Introduction

Wherever clinicians teach, there is a conflict between the provision of clinical service and the provision of quality teaching. For the clinical rheumatologist in the UK, Government waiting list targets, changes in hospital bed use and consultant job planning have put increased pressure on the ability to teach medical students. For academics, there is the additional pressure to produce quality research, underlined by the Research Assessment Exercise in the UK. Add to these pressures a large expansion in student numbers and there is the potential for a very daunting challenge!

This is the situation in Derby and many other medical schools in the UK. In this article, we would like to describe how we have addressed these challenges along ‘best practise’ lines. Our aim is to provide an effective and efficient teaching programme. We hope that this description will be useful for other teaching hospitals that are grappling with similar problems.

For some years, the rheumatology department at Derby has taken students from Nottingham University at two different stages of their training. Firstly, third year (first year clinical) students rotate through our department for a week at a time as part of their junior medical attachment (the Clinical Practice course). The main aim of this week is for them to develop their history taking skills and learn basic musculoskeletal examination in the form of the ‘GALS’ screen [1]. In the final year (the Advanced Clinical Experience course), four blocks of students in turn spend 8 weeks in Derby studying musculoskeletal disorders and disability (MDD), the course being run jointly with the orthopaedics and rehabilitation departments.

As with many UK medical schools, Nottingham has increased the number of students over time, with 200 students per year group in 1999 and 246 in 2004. Furthermore, a large step increase is due in February 2006 as 90 clinical students from the Graduate Entry Medical School in Derby enter the clinical course. For Derby Rheumatology Department this will mean a large increase in students coming through the department. This expansion has already affected the 12 weeks of the year in which we teach the third year students, where numbers have doubled from 6 to 12 at any one time. It will impact on the 36 weeks of the MDD course in 2006 when numbers will increase more than 3-fold, from 12 to 40 students attached to the department in each of the 8-week blocks.

Clinical teaching relies on students seeing a good mix of patients with an enthusiastic clinician with enough time for teaching. Because of therapeutic innovations, such as anti-TNF drugs, and pressure on beds, there are fewer rheumatology in-patients to teach on. In addition, out-patient clinics are under pressure to concentrate on service delivery, and therefore have limitations for student teaching. Whilst in the Derby rheumatology department, we can reduce patient throughput in teaching clinics due to ring-fenced SIFT (Service Increment for Teaching) funding, waiting list pressures have meant that colleagues elsewhere are unable to spend time discussing cases or teaching skills to students. This conflict with service commitments is common within medical education [2]. Despite being able to reduce numbers attending rheumatology clinics, there is no control of the type of patients available for teaching, and accordingly it is difficult to ensure that all topics are covered. This is made worse if the student:patient ratio is increased. Above all, it is important to ensure that teaching should, if anything, be of benefit and not detrimental to the patient. This becomes harder to ensure if there is less time and fewer patients.

The introduction of the new consultant contract in the UK and the European Working Time Directive has meant that clinicians are now less likely to ‘squeeze’ teaching into their weekly schedule. Whilst this may make teaching ‘on the cheap’ difficult, it does delineate the need for all teaching to be in protected and financially recognized time-slots. In Derby, SIFT funding was available to support the extra teaching, but only if it could be shown to be being used directly on teaching and not, for example, to swell consultant numbers. Many established medical schools cannot disentangle SIFT from other service delivery monies paid into the hospital trusts. The disheartening effect is that departments who support teaching see no more resources than disinterested departments. In Derby, the trust has a creditable desire to ring-fence SIFT for teaching. This allows teaching time to be clearly delineated from clinical service time (protecting both aspects) and encourages new teaching developments through a recognition of teaching activities. The patients, the case-mix, the clinical teacher and the available time are all key resources for the provision of quality education. However, each is under threat and traditional teaching needs to adapt accordingly.

Despite the constraints, Derby consultants have always been enthusiastic about undergraduate teaching and were keen that this should remain highly effective. This challenge has given us the opportunity to look at improving quality. However, it was clear that any expanded course needed to be highly efficient. Inefficiencies were evident in the old course, for example in the overlap of teaching between departments and lack of clarity as to which learning objectives were taught and when.

The best practise approach to coping with increased numbers of medical students

Based on the constraints and ideals outlined above, our strategy to meet the challenge of the course expansion was to:

  • maximize efficiency by apportioning learning objectives to specific teaching events;

  • maximize the effectiveness of teaching by using the best evidence to tackle any objective;

  • maximize effective use of our patients to benefit, and not be detrimental to, them;

  • make efficient use of the specialized (and expensive) skills of consultants; and

  • limit the impact on clinical service.

