COMMENTARY
NOTES
FROM THE PEANUT GALLERY OF PEDIATRIC RHEUMATOLOGY
Medical Student Education in Pediatric
Rheumatology
“...although
the diseases that kill attract much of the publics attention, musculoskeletal
or rheumatic diseases are the major cause of morbidity throughout the world,
having a substantial influence on health and quality of life, and inflicting an
enormous burden on health systems...rheumatic diseases include more than 150
different conditions and syndromes with the common denominator of pain and
inflammation.”
World Health Organization
2003
Let us put a question to you: How
important is educating medical students in pediatric rheumatology in the
You may indeed question whether
medical school is the right place to educate physicians about musculoskeletal
and rheumatic diseases in children as pediatric residency may be better. No doubt it is crucial to educate pediatric
residents about our area. We need to
have them spend time in our clinics and give them talks. We need to teach them about the
musculoskeletal history, examination, labs and imaging, assessment and
differential diagnosis, and our treatment approaches from our medical,
non-surgical perspective. But even this
objective is not always easy to achieve for our residents, especially if we
have no opportunity to begin this education during their medical school years.
Consider the North American experience. Our opportunities to teach US pediatric
residents about subspecialty knowledge and skills may be decreasing. In the last two years, the eighty hour work
week regulation for US residents appears to be resulting in less subspecialty
outpatient elective time, making this educational objective even harder to
achieve. Despite the focus on
outpatient care in the 1990’s detailed in reports such as the Future of
Pediatric Education II report of 1999, and the drive for generalists to provide
a medical home for the complex child with chronic disease, inpatient care is
often the new focus in residencies with inpatient months increasing,
particularly pediatric intensive care, neonatal intensive care rotations, and
non-ICU inpatient time. How do future
pediatricians learn about outpatient musculoskeletal and rheumatic problems if
they are spending much of their time in inpatient care and in subspecialties
(NICU, PICU, inpatient pediatrics) that they are not going to have to utilize
often in primary care? How does a
primary care pediatrician provide an excellent outpatient medical home for a
complex chronically ill child when the only time he/she sees him/her in
training is in a transient, episodic inpatient experience and rarely as an
outpatient? They don’t.
In many pediatric residency programs, we do not get
time to teach the residents as those subspecialties that are more outpatient
than inpatient are at a distinct educational disadvantage. Residents may never see much of those subspecialists
and conclude that their subject matter is of relative less importance to
surviving their residency and in their education. They may not be able to focus on the
knowledge and skills they will need in primary care nor appreciate that
allergy, dermatology, orthopedics, outpatient infectious disease, and
rheumatology may be as important as pulmonary, cardiology, PICU, NICU, and
inpatient ID. We recently asked a
primary care pediatrician whose office one of us rents 3 days a month to
describe how he spends his time: 10% well baby nursery, 20%
development/adolescent issues, 30% school physicals, 20% outpatient infectious
disease, and 20% divided between other children with many different
subspecialty complaints including musculoskeletal problems (5%). No patients of their 3000 child practice in
the last year were admitted to the PICU and only two were admitted as pediatric
inpatients. So there seems to be a
disconnect in some medical centers and training programs in the US between what
they are exposed to in their residency and what they need in the real world of
the generalist in the US.
Is pediatric rheumatology all about a 16 year old
lupus patient with severe cutaneous vasculitis, renal disease, depression, and
low quality of life? We know it’s
not. But that may be what a pediatric
resident may conclude after taking care of our seriously ill inpatients and
never going to our clinics. Also, the
powers that be in pediatric departments are often from the revenue-generating
and procedure-focused subspecialties - PICU, NICU, cardiology, molecular
biology, and others. What do they know
about our world? Not much - maybe sick
lupus patients, inpatient consults.
Pediatric residency programs that see their mission as educating mostly
general pediatricians for rural areas and in developing countries may also set
a low priority for rheumatology. Again,
the perception is that we take care of unusual problems only, isn’t that
right? So limiting our educational
efforts to teaching pediatric residents has its drawbacks. Optimal teaching opportunities are often
lacking.
We would
suggest to you that we have to start in medical schools. Succeed
there and with time it will make its way up to residencies. We have allies. Internist rheumatologists, physiatrists,
sports medicine specialists, orthopedists, and neurologists may also see a
deficiency in musculoskeletal education in medical school curricula. Together within each medical school we can
work to develop a coordinated musculoskeletal curriculum. In the US it is also coming from top down as
the American Association of Medical Colleges is issuing a report soon endorsing
a more thorough and multidisciplinary education in musculoskeletal
problems. Some medical schools have
started this effort. These efforts
include multidisciplinary courses, patient partner programs, and structured
clinical instruction modules in musculoskeletal medicine (see references).
