1561 - SPECIAL ARTICLE.- ~ RHEUMATOLOGY EDUCATION IN UNITED STATES MEDICAL SCHOOLS DON L. GOLDENBERG, JOHN H. MASON, RAPHAEL DE HORATIUS, VICTOR GOLDBERG, STEPHEN R. KAPLAN, HAROLD KEISER, MICHAEL D. LOCKSHIN, RICHARD RYNES, JOHN I. SANDSON, H. RALPH SCHUMACHER, and JOHN SKOSEY Although rheumatology manpower in United States medical schools has dramatically increased in the past decade, 13% of medical schools did not have a fulltime staff rheumatologist in 1980. Thirty-eight percent of medical schools had 2 or less full-time rheumatologists. Sta5 rheumatologists and rheumatology fellows provided the majority of medical student education in the clinical aspects of rheumatic disease; however, rheumatologists in less than 50% of medical schools taught in the basic science curriculum or in related fields such as collagen biochemistry, metabolic bone disease, and orthopedic intervention in arthritis. The staff rheumatologists time commitment to medical student education - ~. Don L. Goldenberg, MD: Chairman, ARA Undergraduate Education Subcommittee, Associate Professor of Medicine, Boston University Medical School. Boston, MA; John H. Mason, MA: Socio-Medical Research Associate, Boston University School of Medicine, Boston, MA; Raphael J. De Horatius, MD: Associate Professor of Medicine, Department of Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Victor Goldberg, MD: Associate Professor of Orthopedic Surgery, Case Western Reserve University, Cleveland, Ohio; Stephen R. Kaplan, MD: Associate Professor of Medicine, Brown University Program in Medicine, Providence, RI; Harold Keiser, MD: Associate Professor of Medicine, Albert Einstein College of Medicine, Bronx. NY; Michael D. Lockshin, MD: Chairman, Arthritis Foundation Professional Education Committee, Associate Professor of Medicine, The Hospital for Special Surgery, Cornell University Medical College, NY, NY; Richard Rynes, MD: Associate Professor of Medicine, Albany Medical College, Albany, NY; John I. Sandson, MD: Dean, Boston University School of Medicine, Boston, MA; H. Ralph Schumacher, MD: Chairman, Education Committee, American Rheumatism Association, Professor of Medicine, Hospital of The University of Pennsylvania, Philadelphia, PA; John L. Skosey, MD: Associate Professor of Medicine, University of Illinois College of Medicine, Chicago, IL. Address reprint requests to Don L. Goldenberg, MD, Evans #337, Boston University Medical Center, 75 East Newton St., Boston, MA 021 18. Submitted for publication January 5, 1981; accepted in revised form June 17, 1981. was inversely proportional to the rheumatology faculty size. At medical schools with no rheumatologists, however, there was little, if any, formal education in the rheumatic diseases. Most subjects are taught in systemsoriented lectures. Education is currently limited to the common rheumatic conditions such as bursitis and back pain. Only 62% of medical schools provide a structured course on the musculoskeletal examination. Elective rotations in rheumatology, usually offered in the third or fourth year, are currently being provided to only 15% of U.S. medical students. The adequacy of medical student and house officer education in general medicine and medical subspecialities is currently the subject of much discussion (1). Previous surveys of rheumatology education at US medical schools demonstrated inadequate faculty size but did not explore the content and quality of training in the existing rheumatology sections (2-9). The Undergraduate Education Subcommittee of the Education Committee of the American Rheumatism Association (ARA) was established in 1978-1979 by then ARA President, Dr. Alan S. Cohen, to review the current status of rheumatology training for U.S. medical students. The results of that survey are the basis of this report. As the number of medical schools has increased during the past 2 decades, so has the rheumatology faculty size and time commitment to medical student education. Nevertheless, more than 10% of medical students still receive no formal education in rheumatology. Furthermore, the rheumatology training received by most other medical students may not represent optimal preparation for their future medical practices. Arthritis and Rheumatism, Vol. 24, No. 12 (December 1981)
~ 1562 GOLDENBERG ET AL Table 1. Rheumatologists at U.S. medical schools, 1979-1980 Mean Most Number of per at one schools Rheumatologists Total schools* school with none Full-time 45 1 3.8 19 16 (.13%) Full-time and part-time 764 6.4 24 7 (6%) Fellows 376 3.3 16 25 (22%) Total faculty and 1140 9.6 34 7 (6%) fellows ~ *n = 119. MATERIALS AND METHODS A questionnaire was designed by the committee to tabulate the following items: 1. The total and full-time faculty involved in rheumatology medical student education, including the specific time commitment allocated to such teaching. A staff rheumatologist was considered to be full-time only when designated by the Program Director. 2. The content of any rheumatology education, including titles and specific materials presented in the courses, the percentage of each medical school class participating in the training, time allotted to each subject, the faculty involved in the training, the format of presentation (including text and other material utilized), and the Program Director s assessment of the adequacy of education in 25 selected rheumatologic topics. 