Apportioning learning objectives

The learning objectives for both the third year and fifth year courses are defined in the curriculum, and any approach to teaching needed to address these. Any course is best approached along these lines, rather than concentrating on what is easy to teach, or local interests and enthusiasms [3]. Because knowledge and skills are best learnt within a clinical context [4–6], we chose to divide the objectives into themed weekly modules through which students rotate and concentrate on specified clinical problems (Table 1). For example, there is a module on ‘the spine’. Within each module, learning objectives were apportioned to the most relevant department. Therefore in the spinal module, the orthopaedic department is responsible for teaching on ‘surgical conditions’ e.g. lumbar root entrapment, whilst rheumatology runs a session comparing mechanical and inflammatory back pain (Table 2). Some objectives are more easily categorized than others, but this process allowed more definition of who teaches what and when, minimizing overlaps and keeping learning contextualized.

Table 1.

Theme-based structure of course

Week 1 Basic skills week  
The swollen joint graphic 
 Inflammatory arthritidies  
Systemic illness in rheumatology  
 Connective tissue disease, vasculitides, fibromyalgia  
The failing skeleton  
 Osteoarthritis, osteoporosis, issues of reduced mobility  
The Spine  
 Spinal pain and associated conditions  
Soft tissue conditions  
Bone pain  
 Fractures, malignancy and infection  
Accident and emergency  
 Including rehabilitative aspects of head injury  
Week 1 Basic skills week  
The swollen joint graphic 
 Inflammatory arthritidies  
Systemic illness in rheumatology  
 Connective tissue disease, vasculitides, fibromyalgia  
The failing skeleton  
 Osteoarthritis, osteoporosis, issues of reduced mobility  
The Spine  
 Spinal pain and associated conditions  
Soft tissue conditions  
Bone pain  
 Fractures, malignancy and infection  
Accident and emergency  
 Including rehabilitative aspects of head injury  
Table 2.

Activities for a sample student doing the module on spinal pain

Monday AM Spinal Clinic 9:30–10:30 
 PM Physiotherapy clinical back session 2:00–3:00 
Tuesday AM Rehabilitation prevention and risk (pressure sores), two student groups 
 PM Seminars 1:00–3:00 (All MDD students) 
Wednesday AM Rehabilitation of motor impairment workshop 
 PM Spinal examination skills session 2:00–3:00 
Thursday AM Occupational therapy assistive technology session 
 PM The non-surgical spine: inflammatory and mechanical back pain workshop 
Friday AM The surgical spine: myelopathy and root impingement workshop 
 PM Central lecture teaching in Nottingham 
Monday AM Spinal Clinic 9:30–10:30 
 PM Physiotherapy clinical back session 2:00–3:00 
Tuesday AM Rehabilitation prevention and risk (pressure sores), two student groups 
 PM Seminars 1:00–3:00 (All MDD students) 
Wednesday AM Rehabilitation of motor impairment workshop 
 PM Spinal examination skills session 2:00–3:00 
Thursday AM Occupational therapy assistive technology session 
 PM The non-surgical spine: inflammatory and mechanical back pain workshop 
Friday AM The surgical spine: myelopathy and root impingement workshop 
 PM Central lecture teaching in Nottingham 

Teaching clinical skills

A medical student must become competent at several different types of skills. Firstly, there are psychomotor skills that include, for example, regional examination or the assessment of inflammation in a particular joint. Evidence suggests these skills are best taught in small groups, in a setting which engenders low levels of student anxiety [7] and as true to reality as possible [5, 6, 8]. Previously such skills have been taught by different teachers from different disciplines, but beginners need simple and consistent rules [9], and become all too aware of variation in how they are taught by different teachers [10]. Consequently, we have chosen to base our regional examination on a core skills approach and aim to deter teachers from introducing a confusing assortment of different tests [11]. Our core set of skills is based on Coady's work [12] in reaching a consensus amongst clinicians from a range of backgrounds on the essential skills for students. Further discussion with our colleagues in orthopaedics and rehabilitation departments led to minimal modifications to this core skills set and led to a ‘Derby set’ to be taught by all educators and supported by videos and written documentation. Experience of teaching the GALS examination [1] highlighted the ease with which a choreographed process can be taught and recalled by students. We do not feel that this will cause a fall in standards of student knowledge but rather the establishment of a solid base for development later in the musculoskeletal course.

