n. (in dentistry) non-carious tooth-surface loss caused by tooth-to-tooth contact. A small amount of attrition occurs with age but accelerated wear may occur in *bruxism and with certain diets.
A range of research investigations has developed within medical education. These apply to course monitoring, audit, development and validation, assessment methodologies and the application of educationally appropriate principles at undergraduate and postgraduate levels. Research is undertaken by medical educationalists whose backgrounds include teaching, social sciences and medicine and related health-care specialties, and who will hold a medical or general educational diploma, degree or other appropriate postgraduate quali?cation.
Development and validation for all courses are an important part of continuing accreditation processes. The relatively conservative courses at both undergraduate and postgraduate levels, including diplomas and postgraduate quali?cations awarded by the specialist medical royal colleges (responsible for standards of specialist education) and universities, have undergone a range of reassessment and rede?nition driven by the changing needs of the individual practitioner in the last decade. The stimuli to change aspects of medical training have come from the government through the former Chief Medical O?cer, Sir Kenneth Calman, and the introduction of new approaches to specialist training (the Calman programme), from the GENERAL MEDICAL COUNCIL (GMC) and its document Tomorrow’s Doctors, as well as from the profession itself through the activities of the British Medical Association and the medical royal colleges. The evolving expectations of the public in their perception of the requirements of a doctor, and changes in education of other groups of health professionals, have also led to pressures for changes.
Consequently, many new departments and units devoted to medical education within university medical schools, royal colleges and elsewhere within higher education have been established. These developments have built upon practice developed elsewhere in the world, particularly in North America, Australia and some European countries. Undergraduate education has seen application of new educational methods, including Problem-Based Learning (PBL) in Liverpool, Glasgow and Manchester; clinical and communications skills teaching; early patient contact; and the extensive adoption of Internet (World Wide Web) support and Computer-Aided Learning (CAL). In postgraduate education – driven by European directives and practices, changes in specialist training and the needs of community medicine – new courses have developed around the membership and fellowship examinations for the royal colleges. Examples of these changes driven by medical education expertise include the STEP course for the Royal College of Surgeons of England, and distance-learning courses for diplomas in primary care and rheumatology, as well as examples of good practice as adopted by the Royal College of General Practitioners.
Continuing Professional Development (CPD) and Continuing Medical Education (CME) are also important aspects of medical education now being developed in the United Kingdom, and are evolving to meet the needs of individuals at all stages of their careers.
Bodies closely involved in medical educational developments and their review include the General Medical Council, SCOPME (the Standing Committee on Postgraduate Medical Education), all the medical royal colleges and medical schools, and the British Medical Association through its Board of Medical Education. The National Health Service (NHS) is also involved in education and is a key to facilitation of CPD/CME as the major employer of doctors within the United Kingdom.
Several learned societies embrace medical education at all levels. These include ASME (the Association for the Study of Medical Education), MADEN (the Medical and Dental Education Network) and AMEE (the Association for Medical Education in Europe). Specialist journals are devoted to research reports relating to medical educational developments
(e.g. Academic Medicine, Health Care Education, Medical Education). The more general medical journals (e.g. British Medical Journal, New England Journal of Medicine, The Lancet, Annals of the Royal College of Surgeons) also carry articles on educational matters. Finally, the World Wide Web (WWW) is a valuable source of information relating to courses and course development and other aspects of modern medical education.
The UK government, which controls the number of students entering medical training, has recently increased the quota to take account of increasing demands for trained sta? from the NHS. More than 5,700 students – 3,300 women and 2,400 men – are now entering UK medical schools annually with nearly 28,600 at medical school in any one year, and an attrition rate of about 8–10 per cent. This loss may in part be due to the changes in university-funding arrangements. Students now pay all or part of their tuition fees, and this can result in medical graduates owing several thousand pounds when they qualify at the end of their ?ve-year basic quali?cation course. Doctors wishing to specialise need to do up to ?ve years (sometimes more) of salaried ‘hands-on’ training in house or registrar (intern) posts.
Though it may be a commonly held belief that most students enter medicine for humanitarian reasons rather than for the ?nancial rewards of a successful medical career, in developed nations the prospect of status and rewards is probably one incentive. However, the cost to students of medical education along with the widespread publicity in Britain about an under-resourced, seriously overstretched health service, with sta? working long hours and dealing with a rising number of disgruntled patients, may be affecting recruitment, since the number of applicants for medical school has dropped in the past year or so. Although there is still competition for places, planners need to bear this falling trend in mind.
