1. Mr Pat Spielmann SHO Orthopaedics,
The Carpal Bones: A basic test of medical students’ and junior doctors’ knowledge of anatomy
Mr Pat Spielmann SHO Orthopaedics,
Mr Chris Oliver Consultant Trauma Orthopaedic Surgeon
Edinburgh Orthopaedic Trauma Unit
Royal Infirmary of Edinburgh
Abstract
With the changing emphasis of the modern medical school curriculum many senior doctors and authors are commenting on a decline in anatomical knowledge of trainees. This study was conceived to provide a snapshot of medical students’ and junior doctors’ knowledge of anatomy. The carpal bones were chosen as a benchmark for anatomical knowledge as they are easily objectively examined and have clinical relevance to junior doctors in a number of disciplines. 50 questionnaires were completed by medical students (in their 4th or 5th year) and junior doctors in the presence of one author. A maximum of five minutes was allowed to complete the form and volunteers were not allowed to communicate. The questionnaires were completed over a two-week period. 25 medical students, 15 pre-registration house officers (PRHOs) and 10 senior house officers (SHOs) were recruited. The medical students were all in their fourth or fifth year of a five-year course at Edinburgh University Medical School. The junior doctors worked in a range of hospitals and disciplines across south-east Scotland. Of all participants recruited only 15 could correctly name all eight carpal bones. Seven of these were SHOs in Surgery or A&E. 17 medical students (68%) and nine PRHOs (60%) correctly identified less than five carpal bones. Most SHOs (90%) could name five or more bones; the proportion of PRHOs and medical students correctly naming more than five bones was similar (40% vs. 32%). The scaphoid was the most frequently identified bone, with a 92% hit rate. Only 15 candidates (30%) managed to name the triquetrum. The overall recognition scores obtained by medical students are poor; however the SHO's results are more reassuring. Anatomy teaching should not be forgotten in undergraduate and postgraduate training and it must not be further streamlined.
Introduction
With the changing emphasis of the modern medical school curriculum many senior doctors and authors are commenting on a decline in anatomical knowledge of trainees.1,2,3,4 Time spent in the dissecting room has been reduced and students are now reliant upon textbooks or electronic material to aid in the process of understanding and memorising the normal structure of the human body. For many years the act of dissection or the observation of prosected specimens has enabled students to see the 3-dimensional structures and their relations first hand. Several well documented pressures have caused medical schools to reduce the amount of time devoted to the learning of basic sciences including anatomy: Less funding for the preparation and storage of cadavers, tighter regulations regarding ventilation of dissection rooms 2 the pressure on academics to pursue research rather than teach, and the abandoning of the pre-clinical / clinical undergraduate curriculum. While many of these changes undoubtedly produce well rounded, broadly educated young doctors is the cost in terms of a student’s reduced fund of knowledge too high?
This study was conceived to provide a snapshot of medical students’ and junior doctors’ knowledge of anatomy. The carpal bones were chosen as a benchmark for anatomical knowledge as they are easily objectively examined and have clinical relevance to junior doctors in a number of disciplines.
Methods
50 questionnaires were completed by medical students (in their 4th or 5th year) and junior doctors in the presence of one author PS. A maximum of five minutes was allowed to complete the form and volunteers were not allowed to communicate. The questionnaires were completed over a two-week period. The candidates were chosen at random from a range of disciplines and levels of experience. No prior warning was given and prospective candidates who knew of the test were excluded to give as fair a representation of current knowledge as possible.
Results
All 50 questionnaires were completed as planned over two weeks. 25 medical students, 15 pre-registration house officers (PRHOs) and 10 senior house officers (SHOs) were recruited. The medical students were all in their fourth or fifth year of a five-year course at Edinburgh University Medical School. The junior doctors worked in a range of hospitals and disciplines across south-east Scotland. Six of the SHOs were surgical trainees, two worked in Accident & Emergency (A&E), two in General Medicine. The number of correctly identified carpal bones in each group are presented in Table 1 & Figure 1. Of all participants recruited only 15 could correctly name all eight carpal bones. Seven of these were SHOs in Surgery or A&E. Seventeen medical students (68%) and nine PRHOs (60%) correctly identified less than five carpal bones. Most SHOs (90%) could name five or more bones; the proportion of PRHOs and medical students correctly naming more than five bones was similar (40% vs 32%). The performance of the three groups is presented in Figure 2. The scaphoid was the most frequently identified bone, with a 92% hit rate. Only 15 candidates (30%) managed to name the triquetrum. The results classified by bone are presented in Figure 3.
Discussion
Although this is a crude measure of anatomical knowledge it is an objective test and thus provides an insight into the level of knowledge at different stages of training. Medical students in their 4th & 5th years would normally be preparing for final exams with a view to becoming pre-registration house officers. As such their knowledge of anatomy would be formally tested; it is therefore disappointing that only four of 25 could name all eight bones correctly. The vast amount of knowledge that must be assimilated for these exams is a formidable task but anatomy must still play a central role. The pre-registration house officers scored evenly, some demonstrating a sound grasp of anatomy others less so. The larger, more commonly injured bones are the most recognised by all groups. The trapezium, trapezoid and triquetrum were frequently mixed up, less than one third of candidates were able to identify the trapezium as the bone at the base of the thumb.
The scores obtained by the SHOs are reassuring, anatomy is central to surgical training as well as Emergency Medicine, and is formally examined in the MRCS exam. These results would suggest that gaps in anatomical knowledge are filled by the time junior doctors become SHOs especially if working in surgery or A&E. Postgraduate training has been shortened and is to be further streamlined to produce more doctors trained to a minimum standard of competence. Basic Surgical Training now takes a minimum of two years and with the reduction in working hours less time than ever before is actually spent in the operating theatre. These ‘windows’ 5 should not be used to learn the relevant anatomy rather they should be for the training of surgical skills. The pressure on trainees to get the most out of every working hour is great. A sound knowledge of anatomy remains central to understanding disease processes and the principles of management, let alone surgical technique.
Anatomy teaching should not be forgotten in undergraduate and postgraduate training and it must not be further streamlined.
Figure 1. Number of correctly identified carpal bones.
0-2
3,4
5,6
7,8
Medical Students (yrs 4/5) 5 12 4
PRHO 2
SHO 1 7
Figure 2. Chart showing scores as percentage according to group.
Figure 3. Number of times each bone was correctly identified
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