There are also more cognitive skills with ‘putting of knowledge into action’, such as history taking. This also involves communication and clinical reasoning skills. Again these are best taught in a real-life setting [10, 13]. Traditionally, students take histories unobserved, but observation and immediate feedback can have long lasting benefit [14, 15], even if it is of just a small section of the clerking process [16]. Benefit is also gained by priming the student beforehand [17], including giving an outline of the structure and timing of teaching session, and a brief introduction as to what is wrong with patient. The amount of priming will depend on the objective of the learning session, and the experience of the student. In addition, to help develop a student's clinical problem-solving ability, they should present the particular case in a stepwise manner with interruptions allowing other students to discuss possible diagnoses and the reasoning behind their thoughts [18].

This evidence suggests that students need real patients to practise their history taking skills, but this is best done where the student can be supported, observed, discussion generated and feedback given. Constraints on time, and available and suitable patients, preclude this from being successful in out-patients. To tackle this, we have introduced a series of eight two-hour clinical workshops during the MDD course. Volunteer patients with the appropriate condition are invited. Student:patient ratio is low (aiming at two students per patient), so all students can be actively involved. Each workshop has a short introduction for orientation, then time for the history, using facilitators to observe and assist, a plenary session for student case presentations and finally a summarizing session in which the key points of the histories are discussed. Once in place, each of the themed MDD modules will include two or three such workshops. The piloting of workshops in preparation for course expansion has given a year of experience. The workshops are very popular (according to student feedback) and this has enabled refinement of the content and process in preparation for our next block of students. These workshops will be dependent on patient volunteers but, as discussed below, we do not foresee that as a problem.

A less easily defined skill relates to the art of clinical practice. How does an experienced physician put all these psychomotor and cognitive skills into action? Students clearly need to practise these skills themselves, but there will always be a requirement for observation of the expert. This should not be passive, and we have chosen to devise short, intensive one hour episodes (rather than the traditional ‘morning in clinic’) in which students are encouraged to actively listen and observe, aided by workbooks. Clinicians are not expected to actively teach knowledge or skills, as these learning objectives are addressed elsewhere. This limits the effect of the student on clinical service.

Teaching relevant knowledge

A further area of competency is the acquisition of relevant knowledge. Knowledge has traditionally been imparted through didactic lectures, but as summarized by Ramsden [19], a large body of educational theory would suggest that this is not the most effective. Less effort is required to learn medical knowledge when exposed to it in the context of a particular patient than struggling through a large text or attempting to stay awake in numerous lectures. Psychological research shows that recall (and therefore learning) is best when the learning environment is the same as that of testing or use of the knowledge [20]. Evidence developed in a completely different context (underwater diving) does have face validity, and must add some support to teaching in context and in the practical situation, rather than in the abstract. In addition, the more inexperienced the learner, the greater is need to use concrete, real-life examples [13].

The clerking of patients with ‘cardinal’ conditions is an effective way of gaining knowledge and a tested process in medical education. In 1905, Osler [21] said ‘the best teaching is that taught by the patient himself’ and there is no reason to think this has changed. An outcome of this is ‘illness scripts’ [22]. These are cognitive structures containing the relevant clinical information for a typical case. Illness scripts are often pegged to particular patients and start to be compiled into a cognitive network from the first clinical exposure. They act as an effective but easily accessible store of clinical knowledge. When seeing a new patient the doctor recalls any matching ‘illness script’. Making a diagnosis in rheumatology depends on this type of pattern recognition. To make the ‘patient-stories’ real, students need to be actively involved in the history taking [18]. It is also essential to ask questions of the students during the case discussion, rather than the teaching event being didactic [17].

We have, where possible, apportioned knowledge-based learning objectives to the relevant clinical workshops. It is unlikely that all the objectives will be covered in depth particularly if didactic teaching is avoided. However, the workshops will hopefully engender enthusiasm for students to research topics afterwards. Students retain knowledge better if they have searched it out for themselves, particularly to address a specific question or a need for clarification [23]. There are also areas of knowledge that are difficult in this setting, including more theoretical (e.g. the pharmacology of DMARDs), more ethically challenging (e.g. discussing bone metastases with a patient) and unpredictable or acute conditions that make it difficult to recruit patients (e.g. the acutely septic joint). To address these, we have incorporated a series of interactive case-based seminars in which the topic is approached in the context of a ‘paper’ patient, rather than a real-life case. Many more theoretical topics, such as DMARD options, will still be raised in the workshops to put the information in a clinical and patient-related context.