We are evidence-based on this
issue. In various surveys, 15-30% of
patient visits of patient visits to family practitioners are for a primary
musculoskeletal complaint. In
pediatrics, 10-15% of visits may involve a primary or secondary musculoskeletal
complaint. Then why is our
musculoskeletal education low priority?
It may be partly because our diseases are often chronic and affect
quality of life more than threaten life itself.
They fly beneath the radar and suffer from the Rodney Dangerfield
problem: No respect. Knowledge of the
lay public is lacking. Osteoarthritis
dominates and overshadows (Everyone gets arthritis, right? Nothing you can do! Children don’t get
arthritis, only old people). Changing
old beliefs and misconceptions takes time - start with medical schools, then
residencies, then the public.
As part of an educational project, we have
surveyed pediatric medical school clerkship directors in the
RESULTS:
A) Does your medical school have a pediatric
rheumatologist (PR)?
RESULTS: 39/53 medical schools do (74%); 63 pediatric
rheumatologists total, 10 part-time, 53 full time; mean of 1.8 pediatric rheumatologists
per medical school that have at least one PR.
B) Does a pediatric rheumatologist from another
institution provide your pediatric rheumatology services? RESULT: 4/47 institutions (9%)
C) Are there other faculty members at your institution
who provide the care for your pediatric rheumatology patients? RESULT: 9/53 institutions (17%)
D) Is other medical school faculty involved in teaching
pediatric rheumatology? RESULT: 11/53
medical schools (21%)
E) Does a pediatric rheumatologist have a chance to teach
at morning report,
F) Does a pediatric rheumatologist provide a lecture to
medical students during their pediatric clerkship? RESULT: 12/53
(23%)
G) Do medical students routinely rotate through pediatric
rheumatology clinics? RESULT: 14/52 (27%)
H)
Can medical students at your institution take a pediatric rheumatology
elective? RESULT: 28/53 (53%)
I) Has a visiting professor in pediatric
rheumatology been at your institution?
RESULT: 24/44 (55%)
J)
How would you
rate the importance of teaching rheumatology to medical students during their
pediatric clerkship?
RESULT: Very high __0_____
High___11_____ Moderate ____21____ Low ____16____ Very low ___0____
The point of this survey is an effort to determine
how much opportunity we, as pediatric rheumatologists, currently have to teach
medical students. The survey suggests
that we get a lecture in the student rotations only in ¼ of the medical schools
and have a student in our clinics in only ¼ of the medical schools. We do better in Grand Rounds and core
curriculum lectures, but these exposures for the entire group of medical
students is probably small and most attendees are at the resident level. In the 14 medical schools without a pediatric
rheumatologist, no one teaches medical students about our problems in student
lectures or exposure in Grand Rounds, and resident conferences to our topics is
unusual at best.
If we want to improve education in PR, we must
improve the above data. It is obvious
that we have to keep working to get a PR in every medical school. However, in addition, we would suggest that
we also are not maximizing our educational opportunities in the medical schools
in which we now teach.. In some medical
schools with a pediatric rheumatologist, a PR does not give a student
lecture. In many medical schools with
PR’s, students never rotate through a PR clinic. What are the students missing? Is it just exposure to unusual diseases like
JIA? SLE? Yes, but that‘s not as important as missing
the chance to learn the musculoskeletal and joint exam.
So we
believe that we must market ourselves within our medical schools as the best
pediatricians to teach students the musculoskeletal and joint exam. We are
better at it than orthopedists, sports medicine doctors, physiatrists,
neurologists, and general pediatricians.
No one can teach these important skills and discuss the differential of
musculoskeletal pain in children from the mechanical, inflammatory, infectious,
and rheumatic perspective better than us.
No one. We live it everyday in
our clinics. So let us challenge
ourselves to increase our contribution to teaching students during their
pediatric rotations. We need to tell
our clerkship directors of the importance of teaching students, through formal
lectures and hands-on clinical experience, how to evaluate a child with
musculoskeletal problems. Lobby them and
convince them that this is a basic pediatric examination skill and knowledge
that a student should acquire before graduation from medical school. If there is an existing multidisciplinary
course on musculoskeletal problems for medical students in the medical school,
we should make ourselves a part of it.
Emphasize the importance of having a portion of that curriculum on
children’s musculoskeletal problems. If
there isn’t one, we must lobby for one.
In summary, if we start in medical schools, we
believe that gradually we can achieve success in educating pediatric residents,
pediatricians and the public as well about PR and musculoskeletal problems in
children. It will take time but it can
be done. One day when we introduce
ourselves as pediatric rheumatologists, we hope that other doctors and
professionals and the lay public will know that kids get arthritis and how
expert we are as pediatric rheumatologists at diagnosing and treating these
problems.
Charles
H. Spencer
REFERENCES: