40
RHEUMATOLOGY AND REHABILITATION VOL. XV NO. 1 REFERENCES
HM 62/18 (1962) Note: The Provision of Physiotherapy in Hospitals. Ministry of Health: Central Health Services Council Standing Medical Advisory Committee. Rehabilitation: Report of a Sub-committee of the Standing Medical Advisory Committee (1972) London: H.M.S.O.
3. UNDERGRADUATE TEACHING OF RHEUMATOLOGY BY V. WRIGHT
THIS contribution is not a directive on how rheumatology should be taught, but a description of what is done at the University of Leeds and the reasons behind the course. In every Medical School there are constraints that mould the programme, so that one has sympathy for the battered boxer who gasped to his second in between rounds, 'Couldn't we forget the strategy, and just fight for our lives ?' The great constraint is rinding time in an overcrowded curriculum, so that while rheumatology should most properly be taught in the context of general medicine, it may be easier to slot it into the block of orthopaedic teaching. The one other point to emphasize in a time of financial stringency, when Universities are reluctant to spend money on anything other than undergraduate teaching, is that 'he who learns from a teacher not actively engaged in research drinks from a stagnant pond' (Truscott: Red Brick University).
MATERIAL At Leeds, rheumatological teaching is undertaken in the third, fourth and fifth years. In the third year there is an Introductory Lecture beginning with some well chosen remarks on the importance of the subject (such as the fact that it will figure prominently in the Finals Examination), continuing with the prizewinningfilmProblems In Living (demonstrating the impact of rheumatoid arthritis on the lives of individual sufferers), a short television presentation on history-taking and an opportunity for questions. There is also an intensive three weeks of integrated teaching on the locomotor system with rheumatologists, orthopaedic surgeons, anatomists, bioengineers, pathologists, biochemists and remedial staff members. The organization of the course bows down at the shrine of integrated teaching, and helps to dispel the illusion that a University is a series of departments held together by either a central heating system or a common grievance over parking. Some of the results from a questionnaire given to the students at the conclusion of the course are shown in Table I. It will be seen that while students appreciated the integration of the material, they did not favour the integration of the participants. To run a successful integrated course in which more than one staff member is present at each session demands so much time before and during the course that I do not think the gains are worth the pains. In the fourth year the students are taught for the final 10 days of an orthopaedic block infirmsof up to 12 members. This is the crucial period and will be discussed in more detail. In the fifth year, tutorials on the ward are conducted once a week throughout the year, and students must attend two of those in rheumatology—no more than 12 students being taken at any one time (first come, first served). During an elective period of two months, rheumatology may be selected for all or part of this time. The students become
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on May 28, 2015
Professor of Rheumatology, University of Leeds, Leeds LS2 9JT
GLANVILLE ET AL.: TEACHING RHEUMATOLOGY
41
TABLE I QUESTIONNAIRE ON AN INTEGRATED COURSE ON THE LOCOMOTOR SYSTEM (84 STUDENTS)
33 14 14 6 5 4 4 3 3 2
2. What did you dislike ? Most of lectures Fragmentation Superficiality Orthopaedic surgeons Repetitiveness O.T. Physiotherapy Posture and gait
