Rheumatology 2009;48:587590

doi:10.1093/rheumatology/kep038

Current teaching of paediatric musculoskeletal medicine within

UK medical schoolsa need for change
Sharmila Jandial1, Tim Rapley2 and Helen Foster1

KEY

WORDS:

Medical education, Paediatrics, Musculoskeletal, Undergraduate teaching.

majority will be benign and self-limiting, MSK features may be

the presentation of severe and even life-threatening illnesses [such
as leukaemia, osteomyelitis, muscular dystrophies, vasculitis, juvenile idiopathic arthritis (JIA) or non-accidental injury (NAI)]. It is
known that delay in access to care is well reported in childhood
diseases with MSK features (such as cancer, muscular dystrophy
and JIA [1013]) and although such delay is multi-factorial, the
clinical assessment and appropriateness of management are likely
to be contributory.
The common and potentially significant MSK presentations in
children warrant that qualifying doctors need to have acquired
core paediatric clinical skills (including pMSK medicine) at undergraduate level. A previous survey of UK medical schools has
shown that reference to pMSK medicine is not included within
adult MSK teaching [2]. A core curriculum which includes pMSK
clinical skills has been proposed for US medical schools (www.
comsep.org), although there is no equivalent as yet in the UK. The
aim of our study was to describe the current status of pMSK
clinical teaching in UK medical schools, both in terms of content,
delivery and assessment. This information will inform curriculum
developers in the future, particularly in the light of the emergence
of Foundation Programmes, the need for graduating doctors to
have appropriate clinical skills and the development of pMSK
clinical tools to facilitate clinical teaching.

Background
Core clinical skills are acquired at medical school with further
improvement within postgraduate training and clinical practice.
Although there is currently no standard medical school curriculum in the UK, attainment of clinical and practical skills is one of
the integral principles proposed by the General Medical Council
(GMC) (www.gmc.org.uk) [1]. Emphasis on musculoskeletal
(MSK) medicine within undergraduate teaching is a key recommendation from the GMC but the focus has been on adult MSK
clinical skills which are routinely taught as part of core teaching [2]. However, children are not small adults and the approach
to clinical evaluation is quite different [3]. It cannot be assumed
that MSK teaching in adult patients will translate into competence in the assessment of children; this is exemplified by observations that many doctors involved in the assessment of children,
including those in primary and secondary care, lack confidence in
their paediatric MSK (pMSK) clinical skills despite many having
experienced adult MSK clinical teaching [4]. Teaching of adult
MSK clinical skills has been greatly facilitated by the structured
adult MSK screening examination called GALS (Gait, Arms,
Legs and Spine) [5] and the development of REMS (Regional
Examination of the MSK System) [6]. In recognition of the clinical assessment being different from adults, an MSK screening
examination for school-aged children, called pGALS has been
validated [7], with a free DVD and supplementary information
being available (www.arc.org.uk).
Children with MSK problems invariably present to primary care
or various secondary care specialities rather than sub-specialists
directly. In the UK, many qualifying doctors enter Foundation
Programmes (http://www.foundationprogramme.nhs.uk) involving the care of children within various specialities (such as paediatrics, accident and emergency medicine, primary care and surgery).
pMSK presentations are a common clinical scenario (reported in
430% of the children and adolescents [8, 9]) and although the

Methods
Child health leads at all UK medical schools which deliver clinical
teaching were sent an electronic questionnaire, with reminders
sent at 2 weeks and 1 month later. An explanatory cover letter
assured confidentiality for all participants and their respective
medical schools. The structured questionnaire was piloted for content validity and was similar in design to previous surveys on
undergraduate teaching [2, 14, 15]. Questions referred to generic
child health teaching (GCHT) such as availability of learning outcomes, clinical environment for delivery, student numbers, modes
of delivery for teaching and assessment, and available support for
teachers. Questions specific to pMSK teaching included lecture
content, provision of clinical skills teaching and assessment. The
respondents were also asked, using a Likert scale, to rank the
quality and relative importance of pMSK teaching compared
with other bodily systems. The project was registered with the

1
Musculoskeletal Research Group and 2Institute of Health and Society, Newcastle
University, Newcastle upon Tyne, UK.

Submitted 20 November 2008; revised version accepted 29 January 2009.

