Introduction
Methods
Needs analysis
Burden of RMDs
Region | % total YLDs as per Global Burden of Disease 2016* (lower bound–upper bound) | ||||
---|---|---|---|---|---|
Back and neck pain | Osteoarthritis | Rheumatoid arthritis | Gout | Other MSK | |
North America | 11.93% | 2.34% | 1.34% | 0.25% | 4.88% |
(10.91–12.88) | (1.75–2.96) | (1.10–1.58) | (0.20–0.31) | (3.86–6.16) | |
Australasia | 14.81% | 1.83% | 1.13% | 0.30% | 5.73% |
(13.12–16.50) | (1.39–2.34) | (0.89–1.39) | (0.23–0.38) | (4.46–7.32) | |
Asia Pacific | 15.98% | 2.06% | 0.82% | 0.25% | 3.82% |
(13.94–17.95) | (1.58–2.58) | (0.64–1.00) | (0.19–0.32) | (2.92–5.02) | |
Western Europe | 16.73% | 2.11% | 0.91% | 0.28% | 2.69% |
(14.81–18.71) | (1.61–2.66) | (0.72–1.11) | (0.21–0.35) | (2.02–3.62) | |
Southern Latin America | 15.29% | 1.77% | 1.51% | 0.22% | 5.75% |
(13.44–17.07) | (1.35–2.24) | (1.19–1.84) | (0.16–0.27) | (4.48–7.37) | |
Eastern Europe | 14.04% | 2.89% | 0.68% | 0.12% | 0.71% |
(12.29–15.79) | (2.52–3.27) | (0.53–0.84) | (0.09–0.15) | (0.50–1.01) | |
Central Europe | 15.55% | 2.91% | 0.79% | 0.12% | 0.65% |
(13.44–17.58) | (2.55–3.27) | (0.61–0.98) | (0.09–0.16) | (0.48–0.88) | |
Central Asia | 12.22% | 2.04% | 0.63% | 0.10% | 0.93% |
(10.52–13.87) | (1.80–2.29) | (0.48–0.77) | (0.08–0.13) | (0.63–1.34) | |
Central Latin America | 9.44% | 2.08% | 0.55% | 0.07% | 3.85% |
(8.26–10.64) | (1.82–2.34) | (0.43–0.68) | (0.05–0.09) | (2.97–4.97) | |
Andean Latin America | 11.33% | 1.99% | 0.64% | 0.08% | 2.69% |
(9.77–12.93) | (1.75–2.24) | (0.49–0.79) | (0.06–0.11) | (2.03–3.56) | |
Caribbean | 8.65% | 2.11% | 0.86% | 0.09% | 4.08% |
(7.49–9.77) | (1.84–2.37) | (0.66–1.05) | (0.07–0.12) | (3.18–5.32) | |
Tropical Latin America | 11.93% | 2.03% | 0.65% | 0.08% | 4.17% |
(10.41–13.44) | (1.78–2.28) | (0.50–0.79) | (0.06–0.11) | (3.24–5.32) | |
East Asia | 11.65% | 3.08% | 0.66% | 0.18% | 3.44% |
(10.19–13.13) | (2.67–3.46) | (0.51–0.80) | (0.13–0.23) | (2.62–4.54) | |
Southeast Asia | 11.35% | 1.84% | 0.30% | 0.13% | 4.12% |
(9.83–12.84) | (1.60–2.06) | (0.23–0.36) | (0.10–0.16) | (3.19–5.33) | |
Oceania | 9.07% | 1.52% | 0.27% | 0.09% | 3.29% |
(7.77–10.45) | (1.34–1.70) | (0.20–0.34) | (0.07–0.12) | (2.48–4.30) | |
North Africa and Middle East | 11.23% | 1.80% | 0.61% | 0.08% | 3.80% |
(9.87–12.64) | (1.58–2.04) | (0.47–0.75) | (0.06–0.10) | (2.93–4.89) | |
South Asia | 7.26% | 1.50% | 0.51% | 0.08% | 4.94% |
(6.23–8.27) | (1.32–1.68) | (0.39–0.63) | (0.06–0.10) | (3.79–6.37) | |
Southern sub-Saharan Africa | 7.88% | 1.51% | 0.53% | 0.08% | 2.02% |
(6.82–8.98) | (1.32–1.69) | (0.41–0.65) | (0.06–0.10) | (1.54–2.66) | |
Western sub-Saharan Africa | 8.62% | 1.05% | 0.24% | 0.07% | 1.57% |
(7.24–9.94) | (0.92–1.17) | (0.18–0.30) | (0.05–0.09) | (1.13–2.13) | |
Eastern sub-Saharan Africa | 7.47% | 0.98% | 0.31% | 0.07% | 1.47% |
(6.30–8.64) | (0.87–1.10) | (0.23–0.39) | (0.05–0.09) | (1.07–1.99) | |
Central sub-Saharan Africa | 7.54% | 0.85% | 0.31% | 0.06% | 1.40% |
(6.28–8.75) | (0.75–0.95) | (0.23–0.39) | (0.04–0.08) | (1.04–1.89) |
Patient needs
Workforce needs
Inadequacy in undergraduate RMD education
Region | Inadequacies in undergraduate RMD education |
---|---|
Australia | A national workshop with academic teaching and student representatives confirmed inadequacies in MSK teaching nationally [50]. |
Barbados | In a small study of final year medical students, > 80% failed the Freedman and Bernstein* examination [46]. |
Egypt | > 80% of PCPs surveyed (n = 297) reported low confidence in performing MSK physical examinations and in accordance with this, 75% achieved an unsatisfactory score in the assessment [39]. |
India | The majority (95%) of final year medical students assessed failed to demonstrate basic MSK competency [45]. |