20 19 18 14 6 4 3 2
3. Did the integrated nature of the teaching (more than one expert) help?
4. Did the integrated nature of the subject matter help?
No Marginally Yes Enthusiastic
No Marginally Yes Enthusiastic
50 13 17 —
29 11 38 2
5. Preference on teaching
Orthopaedics Accident Rheumatology Anatomy Bioengineering
More 32 51 45 11 22
Less 17 2 4 26 17
Same IS 21 30 37 37
No Answer 10 10 5 10 8
6. Preference for block rather than spread over a period Yes 58 No 11 No answer 11 part of the Unit, participating in all the activities (including the research meetings at 7.30 a.m.)- The staff go to great trouble to make this of maximum enjoyment and benefit to the student, including financing a visit to a meeting of the B.A.R.R. or Heberden Society if this coincides. One volunteer is worth the 119 pressed men we have during the rest of the year and deserves the elaborate arrangements made. Fourth year The clinical teaching of the fourth year is regarded as the most important The aims of the teachers are: 1. To stimulate the students' interest. 2. To demonstrate the importance of the subject. 3. To teach the students how to analyse and synthesize clinical material. 4. To impart an ability to deal with clinical situations. 5. To make the students discontented with a superficial approach. At the conclusion of each firm a questionnaire is given to the students, which is completed anonymously. Some results are shown in Table II. These are discussed by the staff and amendments made to the teaching content and method in the light of the findings, the zeal of the group of students (the overwhelming desire of a slack group for
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on May 28, 2015
1. What did you like about the course ? Accident (esp. First Aid) Rheumatology Virtually nothing Limited to 3/52 Bioengineering Clinical demonstrations Amusing presentation Anatomy Osteomalacia The physiotherapist!
42
RHEUMATOLOGY AND REHABILITATION VOL. XV NO. 1 TABLE U SOME RESULTS OF A QUESTIONNAIRE AFTER FOURTH-YEAR TEACHING BLOCK
1. Did you find it helpful?
95 5 77 18 5 67 33
8 8 84 41 96
'more coffee breaks' under the heading Constructive Comments is not given undue weight) and the educational objectives. Such feed-back is valuable, but is not of course given from the vantage point of fuller experience and must be interpreted with that reservation. Those students who preferred tutorials did not like ward teachings, and vice versa. This emphasizes that different teaching methods suit different personalities and it is easy to forget the heterogeneity of the group taught. Visits to a special unit such as that at Harrogate were appreciated if special cases were selected and a pre-arranged teaching programme organized. To my surprise the combined Rheumatic-Orthopaedic Clinic is not much appreciated, which raises the question of whether this is a postgraduate discipline rather than a suitable exposure for undergraduates. The need for interpretation of such questionnaires is well illustrated by the inclusion under 'topics you would like covered' of subjects that had in fact been discussed, but from which the student was absent for reasons legitimate or otherwise. Problems The first problem is illustrated by the irate secretary who exclaimed to her demanding boss 'If you didn't give me so much to do I might get some of it done'. Students disliked intensely the clashing of other commitments with the rheumatology teaching. The curriculum is already over-burdened and we are in danger of producing students a mile wide and an inch deep (sorry—a km wide and a cm deep). Whilst wishing to give the student a broad view of medicine, some subjects have to be left to postgraduate training: orthopaedic surgery may well be one such. Secondly, there is the danger of many University departments failing to develop resourcefulness. Too many departments produce students with maximum honours and minimum 'gump'. The latter is a Yorkshire phrase denoting drive, initiative and general competence. The expanded form 'gumption' is to be found in Roget's Thesaurus under 'Activity'—enterprise, enterprisingness, initiative, aggression, pushfulness, pushingness, push, drive, hustle, get, get up, get-up and get-on, go, go-ahead, go-to-itiveness, up-andcomingness, up-and-doingness, go-getoism, and get-there (both slang). It is also found
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on May 28, 2015
2. Was it relevant at this stage? Should be later Should be with medical not a surgical block 3. Duration? Should be longer Same Shorter Abolished 4. Views on Combined Rheumatic-Orthopaedic Clinic Disliked Helpful ' Apathetic 5. What did you like about the course? The A.R.C. Reports on Rheumatic Diseases 6. What did you dislike about the course? Clashing with other commitments
Yes No Yes
GLANVILLE ET AL.: TEACHING RHEUMATOLOGY
43
under 'Intelligence, wisdom'—sagacity, astuteness, acumen, flair, long headedness, hard headedness, foresightedness. Such attributes have much to commend them in a soft society, whatever academic purists may think.