Correspondence to: Helen Foster, Musculoskeletal Research Group, 4th Floor
Catherine Cookson Building, Medical School, Framlington Place, Newcastle
University, Newcastle upon Tyne NE2 4HH, UK. E-mail: h.e.foster@ncl.ac.uk

587
The Author 2009. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

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Objectives. Doctors involved in the assessment of children have low confidence in their clinical skills within paediatric musculoskeletal
(pMSK) medicine and demonstrate poor performance in clinical practice. Core paediatric clinical skills are taught within undergraduate child
health teaching but the extent and content of pMSK clinical skills teaching within medical schools is currently unknown. The aim of this study
was to describe current pMSK teaching content within child health teaching at UK medical schools.
Methods. Structured questionnaires were sent to child health leads at all medical schools within the UK delivering clinical teaching (n 30).
Results. Child health teaching was delivered in all responding medical schools (n 23/30) predominantly by paediatricians (consultants and
senior trainees) and within secondary care. pMSK clinical skills teaching was included in 9/23, delivered predominantly within lectures and
featured uncommonly in assessment (6/23, 26%). pMSK clinical skills were reported as being less well taught than other bodily systems,
although the majority ranked pMSK to be of equal importance, with the exception of development.
Conclusions. pMSK clinical skills medicine is not part of core teaching within child health in the majority of UK medical schools. There is a
need to understand the barriers to effective pMSK clinical skills teaching, to achieve consensus on what should be taught and develop
resources to facilitate teaching at undergraduate level.

Sharmila Jandial et al.

Trust, deemed an audit of current teaching practice and exempted

from ethical approval.

20

Results

16

Number of medical schools

14
12
10
8
6
4
2
0
OSCE

observation

written
exam

long case mini CEX

OSLER

short case

Type of assessment
FIG. 1. Assessments of GCHT at UK medical schools. OCSE: Objective Structured
Clinical Examination; Observation: Observation of student during attachment; miniCEX: Clinical Evaluation Exercise; OSLER: Objective Structured Long Examination Record.

18
taught better than pMSK
taught as well as pMSK
taught less well than pMSK
don't know

Number of child health leads

16
14
12
10
8
6
4
2

in
pm
en
t

sk

ve
lo
de

e
ey

al
ic

ur

ol

m
ne

do

og

in
a

y
to
r
ab

ira

ca

rd

io

va
sc
u

la

Bodily system
FIG. 2. Child health leads perception of how well pMSK clinical skills are taught
compared with other bodily systems.

Discussion
This is the first UK survey to describe pMSK clinical teaching at
undergraduate level, and shows that pMSK clinical skills are
currently taught at a minority of medical schools with marked
variability in content and delivery and were rarely included in
learning outcomes or assessments. These observations, and the
adage that assessment drives learning [16], suggest that pMSK
clinical skills are not perceived as being important to learn, with
little incentive for teachers or students to acquire pMSK clinical
skills. These results are likely to be representative of child health
teaching across the UK with feedback from different types of
medical schools. Furthermore, the study methodology used was
similar to previous studies of teaching in other specialities [14, 15,
17], with a response rate acceptable for a questionnaire study and
optimized by strategies such as pre-testing, reminders and personalized cover letters [18].

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Replies were obtained from child health leads (all paediatricians)

within 23/30 (77%) medical schools (after two reminders) with
representation across England (18/23, 78%), Scotland (3/23,
13%), Wales (1/23, 4%) and Northern Ireland (1/23, 4%), and
covering various models of medical education [problem-based
learning (6/23, 26%), integrated or systems-based learning
(14/23, 61%) and traditional courses (2/23, 9%)] with separate
pre-clinical and clinical components within a 5-year undergraduate course. Amongst the responders, GCHT was delivered at all
medical schools, taught mainly in the latter years [i.e. year 4
(15/23, 65%) and year 5 (10/23, 43%)], with less exposure in
the earlier years [i.e. year 1 (1/23, 4%), year 2 (2/23, 9%) and
year 3 (7/23, 30%)]. Students were predominantly taught in
groups [median 16 (range 460)] and within secondary care
[teaching hospital and district general hospitals (21/23, 91%)]
with less exposure in primary care (13/23, 57%). Most GCHT
was delivered by consultants (23/23, 100%) and specialist registrars in paediatrics (19/23, 83%), with less involvement by primary
care (10/23, 43%), nursing colleagues (10/23, 43%) or patient
educators (4/23, 17%). Support for clinical teachers was available
in 14/23 child health departments, including support methods of
teaching (13/23, 57%) and provision of pre-prepared materials
[slide presentations (10/23, 43%), DVDs (9/23, 39%) and case
summaries for discussion (5/23, 65%)].
Clinical environments for GCHT involved inpatient wards
and outpatient clinics (n 23, 100%), with less use of community
settings (n 5/23, 22%), such as development centres, nurseries
and disability schools. In teaching approaches, the majority used
problem based learning (21/23, 91%), case studies (20/23, 87%)
and seminars (19/23, 83%). Student Selected Components (SSC)
were offered at all medical schools for child health, with few (5/23,
22%) being available in paediatric rheumatology [2/5 were in
larger centres delivering Higher Specialist (Grid) Training in paediatric rheumatology (www.RCPCH.org)]. Assessment of GCHT
(Fig. 1) incorporated both formative and summative assessments
[Objective Structured Clinical Examination (OSCE)], written examinations and global impressions during their attachment.
pMSK clinical skills teaching was delivered within a minority of
child health curricula [pMSK history alone (9/23, 39%), screening
examination (8/23, 35%) and regional examination (5/23, 22%)]
and where specified, was delivered within lectures in 9/23 (39%).
pMSK content was included within assessment in 6/23 (26%)
medical schools. Three child health leads were aware of pMSK
teaching being covered in adult MSK teaching, although the content did not include pMSK clinical skills. The majority of medical
schools (83%) defined GCHT learning outcomes with core presentations, with the limping child in 13/23 (56%). Of the formal
pMSK lectures, recorded content included orthopaedic hip problems (Perthes disease, slipped upper femoral epiphysis, developmental dysplasia of the hip), NAI, and bone and joint sepsis.
Amongst the child health leads, there was a consensus that
pMSK clinical teaching, in relation to other bodily systems, was
less well taught with the exception of development, eyes and skin
(Fig. 2). Nonetheless, the majority rated pMSK clinical teaching
to be equally as important to other systems (Fig. 3). Free text
comments suggested perceived barriers to delivery of pMSK clinical teaching and included pressures on existing busy curricula,
lack of teaching time and the focus of teaching being on acute
paediatric presentations. The majority of the respondents (16/23,
70%) were aware of educational resources to facilitate MSK clinical skills teaching (www.arc.org.uk) with a minority (6/23, 26%)
using the pGALS DVD. The majority (17/23, 74%) were in favour
of a more detailed teaching package to facilitate pMSK clinical
teaching.

18

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sp

588

Teaching of paediatric MSK medicine in UK medical schools

Number of child health leads

16

less important than pMSK

as important as pMSK

more important than pMSK

don't know

12

t
pm
en

in
sk

e
ey

al

lo
de

ve

ur

ol

og

ic

al
m
in
ne

do

ira
sp
re

ab

ul
sc
va
io
rd
ca

Bodily system
FIG. 3. Child health leads perception of importance of pMSK clinical skills compared with other bodily systems.