Teaching appropriate attitudes

The final area of competency is attitude. This can be hard to teach and assess. Doctors they observe in practice can profoundly influence students [24]. We have therefore ensured that whilst a lot of the teaching is carried out away from the clinical service area, students still have opportunities to observe clinical practice. The clinical workshops are an opportunity to discuss ethical issues, often with the patient present so their perspective can be appreciated. All students keep a portfolio to reflect on relevant experience and this is discussed regularly with their portfolio supervisor.

Making best use of clinical material

As outlined above, relying on in-patient or out-patient clinics for patients to teach on brings many difficulties. A large resource is the out-patient community itself, rather than clinic attendees, from which patients might be recruited to help with teaching, particularly in clinical workshops. Rheumatology has a significant number of patients with chronic disease and therefore a large out-patient population that could be used for teaching. By using our experienced nurse specialist to recruit during nurse-run clinics, we have built up an extensive database of volunteers. For some conditions, such as soft-tissue shoulder complaints, we do not see the appropriate ‘simpler’ cases in our clinics. We are therefore aiming to run the relevant workshop with primary care colleagues, recruiting patients from general practice. Patients see themselves making a significant contribution to the student's education [25]. Most volunteer patients are keen to come repeatedly, often refusing any reimbursement. They enjoy ‘giving something back’ and the opportunity to learn more about their condition [26]. There is an argument that the patients used for teaching concurrent to their clinical care are not empowered enough to refuse. We feel that because patients are approached by non-medical staff and separately from their clinical care, they can more easily say no. Others volunteer after seeing posters in the clinical areas.

Patients have been successfully used in a more active role, as teachers rather than models [27, 28]. We are approaching completion of a randomized control trial in this area and may develop this further in the future. We are hoping that for limited clinical skills, such as examination of the rheumatoid hand, or the osteoarthritic knee, a panel of expert patients will be able to teach these skills on their own bodies. There are aspects of disease that patients can teach better than professionals, so that students would not only acquire valuable clinical skills, but also their attitudes to patients and disease would be changed.

Making the best use of manpower

Consultants are an expensive and limited commodity. We asked ourselves which skills, knowledge or attitudes could be taught as well by someone else, and which required the experience of a specialist clinician. There is evidence that non-clinicians can teach basic clinical skills effectively. Physiotherapists, supported by a structured manual and videotape have been shown to be as effective in teaching musculoskeletal examination as internal medicine physicians [29]. Those students who had been taught clinical examination skills by suitably trained nurses performed significantly better when compared with those only taught by doctors [30]. Within rheumatology, orthopaedics and rehabilitation departments, there are highly experienced allied health professionals who have the potential to contribute significantly. For several years, our students have been taught by one of our more experienced nurse specialists in her role as a clinical educator, with very positive student feedback. A study comparing student evaluation of clinical workshops run by this clinical educator compared with a rheumatology consultant has shown no significant difference between the two teachers [31]. We have more recently recruited two more clinical educators, a physiotherapist and an occupational therapist, and have so far trained them to give feedback and discuss third year student case presentations and to teach the GALS screen. Again student feedback has been very positive. Our clinical educators have also been invaluable in finding and liasing with appropriate patients for these ‘novice’ students to see, as well as supporting the students in their early days in the clinical environment. Within orthopaedics, physiotherapists have being used to teach examination skills, and whilst this has underlined the need for a clearly defined core skills set, it has proved feasible and allowed an expansion of teaching beyond that at the consultants could provide.

By constructing a detailed model of the proposed course that included the man-hours requirement for each teaching activity (Table 3), it was possible to calculate the required staffing for each department involved and to put forward detailed bids for funding. Clinical educator time was matched with some SIFT funded clinical service time to enable the post-holders to maintain their clinical skills (one clinical service session:four teaching sessions). For rheumatology, the total requirement came to the equivalent of 1.1 whole time equivalent (WTE) consultants, 2.5 WTE clinical educators as well as several hours of therapy and nursing clinical activity time (for student observation). Together with our colleagues in orthopaedics and rehabilitation, we were successful in our bids to fund new posts along these lines. It was possible, because of the ring-fenced nature of the SIFT funding, for the consultant sessions to ‘back-fill’ clinical sessions of colleagues. This allowed them to increase their teaching commitment whilst still generating an attractive job plan with limited clinical commitments and dedicated time for the delivery and development of teaching. The package was so attractive that an established consultant from Nottingham (CMD) was attracted to the post and started in October 2003. Despite much of the teaching being carried out away from ‘service’ areas, both senior and junior medical staff continue to have an active role in student education.