4. OBJECTIVES IN UNDERGRADUATE TRAINING BY P. H. N. WOOD ARC Epidemiology Research Unit, Stopford Building (University of Manchester), Oxford Road, Manchester MJ3 9PT
IT is helpful to begin by reminding you of Plutarch's aphorism, that teaching is concerned with kindling a flame rather than with filling a vessel. From this stem a number of conclusions. First, the flame is more likely to be kindled by the challenge of individual human problems. Thus clinical exposure is likely to be a much more rewarding educational experience than sitting through a series of theoretical lectures. Yet the latter form not only the staple but almost the only diet available to everyone in a given year at too many medical schools (Wood and Benn, 1972). Secondly, in the limited time available one cannot hope to fill the vessel anyway. Thus one cannot be exhaustive, and all one can strive for is to establish the framework for a philosophy of approach. This philosophy is concerned with problem-solving, particularly in relation to the problems that arise over a long time-scale, as is encountered with a chronic disease like arthritis. This again argues for clinical exposure, trying to build up a composite of the courses patients follow over years. Theoretical models are of very limited value in trying to indicate these personal and human needs.
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on May 28, 2015
SUMMARY AND CONCLUSIONS (1) An outline of the rheumatological teaching in the University of Leeds has been given. (2) In the third year there is an introductory lecture and a three-week Integrated Course on the Locomotor System, in the fourth year a 10-day block of clinical teaching to firms of up to 12 students, and in the fifth year a series of clinical tutorials and an available elective period. (3) The teaching is moulded to some extent by anonymous questionnaires given to the students at the end of each sequence of teaching, and this practice is recommended. (4) Manpower resources and effectiveness of the method should cause serious reconsideration of integrated teaching. (5) The personality of the student in relation to the teaching method must be considered. (6) No other factor is so important as the enthusiasm of the teacher, and this is linked with research involvement, a fact that must not be overlooked in the formulation of mistaken policies that would finance only 'pure' undergraduate teaching. (7) The student is in danger of drowning in a sea of knowledge. A determined attempt must be made to ascertain the subjects which should be left to postgraduate training programmes.
RHEUMATOLOGY AND REHABILITATION VOL. XV NO. 1 REFERENCES
HM 62/18 (1962) Note: The Provision of Physiotherapy in Hospitals. Ministry of Health: Central Health Services Council Standing Medical Advisory Committee. Rehabilitation: Report of a Sub-committee of the Standing Medical Advisory Committee (1972) London: H.M.S.O.
3. UNDERGRADUATE TEACHING OF RHEUMATOLOGY BY V. WRIGHT
THIS contribution is not a directive on how rheumatology should be taught, but a description of what is done at the University of Leeds and the reasons behind the course. In every Medical School there are constraints that mould the programme, so that one has sympathy for the battered boxer who gasped to his second in between rounds, 'Couldn't we forget the strategy, and just fight for our lives ?' The great constraint is rinding time in an overcrowded curriculum, so that while rheumatology should most properly be taught in the context of general medicine, it may be easier to slot it into the block of orthopaedic teaching. The one other point to emphasize in a time of financial stringency, when Universities are reluctant to spend money on anything other than undergraduate teaching, is that 'he who learns from a teacher not actively engaged in research drinks from a stagnant pond' (Truscott: Red Brick University).