3. A more detailed narrative description of the training in the physical examination of the musculoskeletal system and in any clinical electives in rheumatology subjects. 4. The overall adequacy of rheumatology training as assessed by the Program Directors at each institution. Questionnaires were mailed to the Rheumatology Program Directors at each medical school in the U.S., as listed by the American Association of Medical Colleges. If there was no formal rheumatology program, the questionnaire was completed by the Chairman of the Department of Medicine. One hundred and nineteen completed questionnaires, representing every medical school in the U.S., were eventually returned, occasionally after a second mailing and telephone followup. The questionnaire consisted of straightforward, close-ended descriptive statements regarding staff size. teaching involvement, course content, and subject availability. Only a single evaluative question was asked (see item 4, Materials and Methods). Respondent reliability was subject to the accuracy of the responses from the Program Directors. The nature of the relationship between variables was examined. The statistical strength of these relationships was calculated utilizing the nonparametric correlation coefficient Kendall s Tau. Because these inferential statistics were derived from the total population of every medical school, confidence levels for sample populations do not apply. Therefore, all correlation coefficients presented in this report were chosen based on a descriptive strength of 0.20 or higher. RESULTS Staff rheumatologists at U.S. medical schools Staff rheumatologists in 1979-1980 (Table 1). There were 451 full-time staff rheumatologists at the 119 medical schools (mean, 3.8 per school). There were 764 full- and part-time staff (mean, 6.4 per school). The largest number of full-time and total rheumatologists at one medical school were 19 and 24, respectively. Sixteen medical schools (13%) had no full-time staff rheumatologist, and ten others had only one full-time rheumatologist. Seven medical schools (6%) had no full- or part-time rheumatologists. The number of full-time staff rheumatologists correlated positively with the medical school class size (0.35), as did the total rheumatology faculty (0.24). Rheumatology fellows. Since rheumatology fellows were involved in medical student teaching, they were also considered teachers for the purpose of this analysis (Table 1). There was a total of 376 rheumatology fellows in 1979-1980 (3.3 per school). Twenty-five schools (22%) had no fellows. The total number of fellows correlated with the total and full-time rheumatology faculty (0.69). If the fellows and total full-time and part-time staff were combined, there was a rheumatology faculty of almost 10 per school (Table 1). Comparison to staff rheumatologists in 1975. In 1975, 28 of 112 (25%) medical schools had no staf rheumatologist, and 34 others (30%) had only one or two (Table 2). There were more full-time rheumatologists in each category in 1980 than in 1975. There was a greater number of staff rheumatologists at 55% of medical schools in 1980 compared to 1975, and 21% had the same number. Of the 28 schools with no fulltime rheumatologist in 1975, eleven still have none, seven have one, and eight have two or more staff rheumatologists, including two medical schools that now have nine and eight full-time staff, respectively. Ten of the fourteen medical schools that had only one staff rheumatologist in 1975 had at least two in 1980, Table 2. The change in the number of full-time rheumatologists at U.S. medical schools from 1975 to 1980 % of medical schools within Full-time each category rheumatologists per medical school 1975 (n = 112) 1980 (n = 119) 0 25 13 1-2 30 25 3-4 21 28 5 or more 24 34
~~ ~ ~ ~ U.S. RHEUMATOLOGY EDUCATION 1563 Table 3. Time devoted to teaching rheumatology at U.S. medical schools by various faculty groups More %-full than Faculty group* None V2 day day I full day Rheumatology staff I% 41% 33% 21% (n = 112) Rheumatology fellows 2% 51% 34% 13% (n = 94) Other internists 7% 69% 13% 10% (n = 104) Orthopedic staff residents 9% 64% 1% 4% (n = 106) Allied health professionals 21% 63% 14% 2% (n = 70) 'n = number of rheumatology programs using each faculty group. but two still had only one rheumatologist, and two others had lost their sole rheumatologist. Other staff teaching rheumarology. In 87% of medical school programs, other internists, as well as rheumatologists, taught rheumatology to medical students in 1979-80. These other physicians included general internists, immunologists, and physicians trained in rehabilitation medicine. Program Directors in 89% of the medical schools reported that orthopedic staff or trainees were involved in rheumatology training, and 59% of the respondents reported that allied health professionals were involved in rheumatology education for medical students. Faculty time devoted to medical school teaching. Time commitments to rheumatology education were categorized on the basis of average time commitment per staff member. The percentage of staff teaching time was inversely correlated with the size of the rheumatology faculty; that is, the greater the staff size, the less average teaching time per individual. Twentyone percent of rheumatology staff devoted more than a full day each week to a medical student education, and 33% averaged between one-half and a full day per week throughout the year (Table 3). Rheumatology fellows' time commitment to medical student teaching was nearly identical to that of the staff rheumatologists. The time commitment to rheumatology education by other internists, orthopedic surgeons, and allied health professionals was not as great as that of the staff rheumatologists and fellows. Description of education content (Table 4). The broad curricula of courses offered at the medical schools were divided into seven general categories. 