Ireland | Out of 303 participants assessed using the Freedman and Bernstein examination, ~ 70% of general practitioners and general practice trainees failed to achieve a passing score; > 85% of medical students who had completed an intensive 1-week course in MSK medicine also failed the examination [43]. |
Latin America | According to PANLAR online surveys of national society presidents and members, only 29% of Latin American medical schools taught undergraduate rheumatology and 72% of 316 respondents agreed that the majority of doctors in Latin America lacked training or had poor knowledge of clinical rheumatology [51]. |
Mexico | Poor clinical competence in rheumatic disease management was identified by a cross-sectional survey of PCPs (n = 104), > 50% of PCPs demonstrated suboptimal knowledge [52]. |
Nigeria | All pre-internship graduates (from 7 Nigerian medical schools) tested over a 3-year period failed to pass the Freedman and Bernstein examination (scores from 7% to 67%) [41]. |
Saudi Arabia | Overall knowledge of osteoarthritis among PCPs surveyed was found to be inadequate (only ~ 50% of responses received were correct) [53]. |
UK | Assessment of MSK knowledge in junior doctors at the end of their 2-year foundation programme found that > 90% of respondents failed the Freedman and Bernstein competence examination [54]. |
Assessment of the MSK system was shown to be routinely neglected or sub-optimally performed during paediatric in-patient admission at 4 different hospitals. Self-reported confidence of specialist registrars in MSK assessment was found to be low and none could recall learning paediatric MSK examination skills during their undergraduate training [55, 56]. | |
Paediatric MSK clinical skills in the UK were found to only be included in a minority of undergraduate curricula, the content taught was variable and the skills rarely featured in student assessments [57]. | |
USA | |
MSK clinical instruction continues to be underrepresented in undergraduate curricula: MSK clerkships were found to only feature in 15% of medical schools (mean of 2 ± 1 weeks) and clinical MSK medicine selectives were only offered in 34% of medical schools [36]. |
Shortfalls in rheumatologists
Curriculum content
Core recommendations and curriculum design
MSK anatomy and basic science
GALS and pGALS
Description of online/app-based resource | |
---|---|
AMSEC | The AMSEC website (amsec.org.au) provides access to the AMSEC competency document and framework, in addition to associated MSK teaching resources. |
EULAR School of Rheumatology | The EULAR School of Rheumatology website hosts training videos (35 min) covering the principles of MSK history and examination and the GALS screen [80]. |
EULAR Ultrasound Scanning Guide | The EULAR ultrasound scanning app [90], is a comprehensive digital technical manual of image acquisition in rheumatologic ultrasound. |
Paediatric Musculoskeletal Matters (PMM) | To support students and non-specialists who lack confidence in performing the pGALS examination and diagnosing paediatric MSK conditions [88, 89]. PMM is endorsed by professional organisations (Paediatric Rheumatology European Society [PReS], British Society for Paediatric and Adolescent Rheumatology [BSPAR]) and NICE. The content of PMM is tailored to reflect different health contexts. For example, PMM for India (September 2015) was adapted in partnership with the Indian Academy of Pediatrics [91]. Further globalisation of PMM is in progress to provide content relevant to healthcare contexts around the world. A free pGALS app is available and the most recent version includes multiple language translations based on user feedback. Free online e-learning about pGALS is also available (cpd.ncl.ac.uk) targeting medical students and PCPs. |
PANLAR Edu (reumati.co) | The Pan-American League of Associations of Rheumatology (PANLAR) has launched Panlar Edu https://www.reumati.co/, an ILAR grant-funded, free Spanish-language website to improve the undergraduate medical education in Latin America [92]. It offers an interactive rheumatology curriculum, based on “Rheum2Learn” by ACR but adapted by Latin American rheumatologists, to facilitate active learning. |