Another factor to be considered for the future is the nature of the medical curriculum. In Britain and western Europe, the age structure of a probably declining population will become top-heavy with senior citizens. In the ?nancial interests of the countries affected, and in the personal interests of an ageing population, it would seem sensible to raise the pro?le of preventive medicine – traditionally rather a Cinderella subject – in medical education, thus enabling people to live healthier as well as longer lives. While learning about treatments is essential, the increasing specialisation and subspecialisation of medicine in order to provide expensive, high-technology care to a population, many of whom are suffering from preventable illnesses originating in part from self-indulgent lifestyles, seems insupportable economically, unsatisfactory for patients awaiting treatment, and not necessarily professionally ful?lling for health-care sta?. To change the mix of medical education would be a di?cult long-term task but should be worthwhile for providers and recipients of medical care.... medical education
Causes There is a major immunogenetic predisposition to rheumatoid arthritis in people carrying the HLA-DR4 antigen (see HLA SYSTEM). Other minor immunogenetic factors have also been implicated. In addition, there is a degree of familial clustering which suggests other unidenti?ed genetic factors. Genetic factors cannot alone explain aetiology, and environmental and chance factors must be important, but these have yet to be identi?ed.
Epidemiology Rheumatoid arthritis more commonly occurs in women from the age of 30 onwards, the sex ratio being approximately 4:1. Typical rheumatoid arthritis may occur in adolescence, but in childhood chronic SYNOVITIS usually takes one of a number of di?erent patterns, classi?ed under juvenile chronic arthritis.
Pathology The primary lesion is an in?ammation of the synovial membrane of joints. The synovial ?uid becomes diluted with in?ammatory exudate: if this persists for months it leads to progressive destruction of articular CARTILAGE and BONE. Cartilage is replaced by in?ammatory tissue known as pannus; a similar tissue invades bone to form erosions. Synovitis also affects tendon sheaths, and may lead to adhesion ?brosis or attrition and rupture of tendons. Subcutaneous and other bursae may be involved. Necrobiotic nodules also occur at sites outside synovium, including the subcutaneous tissues, the lungs, the pericardium and the pleura.
Clinical features Rheumatoid arthritis varies from the very mild to the severely disabling. Many mild cases probably go undiagnosed. At least 50 per cent of patients continue to lead a reasonably normal life; around 25 per cent are signi?cantly disabled in terms of work and leisure activities; and a minority become markedly disabled and are limited in their independence. There is often an early acute phase, followed by substantial remission, but in other patients gradual step-wise deterioration may occur, with progressive involvement of an increasing number of joints.
The diagnosis of rheumatoid arthritis is largely based on clinical symptoms and signs. Approximately 70 per cent of patients have rheumatoid factor ANTIBODIES in the SERUM but, because of the large number of false positives and false negatives, this test has very little value in clinical practice. It may be a useful pointer to a worse prognosis in early cases if the level is high. X-RAYS may help in diagnosing early cases and are particularly helpful when considering surgery or possible complications such as pathological fracture. Patients commonly develop ANAEMIA, which may be partly due to gastrointestinal blood loss from antiin?ammatory drug treatment (see below).
Treatment involves physical, pharmacological, and surgical measures, together with psychological and social support tailored to the individual patient’s needs. Regular activity should be maintained. Resting of certain joints such as the wrist with splints may be helpful at night or to assist prolonged manual activities. Sound footwear is important. Early use of antirheumatic drugs reduces long-term disability. Drug treatment includes simple ANALGESICS, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS), and slow-acting drugs including GOLD SALTS (in the form of SODIUM AUROTHIOMALATE), PENICILLAMINE, SULFASALAZINE, METHOTREXATE and AZATHIOPRINE.
The non-steroidal agents are largely e?ective in reducing pain and early-morning sti?ness, and have no e?ect on the chronic in?ammatory process. It is important, especially in the elderly, to explain to patients the adverse effects of NSAIDs, the dosage of which can be cut by prescribing paracetamol at the same time. Combinations of anti-rheumatic drugs seem better than single agents. The slow-acting drugs take approximately three months to act but have a more global e?ect on chronic in?ammation, with a greater reduction in swelling and an associated fall in erythrocyte sedimentation rate (ESR) and rise in the level of HAEMOGLOBIN. Local CORTICOSTEROIDS are useful, given into individual joints. Systemic corticosteroids carry serious problems if continued long term, but may be useful under special circumstances. Much research is currently going on into the use of tumour necrosis factor antagonists such as INFLIXIMAB and etanercept, but their precise role remains uncertain.... rheumatoid arthritis
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