whom neither rheumatologists nor orthopaedic surgeons wished to see— those previously seen by physical medicine specialists; that is an indictment of both groups of doctors. At Guy's Hospital the orthopaedic surgeons and rheumatologists are now looking at their referrals conjointly, to direct the patient to the appropriate department.
THE DEAN'S VIEW The General Medical Council, Professor Shaw said, was pressing for an integrated curriculum to help accomplish appropriate educational objectives. He felt that the current curriculum tends to quash curiosity— but it has to be said that this educational approach occurs long before students arrive at medical school. Jack Stevens, Emeritus Professor of Orthopaedic Surgery at Newcastle (introduced by Professor Gregg as a man with strong views—but which orthopaedic surgeon hasn't?), endorsed this wholeheartedly from his extensive experience in England and in the USA, where he gained the Golden Apple award for the outstanding teacher of the year at North Western University. His radical solution was to teach clinical medicine and basic science in parallel from the start. On day 1 students would see patients in the NHS. On day 2 they would be taught how to use the library. On day 3 these would be reviewed. He would decrease the medical course to 4 years, and give students a maximum of 4 weeks holiday annually. The shortened curriculum is employed in the USA and recently at the University of Sydney, but it should be noted that these Medical Schools only take graduates. Professor Shaw felt that decreasing the length of undergraduate courses would increase the length of postgraduate training, with no net gain in time. To achieve the aims of the General Medical Council, the days of the Professorial robber barons would have to be terminated, said Prof. Harris, Dean at Leicester. Gone are the times when medicine and surgery could have large chunks of time entirely to themselves. This found favour with Dr Wood, Professor of Anatomy at
CLINICAL TEACHERS' VIEW The rheumatic diseases are a superb model for the teaching of knowledge, attitudes and skill. Prof. Galasko discussed aims at some length. If we aim at nothing we will certainly hit it. Prof. Duthie expanded these and saw the aims of the teacher as stimulating intellectual creativity, refining critical judgement, firing imagination, ensuring correct values, developing social consciousness, encouraging a good grasp of the mother tongue, and appreciating the scientific method. The student must grasp the truth enunciated by T. S.
Submitted 17 December; accepted 23 December 1991. Correspondence to Prof. V. Wright, Rheumatology and Rehabilitation Research Unit, 36 Clarendon Road, Leeds LS2 9NZ. 279
Downloaded from http://rheumatology.oxfordjournals.org/ at Cornell University Library on July 12, 2015
Liverpool, who characterized good teachers of anatomy by competence, enthusiasm, emphasis on functional anatomy, and efficiency. Professor Walton was keen to see teaching of the musculoskeletal system placed firmly within the 12point Edinburgh Declaration of the European Medical Students Association. In particular he emphasized health promotion and disease prevention. Prof. Woodrow was dubious about how much we had to contribute at the moment in that area; he was far from convinced that instruction about posture and exercises would reap prophylactic benefits.
THE main complaint of medical students is that the curriculum is overloaded. At the same time medical teachers are worried that educational objectives (viz. that the student's mind is not a vessel to befilledbut a flame to be ignited) have been lost in conveying a great mass of information. Changes in the NHS and medical practice are forcing medical schools to rethink the way students gain their clinical experience. These and other pressures are heightening the level of debate and creating unprecedented opportunities for innovation in medical education. A meeting of the Association of Orthopaedic Professors, organized in Liverpool by Professor Klenerman, to which a number of rheumatologists, general practitioners, and two medical students were invited, discussed undergraduate education in the locomotor system.
280
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 4 cation—Student orientation, Problem solving, Integration, Community based, Elective, Systematic in approach. Prof. Porter (Aberdeen) had produced an experimental self-learning programme on back problems. He was sufficiently impressed to develop another programme next year. If teaching methods are to change then we must develop appropriate assessments of outcome; at Dundee they use a questionnaire which measures 'happiness with medical education'. THE STUDENTS' VIEW Finally, two students described their elective experience. Mr Calder had been in Thailand (with high technology in the hospitals and grinding poverty in the community), and Miss Jones had visited Washington, the most violent city in America where a black male has a 1 in 50 chance of being murdered, where 50% of trauma is drug-related (as in England except that our drug is alcohol), and where 50% of their casualties arrive by helicopter, since it has been shown to reduce mortality substantially. The accident team was routinely videoed and their deficiencies discussed later! Miss Jones surveyed the students in her year to find who would wish to go into orthopaedic surgery—six women did (for interest) and three men (for money). The reasons why the other 123 did not wish to do so were that it is surgery, it is too male-dominated, it involves too much hard work, and there is the risk of AIDS. CONCLUSION In conclusion it was agreed that: 1. We must take aboard the conclusions of the General Medical Council. 2. Musculoskeletal diseases must be a core subject in the curriculum. 3. We should abandon the terms 'orthopaedic surgery' and 'rheumatology' for teaching purposes, and develop courses on the musculoskeletal system. 4. Disorders of this system form an excellent model for education in terms of vital knowledge, important skills of examination and differential diagnosis, and the development of attitudes in relation to longterm disease and community care. They also encompass basic science. 5. They should be taught from the beginning of the medical course and not left until the third year. 6. The paper produced by Professor Mollan and the complementary one from the British Society of Rheumatology and the Arthritis and Rheumatism Council are to be welcomed. Those on curriculum committees would like each distilled to a single summary page.
Downloaded from http://rheumatology.oxfordjournals.org/ at Cornell University Library on July 12, 2015
Eliot that difficulties which are unexamined never emerge from the obscurity of prejudice. At Oxford he regularly introduces basic science to the discussion of musculoskeletal problems. Combined courses between rheumatologists and orthopaedic surgeons are being increasingly developed. These were discussed by Prof. Dickson, Prof. Wright and Dr Helliwell (Leeds), Dr Doherty (Nottingham), and Prof. Solomon (Bristol). The Bristol group has an interesting exercise at the beginning and end of their course (the first to interest, the last to examine the student). Twenty stations have demonstrations (e.g. an article from a newspaper, a worn shoe, an X-ray, a patient's hand), with a tutor, who discusses the issue on the first attendance, and asks a single question on the last. Prof. Mollan introduced the draft document from the British Orthopaedic Association, the Royal College of General Practitioners, and the British League Against Rheumatism on musculoskeletal education of the undergraduate. He worries about the incompleteness of the General Medical Council guidelines, believing they will lead to a confused student. The Belfast course certainly has much to commend it, with its emphasis on project work and problem solving. He believes this is successful because it is focused, relevant, cost-time efficient, and motivating intellectually. Much of this approach requires self-learning. The role of textbooks was discussed by Mr Dandy. They must be readable, relevant, and rememberable. Prof. Solomon has analysed their requirements in more depth. He regarded the textbook as a dialogue between the author and the reader's inner self, so that the reader felt in the end he had written the book. Indeed, Solomon favoured leaving two blank pages at the end of each chapter for the student to complete. The illustrations should tell a story—i.e. not a simple picture, but a sequence (e.g. clinical picture, X-ray and diagram in the one frame). Instead of a single X-ray reproduction of the sacroiliac joints, have one with a colostomy. Instead of an X-ray of a Pagetic skull, have one with wires of a hearing aid. These he believed would be more likely to stimulate the student. Indeed, he felt the student would like them. One contributor thought Prof. Solomon would like the student to like them—which is not the same thing. Make the book as short as possible, commented Prof. Duckworth, and think of it for general practitioners, then it would do for students also. At Dundee they have produced self-learning modules in orthopaedic surgery, interspersed with small group tutorials. Mr Dent described these. He also described the principles of SPICES in medical edu-