Table 3.

Teaching activities provided by the rheumatology department

 Monday Tuesday Wednesday Thursday Friday 
0900 Module B: Cases workshop (Dr and CE) Module A: Skills (Dr) Investigations Module B: Skills (CE)–repeat Module B: Cases workshop 2 (Dr and CE) Module A: Cases workshop 2 (Dr and CE) 
1000  Clinic observation (two module B students)  Module A Skills (CE)-repeat  
1100 Module A: Skills (CE) Assessing a joint for inflammation/ disease activity Module D: Cases workshop (Dr and CE) Clinic observation (two module A students) Clinic observation (two module A students) Clinic observation (two module B students) 
1200   DMARD counselling (two module A students)  Module B: Skills (Dr) Investigations 
1300      
1400 Clinic observation (two module A students) Seminar (All students) DMARD counselling (two module A students) Clinic observation (two module B students)  
 Module B: Skills (CE) three students     
 Muscle power and fibromyalgia trigger points     
1500 Module C: Cases workshop (Dr and CE) DMARD counselling (two module A students) Module A: Cases workshop 1 (Dr and CE) Module E: Cases workshop 1 (Dr and CE)  
1600      
 Monday Tuesday Wednesday Thursday Friday 
0900 Module B: Cases workshop (Dr and CE) Module A: Skills (Dr) Investigations Module B: Skills (CE)–repeat Module B: Cases workshop 2 (Dr and CE) Module A: Cases workshop 2 (Dr and CE) 
1000  Clinic observation (two module B students)  Module A Skills (CE)-repeat  
1100 Module A: Skills (CE) Assessing a joint for inflammation/ disease activity Module D: Cases workshop (Dr and CE) Clinic observation (two module A students) Clinic observation (two module A students) Clinic observation (two module B students) 
1200   DMARD counselling (two module A students)  Module B: Skills (Dr) Investigations 
1300      
1400 Clinic observation (two module A students) Seminar (All students) DMARD counselling (two module A students) Clinic observation (two module B students)  
 Module B: Skills (CE) three students     
 Muscle power and fibromyalgia trigger points     
1500 Module C: Cases workshop (Dr and CE) DMARD counselling (two module A students) Module A: Cases workshop 1 (Dr and CE) Module E: Cases workshop 1 (Dr and CE)  
1600      

Sessions are taught to students ‘belonging’ to one of the seven weekly modules (A–G). The times shown are only approximate. Case workshops last 2 h, skills sessions and clinic observation 1 h. In calculating man-power requirements additional time was added for preparation. Some skills sessions run to only three students at a time and are therefore repeated. CE = Clinical educator.

Recruitment of the clinical educators was done in close conjunction with nursing and therapy departments. Because we have been able to appoint our additional clinical educators (one additional nurse, one physiotherapist and one part-time occupational therapist) well in advance of the course expansion, we have and will be able to train them both in medical knowledge and skills, and in teaching skills. Their training programme consists of two phases: a ‘basic’ 8 weeks prior to the third year students starting their classes and a more prolonged 9 months ‘advanced training’ before the increased number of fifth year students start. During the latter they will develop a higher level of knowledge and skills, as well as experience teaching on the smaller number of students. Because of the variation in knowledge and experience that exists between the educators, we have chosen to address the teaching of clinical knowledge by means of a problem-based approach based on weekly clinical cases about which they themselves, with guidance, determine what they need to research and learn. They also participate in dedicated skills teaching as well as have plenty of opportunity to attend current teaching sessions, clinics and ward rounds. Whilst senior nurses are highly likely to have received some formal teaching-skills training, this is currently not the case for therapists. There was, therefore, a need for such training. CMD now delivers a ‘teaching the teachers’ type course, not only for our own clinical educators, but also for other clinical educators in the trust. A ‘peer-evaluation’ scheme by which clinical educators observe each other's teaching and offer mutual support and development is also being set up. It is equally important to ensure that all the medical staff attend similar training. A number of us have either completed, or are undertaking, Master's Degrees in Medical Education. This would be recommended for anyone in a similar position.

Conclusion

It has been a challenging but exciting time for medical education in Derby. The presence of enthusiastic patient volunteers, medical staff and allied health professionals, and the possibility to bid for easily identifiable SIFT funding have been all contributed to what we hope will be a successful development. Evaluation of the course is the important next step and will inform us as to which aspects of the course work well and what need further change. At present we are all very positive!

graphic

The authors have declared no conflicts of interest.

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