1. Basic science. This was usually taught in the first or second year and included any rheumatology education given during traditional basic science subjects such as pathology, anatomy, physiology, pharmacology, biochemistry, or immunology. Rheumatology training was offered within the basic sciences in only 30% of medical schools. Nearly all students in the schools that offered such training received an average of 15 hours of the training per student. Rheumatology staff participated in the instruction at 80% of these schools, although fellows taught at only 10% of the schools offering such training. 2. Physical diagnosis. This usually occurred in the second year and was generally a subsection of a course in general physical diagnosis. Sixty-two percent of medical schools provided formal physical diagnosis in rheumatology, and 91% of the class was taught at these schools. Faculty included rheumatology staff at 90% of the schools and rheumatology fellows at 38% of schools. The mean duration of time spent per student was 6 hours. 3. Introduction to clinical medicine. This described various formats by which clinical rheumatology was taught, usually in the second or early in the third year. It included various clinical subjects with Table 4. Rheumatology curriculum taught at U.S. medical schools. 1979-1980 -- 5% of % of these 76 of these medical schools Mean o/c schools utilizing schools utiliring in which of class rheumatology rheumatology Broad category each category taught in staff to fellows to of curriculum was taught these schools teach subject teach subject Basic science 30 94 80 10 Physical diagnosis 62 91 90 38 Introduction to clinical medicine 81 91 99 38 Rheumatology inpatient 7 27 86 71 Rheumatology consultation 85 18 100 17 Research 7 2 100 61 Other clinical Courses 35 76 95 46
1564 GOLDENBERG ET AL Table 5. Rheumatology subjects taught at U.S. medical schools, 1979-1980 Subject Osteoarthritis Serologic tests in rheumatology Rheumatoid arthritis Systemic lupus erythematosus Ankylosing spondylitis Gout and uric acid metabolism Infectious arthritis Polymyositis Reiter's disease Arthrocentesis Physical examination Scleroderma History taking in arthritis Vasculitis Pharmacology Juvenile rheumatoid arthritis Inflammatory response Metabolic bone disease Collagen biochemistry Orthopedic intervention Low back pain Rheumatic fever Shoulder pain Rehabilitation Psychosocial aspects of rheumatic disease 95 of schools that teach each subject 91 91 90 90 89 88 88 87 86 86 86 80 78 78 77 75 72 67 67 65 59 58 52 52 32 assignments in textbooks of rheumatology, in the Primer on the Rheumatic Diseases, or in other distributed material. Eighty-one percent of schools offered such courses to essentially all medical students at each school. Rheumatology staff were always included as teachers. The number of individual components of these sessions were variable, and the mean of total hours was 23. 4. Rheumatology inpatient teaching service. This included any rotation on an inpatient teaching service consisting largely or totally of rheumatology rather than general medicine patients. Only 7% of schools had such inpatient units. At these schools, an average of less than one-third of the class received such training. The duration of this rotation was 1-2 months. Teaching was done by rheumatology staff and fellows. 5. Rheumatology consultation (elective). This training was usually provided in the third or fourth years for 1-2 months. It consisted of inpatient consultation, some exposure to ambulatory patients, and formal attending rounds. This was the most common rheumatology education format, used at 85% of schools. However, only 18% of medical students participated in such training because only a limited num- ber of such electives was available. Teaching on the consult service was always done by rheumatology faculty, and fellows taught in 77% of these schools as well. 6. Research. This was defined as any research experience in rheumatology or related discipline. A research elective was offered at only 7% of the schools and was provided to only 2% of the class at these schools. The research time was usually at least 2 months and was always supervised by a staff rheumatologist. 