There is delivery of GCHT in all responding medical schools,

predominantly in the latter years of the undergraduate course but
exposure in the early years reflects the change from traditional
courses with clearly defined clinical and pre-clinical years to integrated or systems-based courses with early clinical involvement
(http://www.gmc-uk.org). However, pMSK medicine and pMSK
clinical skills teaching are included in a minority of GCHT
although there was some inclusion of pMSK medicinebut not
clinical skillswithin adult MSK teaching. Most medical schools
have learning outcomes for GCHT but these invariably did not
include pMSK medicine or clinical skills. Where included, however, themes mentioned were orthopaedic conditions of the hip,
bone and joint infections and NAI. Undoubtedly, these are important but it is noteworthy that common MSK presentations in
primary care and the general paediatric setting (such as normal
variants, non-flammatory MSK conditions and chronic disease
such as JIA) are routinely not included. It is possible that
pMSK themes are covered in other areas of the curriculum (e.g.
gait in neurology or developmental paediatrics), but students
may not necessarily be taught how to approach pMSK assessment
and acquire the appropriate knowledge. Although medical students will be taught adult MSK clinical skills including GALS
[5] and REMS [6], it cannot be assumed that knowledge and
skills learned within adult MSK medicine can either be transferred
or are indeed relevant to paediatrics; furthermore, it is important
to take into account differences within history taking, developmental stage, social and community context, and different disease
processes [3].
Clinical skill acquisition is integral to undergraduate education
and graduating doctors need to be competent in core pMSK clinical skills to assess and appropriately triage children and adolescents who they will commonly encounter with MSK presentations
within Foundation Programmes. The current teaching of pMSK
clinical teaching in UK medical schools is inadequate and this is
recognized by child health leads, who regarded the acquisition of
pMSK clinical skills to be as important as other bodily systems
and yet perceived this to be poorly taught. Barriers to changing
the current situation are complex, include lack of time and pressures of a busy curriculum [19] and may include low self-rated
confidence in pMSK clinical skills confidence amongst qualified
doctors [4], many of whom may be clinical teachers.

We believe that clinical skills pertinent to children are optimally taught within GCHT, both to reinforce their importance
in clinical practice and also to emphasize the differences from
adults. GCHT is currently mainly taught by consultants and
senior training doctors in paediatrics within traditional environments of inpatient wards and outpatient clinics. Notably there is
less teaching by primary care doctors, nurses, therapists or patient
educators, presumably reflecting the current focus being on acute
paediatrics in hospital rather than the child in the community with
chronic disease or common clinical scenarios that may not necessarily require referral to secondary care. It is important that
GCHT is relevant to subsequent clinical practice and is delivered
by clinicians working in such clinical environments. Core paediatric clinical skills, including pMSK, should be taught by paediatricians and also clinicians who see children routinely in their
clinical practice, namely primary care doctors, nurse practitioners
and physical therapists; such individuals can facilitate clinical
teaching in various health care environments and ensure that students are exposed to the broad spectrum of pMSK medicine and
not just acute scenarios in the hospital setting. However, teachers
within GCHT are likely to require additional support given that
many doctors from paediatrics and primary care are not confident
in their pMSK clinical skills [4], and it has been shown that clinicians in adult medicine (and who are not rheumatologists or
orthopaedic surgeons) rank their ability to teach MSK clinical
skills to be lowest compared with the main other bodily systems
with their confidence in teaching being inversely related to the
frequency of performing the skill in their clinical practice [20].
Our study shows that currently there is little support for clinical educators delivering pMSK medicine but that provision of
a teaching package would be welcomed. It is important that
pMSK sub-specialists (i.e. paediatric rheumatologists and paediatric orthopaedic surgeons) are involved in GCHT although their
input is currently not commonplace [4], presumably as they are
often located in larger centres which may be detached from mainstream GCHT teaching in peripheral hospitals.
Changing the current status of pMSK teaching in the UK is a
challenge that requires several issues to be addressed. There needs
to be consensus about pMSK learning outcomes to be acquired
in undergraduate training; they need to include clinical skills and
knowledge relevant to the broad spectrum of pMSK presentations and need to take into account views of doctors in primary,
community and secondary care. The availability of pGALS and
supportive educational resources will raise awareness of the need
to distinguish paediatric from adult MSK teaching but further
resources are required to encourage and support other health
care professionals to become clinical teachers. It is important
that pMSK learning outcomes are included in assessment, with
appropriate validated tools used and akin to those used in postgraduate training; pMSK clinical skills and knowledge are now
integral to general paediatric trainees within competency-based
frameworks (www.rcpch.ac.uk). An increase in the availability
of SSC options (as recommended by the GMC, and often a positive experience for students which may influence final career
choice [21]), will increase exposure to pMSK medicine for students
and as they are invariably offered by paediatric rheumatologists,
this will provide opportunity for greater collaboration with
general paediatric colleagues and facilitate development of pMSK
teaching.
We strongly believe that pMSK medicine should be integral to
core paediatric clinical teaching and as with all other core skills,
be delivered by general paediatricians and primary care doctors.
There is a need to explore and overcome potential barriers to
pMSK clinical teaching, which includes the fact that many doctors
currently involved in GCHT are not confident in their own pMSK
clinical skills [4]. Consequently, in order to deliver improved
pMSK clinical teaching, there is a need to teach the teachers
within paediatrics and primary care. This will require input
from specialists within paediatric rheumatology and paediatric

