Developing rheumatology in the Asia‐Pacific region: it starts with our medical students

At the end of one of my general medical ward rounds last week, I asked my students if they had any questions. The response was almost instantaneous, but not related to the general cases that we had just seen. They wanted extra rheumatology teaching sessions from me. Asked why they needed these sessions, the unanimous reply was ‘rheumatology is difficult’ and ‘I do not know how to properly evaluate a rheumatic disease patient’. This was not the first time my students had asked for extra teaching sessions or commented on how difficult rheumatology was. The possible reasons are manifold. It could be a true reflection of just how difficult rheumatology is for undergraduate students, or that students at my university have extra hunger for knowledge, or my teaching has been substandard. I am glad to read from Dr Geoffrey McColl's article ‘A survey of the musculoskeletal curricula of medical schools in the Asia-Pacific region’1 in this issue that the more probable answer is we allocate too little time in musculoskeletal system teaching. Of the 44 medical schools, out of the 130 approached, who responded to Dr McColl's questionnaire, the average total number of hours of musculoskeletal teaching represented approximately 2% of the total student contact hours only. Although the author stated that this figure was not dissimilar to that from the Canadian medical school average, personally, I feel this is a significant inadequacy considering musculoskeletal disorders are expected to account for approximately 25% of all chronic physical disabilities in developed countries 20 years from now. There is a more urgent need for Asia-Pacific countries to train doctors to manage patients with musculoskeletal complaints because we have fewer rheumatologists, orthopedic surgeons and family physicians per capita compared with Western countries, while our population is ageing at the same, if not greater, rate as the rest of the world. This has to start at the undergraduate level. It is widely believed among medical educationalists that knowledge acquired in the few years spent at a medical school as a student shapes the subject's learning in medicine, as well as his/her future approach to patients. A basic understanding of how to clinically evaluate a person who presents with a musculoskeletal complaint, the patho-etiology of common rheumatic disorders, and the principles of management of these syndromes is essential. Explosion in the understanding of the immunopathology of many chronic rheumatic disorders such as rheumatoid arthritis, ankylosing spondylitis and systemic lupus erythematosus means that close coordination with immunology teaching is desirable. As Dr McColl rightly points out, metabolic bone disorders are going to be a major burden of many health authorities in the next 1–2 decades, thus more emphasis in this area is important. The biochemist, endocrinologist, rheumatologist and orthopedic surgeon need to be brought together to formulate an appropriate teaching program. But how can this be done? First, medical school deans and those who are responsible for running the undergraduate medical curriculum need to be convinced of the potential impact musculoskeletal disorders have on our society. Studies on the cost of arthritis on both local and regional levels are to be encouraged. Second, a structure for the development of a musculoskeletal curriculum needs to be developed. The Bone & Joint Decade has taken this initiative, and the structure suggested by Woolf et al.2 are to be recommended with adaptations to suit local needs. APLAR may have a role here by encouraging the COPCORD Standing Committee to coordinate regional and local cost studies, as well as reinforcing medical schools in this region regarding the importance of a comprehensive undergraduate musculoskeletal curriculum. I commend Dr McColl for conducting the survey. It is an important reminder to us all that while we applaud how efficacious the many novel biologic drugs are in the treatment of common chronic rheumatic disorders, they are of no use if the patients are not being identified, and that musculoskeletal disease awareness starts at an elementary level. Finally, did I find out from my students if my teaching had been substandard? I dared not ask them. However, the Faculty Teaching Medal that was awarded to me 2 years ago did reassure me that I might not be that bad after all!

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