7. Other clinical training. This was a miscellaneous category of other formal training in clinical rheumatology, usually in the third or fourth year. It included specific lecture series given during rotations on general medicine or other clinical services. Sometimes courses such as clinical correlates or return-tobasic-science were integrated within the clinical year's framework. Thirty-five percent of the schools offered such training. Specific subject matter taught in the rheumatology curriculum. Twenty-five specific subjects considered most relevant to the education of medical students in rheumatology were listed on the questionnaire (Table 5). The Program Directors were asked to comment on the inclusion of each of these items in their medical student rheumatology education. The percentage of medical schools offering each subject ranged from 91% for subjects such as the use of the serologic tests in rheumatology to only 32% for teaching the psychosocial aspects of arthritis. Other subjects taught at less than two-thirds of medical schools included rehabilitation (48%), shoulder pain (52%), and rheumatic fever (58%). Subjects offered at about 90% of schools included osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, infectious arthritis, polymyositis, and uric acid metabolism. Although most subjects were taught in didactic sessions for 1-2 hours, the range of hours was quite variable. These topics were required at more than three-quarters of the schools at which they were offered. Rheumatology staff physicians were teachers 80-90% of the time in most of these subjects. However, they participated in only 43% of the topics on orthopedic intervention in rheumatology. 48% of education in collagen biochemistry, 55% of courses on metabolic bone disease, and 69% of the lectures on the inflammatory response and lower back pain. There was a strong correlation with the rheumatology faculty size and the number of these subjects that were offered at each medical school. This was
U.S. RHEUMATOLOGY EDUCATION I565 most significant for juvenile rheumatoid arthritis (0.37), collagen biochemistry (0.35), uric acid metabolism (0.33), and systemic lupus erythematosus (0.32). Rheumatology fellows participated in these courses at approximately 25% of the schools, always teaching in concert with a staff rheumatologist. Medical schools used a specific rheumatology textbook for these topics 61% of the time and used the Primer on the Rheumatic Diseases 78% of the time. Rheumatology training during clinical clerkships. Seventy-three percent of medical schools reported additional informal training in rheumatology during the medicine clerkship, 30% provided some in surgery (including orthopedics) and 25% in pediatrics. Neither the content nor duration of such training was indicated, but formal or informal teaching rounds by full-time rheumatology faculty were usually listed. Opinion of Program Directors regarding the adequacy of training of medical students. Seventy-two percent of Program Directors thought that their rheumatology training of medical students was not adequate. Fifty-six percent of Program Directors wanted more in-depth rheumatology elective positions, 45% wanted to increase the training in the physical diagnosis of patients with musculoskeletal problems, and 33% wanted more rheumatology exposure in the basic science years. Only 22% of Program Directors thought that they needed a larger faculty to enhance their medical student education. DISCUSSION This report represents an effort to document the extent and content of rheumatology education being provided to U.S. medical students. Although the questionnaire form was primarily descriptive, the interpretation of these data is subject to the accuracy of the responses from the Program Directors. Validity testing was not performed in regard to the Program Directors responses. For example, each Program Director determined the definition of a rheumatologist and rheurnatology training. Materials relevant to rheumatology may be presented in other disciplines, such as biochemistry, physiology, or endocrinology without the explicit knowledge of the rheumatology Program Director. However, since we surveyed the entire population, i.e. 100% of medical schools, the reliability of such responses should be greatly enhanced. Furthermore, the questionnaire was completed by the Program Director at every medical school with a rheuma- tologist and by the Chairman of the Department of Medicine at seven other schools. This survey does provide useful information in regard to medical student training in rheumatology. We have documented a continued growth in rheumatology faculty manpower during the past decade (Table 2). However, 13% of medical schools still do not have a full-time rheumatologist, and another 9% have only one rheumatologist. These schools provide limited rheumatology education. Rheumatologists at medical schools with a large rheumatology faculty spend significantly less time teaching medical students than rheumatologists at schools with only one or two faculty members. Therefore, it may be possible to effectively use a few staff rheumatologists as teachers if they are provided with adequate protected time. This time is scarce, however, when faculty must also participate in patient care, research, and administration. One survey also reported that the total number of rheumatology subjects taught at each medical school was proportional to the rheumatology faculty size. Thus, there must be a sufficient number of staff rheumatologists to provide adequate medical student education, although simply extending the faculty size does not assure increased