Joints: if relevant. Do available textbooks contain adequate information about musculoskeletal examination skills for medical students?

Cross-sectional survey of the undergraduate rheumatology curriculum in European medical schools: a EULAR School of Rheumatology initiative

Objectives

To survey the undergraduate rheumatic and musculoskeletal diseases (RMDs) curriculum content in a sample of medical schools across Europe.

Methods

The undergraduate musculoskeletal diseases and disability curriculum of University of Nottingham, UK, was used as a template to develop a questionnaire on curriculum content. The questionnaire elicited binary (yes/no) responses and included the option to provide additional information as free text. The survey was mailed to members of the European League Against Rheumatism (EULAR) School of Rheumatology (Undergraduate Classroom) and to EULAR Standing Committee on Education and Training members in January 2017, with a reminder in February 2017.

Results

Responses were received from 21 schools belonging to 11 countries. Assessment of gait, hyperalgesic tender site response and hypermobility were not included in many curricula. Similarly, interpretation of investigations undertaken on synovial fluid was taught in only 16 schools. While disease-modifying anti-rheumatic drugs and biological agents, and urate-lowering treatment were included in the curricula of 20 and 21 institutions, respectively, only curricula from 18 schools included core non-pharmacological interventions. Osteoarthritis, gout, rheumatoid arthritis, spondyloarthropathy, polymyalgia rheumatica and lupus were included in the curriculum of all institutions. However, common RMDs such as calcium pyrophosphate deposition, fibromyalgia, giant cell arteritis and bone and joint infection were included in 19 curricula.

Conclusion

This survey highlights areas of similarities and differences in undergraduate curricula across Europe. It is hoped that the results of this survey will catalyse the development and agreement of a minimum core European Curriculum for undergraduate education in RMDs.

Sustained impact of a short small group course with systematic feedback in addition to regular clinical clerkship activities on musculoskeletal examination skills--a controlled study

BACKGROUND

The discrepancy between the extensive impact of musculoskeletal complaints and the common deficiencies in musculoskeletal examination skills lead to increased emphasis on structured teaching and assessment. However, studies of single interventions are scarce and little is known about the time-dependent effect of assisted learning in addition to a standard curriculum. We therefore evaluated the immediate and long-term impact of a small group course on musculoskeletal examination skills.

METHODS

All 48 Year 4 medical students of a 6 year curriculum, attending their 8 week clerkship of internal medicine at one University department in Berne, participated in this controlled study. Twenty-seven students were assigned to the intervention of a 6×1 h practical course (4-7 students, interactive hands-on examination of real patients; systematic, detailed feedback to each student by teacher, peers and patients). Twenty-one students took part in the regular clerkship activities only and served as controls. In all students clinical skills (CS, 9 items) were assessed in an Objective Structured Clinical Examination (OSCE) station, including specific musculoskeletal examination skills (MSES, 7 items) and interpersonal skills (IPS, 2 items). Two raters assessed the skills on a 4-point Likert scale at the beginning (T0), the end (T1) and 4-12 months after (T2) the clerkship. Statistical analyses included Friedman test, Wilcoxon rank sum test and Mann-Whitney U test.

RESULTS

At T0 there were no significant differences between the intervention and control group. At T1 and T2 the control group showed no significant changes of CS, MSES and IPS compared to T0. In contrast, the intervention group significantly improved CS, MSES and IPS at T1 (p < 0.001). This enhancement was sustained for CS and MSES (p < 0.05), but not for IPS at T2.

CONCLUSIONS

Year 4 medical students were incapable of improving their musculoskeletal examination skills during regular clinical clerkship activities. However, an additional small group, interactive clinical skills course with feedback from various sources, improved these essential examination skills immediately after the teaching and several months later. We conclude that supplementary specific teaching activities are needed. Even a single, short-lasting targeted module can have a long lasting effect and is worth the additional effort.

A multimedia CD-ROM tool to improve student understanding of bile salts and bilirubin metabolism: evaluation of its use in a medical hybrid PBL course