Reumacademia | The Reumacademia project was launched by the Spanish Rheumatology Society with sponsorship from the Roche Institute; one of its aims was to develop materials for the teaching of rheumatology in undergraduate medicine [93, 94]. The website contains links to teaching guides (in Spanish) based on case studies and problem-based learning, which include comprehensive descriptions of didactic goals, objectives, structure and content of learning sessions, and assessment. Topics include rheumatoid arthritis, primary Sjögren’s syndrome, systemic lupus erythematosus, gout and metabolic osteo-pathologies. |
‘Reumatología chuac’ YouTube channel | |
University of Barcelona teaching resources | Rheumatology teaching resources (problem-based learning and case study method) have been developed by the University of Barcelona and are freely available online (in Spanish) [93]. |
Interprofessional education
Teaching and learning methods
Curricular reform
Learning methods and interventions
Implementation
Barriers to effective RMD education | Recommendations for improvement of RMD teaching |
Poor knowledge of basic/biomedical science and MSK anatomy (gained or retained) in pre-clinical years [42] | |
Lack of clinical opportunities in general, as well as exposure to rheumatology patients in the ambulatory setting in particular | Increased clinical exposure to RMDs: ‘The Stealth Approach’ (integrating MSK education across all years of medical school, progressively building on knowledge) and ‘Reclaiming the Fourth Year’ (refreshing MSK knowledge taught during pre-clinical years through electives) [74]. However, as electives would not provide exposure for all students, MSK anatomy should also be revisited during clerkship or clinical years [78] |
Insufficient time for bedside teaching [42] | |
Over-reliance on technology for teaching clinical examination skills [42] | Protected time for rheumatology educators to mentor students |
Increased awareness of global core competencies for undergraduate RMD education and harmonisation of RMD teaching, learning methodologies and assessment strategies worldwide [129] | |
Scarcity of effective teaching patients [42] | Incorporation of innovative approaches such as patient/parent partners/educators, to involve the patient perspective in the teaching of future professionals [130], blended learning and IPE |
Poor communication between relevant specialties [128] | |
Assessment and course evaluation
Assessment of learners
Assessment type | Description |
---|---|
Freedman and Bernstein test | This basic MSK competency test is the only validated assessment tool currently available (pass score > 73.1%). However, some studies have questioned the contextual relevance of the test and no information is currently available on the correlation between competence as assessed by the Freedman and Bernstein test and patient outcomes [41, 45]. |
Script concordance test | A script concordance test in rheumatology was recently developed by a panel of rheumatology experts, including community rheumatologists, in France [131]. The test, consisting of 60 questions, was designed for fifth year medical students with a view to including it in their computer-based national ranking examination (iNRE) [131]. |
OSCEs | |
MSK subject examination | The National Board of Medical Examiners in the USA have developed a MSK subject examination [136]. |
Longitudinal assessment | A ‘progress test’ to estimate gains in student MSK knowledge as they progressed through the undergraduate course was devised at the University of Sheffield, UK. The computer-based assessment evaluated competence in clinical MSK medicine and underpinning basic science that would be required of a newly qualified doctor [137]. |