teaching commitment. Our report reviewed the format and content of medical student education in rheumatology. The format has not changed substantially in the last 10 years (6). Less than one-third of the medical schools use rheumatologists as teachers in courses concerning the basic sciences. Most clinical rheumatology is taught in a systems-oriented curriculum, usually in the second or third year. A course on the musculoskeletal examination is offered in less than two-thirds of U.S. medical schools. Inpatient rheumatology units or research experience in rheumatology are offered at only 7% of medical schools. Although a clinical elective is offered in all medical schools that have any rheumatology faculty, less than 15% of U.S. medical students participated in such electives. Thus, most medical students do not have an opportunity to interview and examine many patients with common musculoskeletal problems, although these skills are considered the most important rheumatology training objectives by practicing physicians (9). Although most medical students do receive training in the systemic rheumatic diseases such as rheumatoid arthritis or systemic lupus erythematosus, they often receive no didactic or practical education about low back pain, chronic joint pain, and tendinitis or bursitis (Table 5). These are the problems that generalists and
1566 GOLDENBERG ET AL specialists in other medical fields will be treating, and it is therefore appropriate that medical students become familiar with the diagnosis and treatment of these common problems. Since postgraduate rheumatology education was not examined in our survey, there may be some residency training in the common rheumatic illnesses, and the necessary skills to examine and treat ambulatory rheumatology patients may be learned during house officer training. Although some of this training probably occurs in internal medicine, primary care, and orthopedic programs, it is doubtful whether there is much rheumatology education in other medical house officer programs. Therefore, if a core knowledge of rheumatology is important for most, if not all, practicing physicians, the medical schools must provide it. The rheumatology Program Directors responded that to attain better medical student education, the top priority is more in-depth clinical electives. This is not, however, a practical means to teach basic rheumatology skills to all medical students. A core rheumatology training should be integrated into the basic sciences and clinical curriculum. There must be a greater reliance on a multidisciplinary faculty, including rheumatology fellows, other internists. orthopedic surgeons, physiatrists, and allied health professionals. Clinical subjects should emphasize the most frequent or severe rheumatic disorders. Ambulatory training sites must be used to teach common rheumatic problems. Learning objectives should be developed and then tested. In summary, 13% of medical schools still do not have a full-time rheumatologist, and nearly 25% do not have a fellowship training program. These schools often do not provide adequate rheumatology education to their medical students. Medical schools with only one or two rheumatologists use their faculty time in medical student education to a greater extent than schools with a larger faculty. There is no means to assess the most effective faculty use of teaching time, but this time can be tailored to each schools needs. Some minimum rheumatology training is necessary for all medical students; these training objectives should be developed, and curriculum planning should incorporate the delivery of this knowledge throughout the 4 years of medical school. ACKNOWLEDGMENTS The authors wish to thank the rheumatology Program Directors who participated in this study and Drs. Alan S. Cohen, Daniel J. McCarty, and Giles G. Bole, Jr., whose support of this project during their respective terms as President of the American Rheumatism Association was essential. REFERENCES I. Girard RA, Mendenhall RC, Tarlov AR, Radeck SE, Abrahamson S: A national study of internal medicine and its specialties. I. An overview of the practice of internal medicine. Ann Intern Med 90:965-975, 1979 2. Bunim JJ, editor: Kesearch and education in rheumatic diseases: transaction of the First National Conference at the National Institute of Health, Bethesda, 1953 (unpublished) 3. Bunim JJ, editor: Research and education in rheumatic diseases: transaction of the Second National Conference at the National Institute of Health, Bethesda, 1956 (unpublished) 4. Wyngaarden JB: Current problems of undergraduate medical curricula. Arthritis Rheum 11 :235-239, 1968 5. Polley HF, Rudd E: Undergraduate training in rheumatology in medical schools in the USA: abstracts of the Seventh European Rheumatology Congress. London, Arthritis and Rheumatism Council, 1971 (unpublished) 6. The Arthritis Foundation: Professional Education Committee survey, June 1975 (unpublished) 7. Lockshin MD: Do medical students in the United States learn clinical rheumatology? Arthritis Kheum 20:759-760, 1977 8. Rudd E, Lockshin MD: Education in rheumatology for the primary care physician. J Rheumatol 5:99-111, 1978 9. Samuelson 0, Cockayne TW, Williams NJ: Rheumatology: what should students know? Arthritis Rheum 22:290-293, 1978