Over the last 35 years our understanding of bile salts, bilirubin metabolism, and hepatobiliary transport has progressively increased. From 1965 to the end of 2002, 3,610 articles and review papers have been published on hepatobiliary and enterocyte transport of bile salts. However, there is a lack of information in the content of current textbooks about hepatobiliary physiology, bile salt transporters, bile formation, mechanisms underlying cholestasis, and drug-induced liver injury. The use of an integrated multimedia program on the liver covering these gaps in textbooks may be useful to student learning. This study aims to 1) assess student views on a multimedia CD-ROM ("The Liver") integrating basic and clinical sciences related to the liver, bile salts, and bilirubin metabolism, 2) assess the usefulness of problem-based learning (PBL) cases included in the multimedia CD-ROM, and 3) assess student learning before and after use of the multimedia CD-ROM. A total of 106 first-year medical students (27 with and 79 without a prior university degree) at the University of Melbourne participated in this study. Students were tested on the liver, bile salts, and bilirubin metabolism before and after using the multimedia CD-ROM. After completing the multimedia CD-ROM, each student filled out a 5-point Likert scale questionnaire evaluating the features of the program and its usefulness to their learning. Results show that the aims of the package were clear to participants, the contents were logically organized and clear, the key concepts were easy to identify, the contents were pitched to an appropriate level, and the package was interactive and encouraged participants to reflect on their learning. Students also agreed that the assessment tools used in the program and the feedback provided were meaningful and helpful to their learning. No differences were found when responses were compared on the basis of academic background, gender, citizenship, or first language of participants. Students agreed that the PBL cases in the CD-ROM kept them engaged, were useful to their learning, and matched with the overall philosophy of the program. Compared with graduate-entry students (those with a prior university degree), school leavers (those with no prior university degree) showed a more positive attitude toward the PBL cases included in the multimedia CD-ROM and agreed that cases kept them engaged (P = 0.033). Students who completed the test after using the multimedia CD-ROM scored higher compared with those who completed the test before using the multimedia CD-ROM (P < 0.001). In conclusion, using bile salts, bilirubin metabolism, and their hepatobiliary transport as an example, the incorporation of a multimedia CD-ROM into the first-year medical course has the potential to improve student understanding of the main concepts in a variety of body systems.

Do recommended textbooks contain adequate information about bile salt transporters for medical students?

Several studies have recently highlighted a number of limitations in medical textbooks. The aims of this study were to 1) to assess whether available medical textbooks provided students with adequate information about bile salt transporters, 2) compare the level of detail and the amount of information provided in current textbooks on hepatic transport mechanisms with those available in the literature, and 3) compare the amount of information provided in medical textbooks on hepatocyte transport mechanisms with those involving other transporters e.g., those found in the nephron. Seventy medical textbooks from disciplines including physiology, pathology, cell biology, medicine, pediatrics, pharmacology, pathophysiology, and histology published during the past six years were examined. The literature on bile salt transport has been searched mainly from the Internet (MEDLINE and PubMed). Most textbooks failed to provide any information on transporters found in the basolateral and canalicular membranes of hepatocytes. There are also deficiencies in information on bile salt transporters in the terminal ileum. However, up to the end of 2002, 3,610 articles and reviews had been published on hepatobiliary and enterocyte transport of bile salts. During the same period (from 1965), 10,757 articles had been published on renal transport. Thus the contents of textbooks may reflect the overall volume of research knowledge on renal transport. However, despite our current understanding of hepatic and intestinal transport of bile salts and extensive research, particularly over the past 12 years, there are major deficiencies in textbooks in this area. These findings indicate that there is an imbalance in the contents of current textbooks and a lack of information about hepatobiliary physiology, bile salt transporters, bile formation, and mechanisms underlying cholestasis and drug-induced injury. Authors, editors, and publishers of medical textbooks should consider the need to update the information provided on bile salt transporters.

Regional Examination of the Musculoskeletal System (REMS): a core set of clinical skills for medical students

OBJECTIVES

The aim of this study was to determine an agreed set of core regional musculoskeletal examination skills for medical students to learn.

METHODS

Initially focus groups were undertaken amongst Rheumatologists, Orthopaedic Surgeons, Geriatricians and General Practitioners. These findings were used to inform the production of a questionnaire survey. The findings from both the questionnaire survey and focus groups were assessed using a group nominative technique with national representation from each of the four specialties involved.

RESULTS

This process has led to the identification of 50 items, considered to be core regional musculoskeletal examination skills for medical students.

CONCLUSIONS

This core set of musculoskeletal clinical skills may now be used to inform the production of teaching materials aimed at medical students.

Do textbooks of clinical examination contain information regarding the assessment of critically ill patients?

We postulated that some of the reported deficiencies in trainee doctors' knowledge of acute care might be due to the quantity and quality of available information about the examination and clinical assessment of critically ill patients in commonly used medical textbooks. Using an agreed assessment system, 30 routinely available texts of clinical examination were reviewed. None of these contained a section devoted specifically to "assessing the critically ill patient" and few could be regarded as giving a comprehensive, systematic description of an assessment system suitable for use with the acutely ill. In general, descriptions of how to assess airway patency were rare, with only one describing how to differentiate partial from complete airway obstruction. Only four of the texts mentioned that measuring the respiratory rate would be useful in critically ill patients and the assessment of capillary refill time was poorly covered. Use of the AVPU scale to describe neurological status was found in only 3% of texts, and there was poor description of the clinical significance of hypotension, tachycardia, oliguria, hypothermia and pyrexia. We conclude that the current texts available to medical students and junior doctors do not provide sufficient information regarding the assessment of critically ill patients.