MATERIAL At Leeds, rheumatological teaching is undertaken in the third, fourth and fifth years. In the third year there is an Introductory Lecture beginning with some well chosen remarks on the importance of the subject (such as the fact that it will figure prominently in the Finals Examination), continuing with the prizewinningfilmProblems In Living (demonstrating the impact of rheumatoid arthritis on the lives of individual sufferers), a short television presentation on history-taking and an opportunity for questions. There is also an intensive three weeks of integrated teaching on the locomotor system with rheumatologists, orthopaedic surgeons, anatomists, bioengineers, pathologists, biochemists and remedial staff members. The organization of the course bows down at the shrine of integrated teaching, and helps to dispel the illusion that a University is a series of departments held together by either a central heating system or a common grievance over parking. Some of the results from a questionnaire given to the students at the conclusion of the course are shown in Table I. It will be seen that while students appreciated the integration of the material, they did not favour the integration of the participants. To run a successful integrated course in which more than one staff member is present at each session demands so much time before and during the course that I do not think the gains are worth the pains. In the fourth year the students are taught for the final 10 days of an orthopaedic block infirmsof up to 12 members. This is the crucial period and will be discussed in more detail. In the fifth year, tutorials on the ward are conducted once a week throughout the year, and students must attend two of those in rheumatology—no more than 12 students being taken at any one time (first come, first served). During an elective period of two months, rheumatology may be selected for all or part of this time. The students become
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on May 28, 2015
Professor of Rheumatology, University of Leeds, Leeds LS2 9JT
GLANVILLE ET AL.: TEACHING RHEUMATOLOGY
41
TABLE I QUESTIONNAIRE ON AN INTEGRATED COURSE ON THE LOCOMOTOR SYSTEM (84 STUDENTS)
33 14 14 6 5 4 4 3 3 2
2. What did you dislike ? Most of lectures Fragmentation Superficiality Orthopaedic surgeons Repetitiveness O.T. Physiotherapy Posture and gait
20 19 18 14 6 4 3 2
3. Did the integrated nature of the teaching (more than one expert) help?
4. Did the integrated nature of the subject matter help?
No Marginally Yes Enthusiastic
No Marginally Yes Enthusiastic
50 13 17 —
29 11 38 2
5. Preference on teaching
Orthopaedics Accident Rheumatology Anatomy Bioengineering
More 32 51 45 11 22
Less 17 2 4 26 17
Same IS 21 30 37 37
No Answer 10 10 5 10 8
6. Preference for block rather than spread over a period Yes 58 No 11 No answer 11 part of the Unit, participating in all the activities (including the research meetings at 7.30 a.m.)- The staff go to great trouble to make this of maximum enjoyment and benefit to the student, including financing a visit to a meeting of the B.A.R.R. or Heberden Society if this coincides. One volunteer is worth the 119 pressed men we have during the rest of the year and deserves the elaborate arrangements made. Fourth year The clinical teaching of the fourth year is regarded as the most important The aims of the teachers are: 1. To stimulate the students' interest. 2. To demonstrate the importance of the subject. 3. To teach the students how to analyse and synthesize clinical material. 4. To impart an ability to deal with clinical situations. 5. To make the students discontented with a superficial approach. At the conclusion of each firm a questionnaire is given to the students, which is completed anonymously. Some results are shown in Table II. These are discussed by the staff and amendments made to the teaching content and method in the light of the findings, the zeal of the group of students (the overwhelming desire of a slack group for
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on May 28, 2015
1. What did you like about the course ? Accident (esp. First Aid) Rheumatology Virtually nothing Limited to 3/52 Bioengineering Clinical demonstrations Amusing presentation Anatomy Osteomalacia The physiotherapist!
42
RHEUMATOLOGY AND REHABILITATION VOL. XV NO. 1 TABLE U SOME RESULTS OF A QUESTIONNAIRE AFTER FOURTH-YEAR TEACHING BLOCK
1. Did you find it helpful?
95 5 77 18 5 67 33
8 8 84 41 96
'more coffee breaks' under the heading Constructive Comments is not given undue weight) and the educational objectives. Such feed-back is valuable, but is not of course given from the vantage point of fuller experience and must be interpreted with that reservation. Those students who preferred tutorials did not like ward teachings, and vice versa. This emphasizes that different teaching methods suit different personalities and it is easy to forget the heterogeneity of the group taught. Visits to a special unit such as that at Harrogate were appreciated if special cases were selected and a pre-arranged teaching programme organized. To my surprise the combined Rheumatic-Orthopaedic Clinic is not much appreciated, which raises the question of whether this is a postgraduate discipline rather than a suitable exposure for undergraduates. The need for interpretation of such questionnaires is well illustrated by the inclusion under 'topics you would like covered' of subjects that had in fact been discussed, but from which the student was absent for reasons legitimate or otherwise. Problems The first problem is illustrated by the irate secretary who exclaimed to her demanding boss 'If you didn't give me so much to do I might get some of it done'. Students disliked intensely the clashing of other commitments with the rheumatology teaching. The curriculum is already over-burdened and we are in danger of producing students a mile wide and an inch deep (sorry—a km wide and a cm deep). Whilst wishing to give the student a broad view of medicine, some subjects have to be left to postgraduate training: orthopaedic surgery may well be one such. Secondly, there is the danger of many University departments failing to develop resourcefulness. Too many departments produce students with maximum honours and minimum 'gump'. The latter is a Yorkshire phrase denoting drive, initiative and general competence. The expanded form 'gumption' is to be found in Roget's Thesaurus under 'Activity'—enterprise, enterprisingness, initiative, aggression, pushfulness, pushingness, push, drive, hustle, get, get up, get-up and get-on, go, go-ahead, go-to-itiveness, up-andcomingness, up-and-doingness, go-getoism, and get-there (both slang). It is also found
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on May 28, 2015
2. Was it relevant at this stage? Should be later Should be with medical not a surgical block 3. Duration? Should be longer Same Shorter Abolished 4. Views on Combined Rheumatic-Orthopaedic Clinic Disliked Helpful ' Apathetic 5. What did you like about the course? The A.R.C. Reports on Rheumatic Diseases 6. What did you dislike about the course? Clashing with other commitments
Yes No Yes
GLANVILLE ET AL.: TEACHING RHEUMATOLOGY
43
under 'Intelligence, wisdom'—sagacity, astuteness, acumen, flair, long headedness, hard headedness, foresightedness. Such attributes have much to commend them in a soft society, whatever academic purists may think.
4. OBJECTIVES IN UNDERGRADUATE TRAINING BY P. H. N. WOOD ARC Epidemiology Research Unit, Stopford Building (University of Manchester), Oxford Road, Manchester MJ3 9PT
IT is helpful to begin by reminding you of Plutarch's aphorism, that teaching is concerned with kindling a flame rather than with filling a vessel. From this stem a number of conclusions. First, the flame is more likely to be kindled by the challenge of individual human problems. Thus clinical exposure is likely to be a much more rewarding educational experience than sitting through a series of theoretical lectures. Yet the latter form not only the staple but almost the only diet available to everyone in a given year at too many medical schools (Wood and Benn, 1972). Secondly, in the limited time available one cannot hope to fill the vessel anyway. Thus one cannot be exhaustive, and all one can strive for is to establish the framework for a philosophy of approach. This philosophy is concerned with problem-solving, particularly in relation to the problems that arise over a long time-scale, as is encountered with a chronic disease like arthritis. This again argues for clinical exposure, trying to build up a composite of the courses patients follow over years. Theoretical models are of very limited value in trying to indicate these personal and human needs.
Downloaded from http://rheumatology.oxfordjournals.org/ at New York University on May 28, 2015
SUMMARY AND CONCLUSIONS (1) An outline of the rheumatological teaching in the University of Leeds has been given. (2) In the third year there is an introductory lecture and a three-week Integrated Course on the Locomotor System, in the fourth year a 10-day block of clinical teaching to firms of up to 12 students, and in the fifth year a series of clinical tutorials and an available elective period. (3) The teaching is moulded to some extent by anonymous questionnaires given to the students at the end of each sequence of teaching, and this practice is recommended. (4) Manpower resources and effectiveness of the method should cause serious reconsideration of integrated teaching. (5) The personality of the student in relation to the teaching method must be considered. (6) No other factor is so important as the enthusiasm of the teacher, and this is linked with research involvement, a fact that must not be overlooked in the formulation of mistaken policies that would finance only 'pure' undergraduate teaching. (7) The student is in danger of drowning in a sea of knowledge. A determined attempt must be made to ascertain the subjects which should be left to postgraduate training programmes.