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Sharmila Jandial et al.

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orthopaedics, although currently within the UK there is inadequate clinical service provision of paediatric rheumatology and
paediatric orthopaedic surgery with a paucity of clinical academic
posts with emphasis on pMSK teaching. A co-ordinated national
implementation strategy is required to provide medical schools
with guidance based on evidence and consensus-based learning
outcomes, assessments and educational resources, which need to
be implemented and evaluated. At a local level it is important that
specialists in pMSK medicine (rheumatology and orthopaedics)
work with colleagues in general paediatrics and primary care
and use clinical networks to facilitate opportunities for pMSK
teaching and learning. Clearly, there is further work to be done
with implications for organization and funding of the delivery
of GCHT, but ultimately these important changes will improve
the acquisition of appropriate pMSK clinical skills for graduating doctors and facilitate improved clinical assessment and
appropriate clinical care for children presenting with MSK
complaints.

Delay in access to specialist care is observed in children with

MSK conditions.

Practising doctors report low self-confidence in their pMSK
clinical skills.

Graduating doctors are likely to encounter paediatric patients
as part of the Foundation Programmes.

What does this study add?

pMSK clinical teaching is not core in most UK medical schools
with variable content and delivery and is infrequently included
in assessment.

Child health leads perceive MSK clinical skills to be as important as, but less well taught than, other bodily systems.

There is a need to achieve consensus on learning outcomes for
pMSK clinical teaching, for pMSK to be included in student
assessments, and for further work to engage health care professionals other than doctors in clinical teaching and provide the
appropriate support and training.

There is a need to develop a national strategy to implement and
evaluate changes to medical school curricula to include pMSK
medicine.

Rheumatology key messages

Most UK medical schools do not include pMSK in core clinical
teaching or assessment.

Consensus on learning outcomes for pMSK clinical teaching and
assessment is needed.

National strategy to implement changes to undergraduate curricula to include pMSK medicine is required.

S.J. is an Educational Research Fellow and T.R. is a social scientist, and both are currently funded by the Arthritis Research
Campaign. Thanks to Dr Kevin Windebank for his help in developing the questionnaire and to all child health leads for their
participation.
Funding: This study was funded by a Newcastle University
Teaching and Research Fellowship.
Disclosure statement: The authors have declared no conflicts of
interest.

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What is already known on this topic?

Acknowledgements