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Disclosures Knowledge of Clinical Anatomy • The authors have no relevant financial by Rheumatology Trainees and relationships to disclose Rheumatologists in Latin America

Navarro-Zarza JE, Hernández-Díaz C, Saavedra MA, Kalish RA, Canoso JJ, and Villaseñor-Ovies P

Mexican Taskforce for the Advancement of Clinical Anatomy, Mexico

Background The Mexican Study Group for the Advancement of Clinical Clinical anatomy is needed in rheumatology Anatomy for: • Rheumatologic physical examination • Regional pain syndromes* GMAC • Better communication with related subspecialties • A rational use of diagnostic aids

Clinical anatomy: an unmet agenda in rheumatology training. Kalish RA,. J Rheumatol. 2007

Background Objective

• Musculoskeletal (MSK) education, including anatomy, is inadequate in: • To explore the level of knowledge in • Pre-graduate students Anatomy that Rheumatologists and • Non-orthopaedic subspecialties Rheumatology trainees have. • No information on anatomical knowledge is available in: • Practicing rheumatologists • Rheumatology trainees • Perception: knowledge is scarce.

The inadequacies of musculoskeletal education. Abou-Raya A. Clin Rheumatol. 2010 Clinical anatomy: a basic discipline for the rheumatologist. Canoso JJ. Reumatol Clin. 2011

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Methods Clinical Anatomy Workshops • During 2009-2011 • 12 Workshops on Clinical Anatomy in Rheumatology • 7 Countries in Latin America GMAC´s • By invitation from Society or Training Program • Teaching methods dress code • Anatomy is reviewed in relation to clinical vignettes • Dress code • Practicality is prioritized • Total participants • 412

GMACs Workshops 2007-2011 Methods Country Date Duration No. No. Evaluation The evaluation (hrs) Participants Trainees (%) Mexico City, Mexico* 2007 8 48 48 (100) 48 • Anatomical knowledge examination Mexico City, Mexico* 2009 8 50 48 (96) 0 Avandaro, Mexico 2009 8 50 34 (68) 34 – Individual Montevideo, Uruguay 2010 28 60 7 (11.6) 60 – Pre-seminar (scheduled) Quito, Ecuador 2010 8 22 4 (18) 22 – Voluntary Mexico City, Mexico 2010 8 50 26 (52) 0 San Salvador, El Salvador 2010 14 15 2 (13.3) 15 – Administered by GMAC members Cancun, Mexico 2011 8 33 33 (100) 0 – Duration: approximately 5 minutes Cancun, Mexico 2011 8 47 15 (45) 0 Buenos Aires, Argentina 2011 8 23 23 (100) 23 – Anatomical designations (Nomina Anatomica Sao Paulo, Brazil 2011 8 21 0 0 vs traditional French) Antofagasta, Chile 2011 8 13 4 (30.7) 13 – 20 questions were asked Total 112 412 244 215

Methods Methods Evaluation Instrument Clinical Anatomy Examination • Questions developed from the clinical The evaluator seated, vignettes presented in workshops. with elbow flexed 90º, • Evaluated and judged important by all asks the participant to members of the group. evaluate the action of – Plus all upper extremity questions reached consensus by subscapularis muscle. experts (ACR 2011, Poster #95) • Pool of 42 questions – Cognitive (n=1) The evaluator asks the – Identification (n=18) participant to find in his – Demonstration of action (n=23) knee the “pes anserinus”

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List of Anatomical Items Results

• Anatomical Snuffbox limits (id) • Tibiotalar joint (do) • 191 participants examined (46% of total) • Lister´s tubercule (id) • Subtalar joint (do) • Radial styloid (id) • Tibialis anterior tendon (do). – Rheumatology fellows:113 (59%) • Intrinsic muscles of the hand (do) • Extensor digitorum muscle (do) – Practicing rheumatologists: 55 (28%) • Movements of thumb (do) • Anatomical snuffbox bones (id) • Biceps Braquialis muscle. (do) • Anatomical snuffbox artery (t) – Other: 23 (12%) • Braquioradial muscle. (do) • A1 pulley (id) • Supraspinosus muscle. (do) • Opponens Pollicis muscle (do) • Infraspinosus muscle. (do) • Extensor carpi radialis muscle (do) • 3597 Questions asked • Occipital-Atlantoid joint.(do) • Subscapularis muscle (do) • Atlanto-axoid joint (do) • Deltoid muscle (do) – 2278 (63.3%) Demonstration of action • Tensor fascia lata muscle (do) • Zygoapofisiary joints (do) – 1295 (36.1%) Identification • Gluteal muscles (do) • Spinous process C7 (id) • Hoffa`s fat (id) • Iliotibial band (id) – 24 (0.6%) Cognitive knowledge • Pes anserinus (id) • Biceps femoris muscle (id) • Tibial posterior tendon (id) • Peroneal tendons (id) Id= identification; do= demonstration of action

Results Results

Rheumatology Trainees All evaluated participants, n=191 Mean Correct Answers

Group Mean ± SD

1.Rheum. trainees 9.24 ± 3.21 5.4% 2.Rheumatologists 9.04 ± 3.68

Rheumatologists 3.Other 7.91 ± 4.22 T test 1 vs 2, p=0.49 ANOVA p=0.032

Mean correct answers = 9.04 ± 3.65

Knowledge according to experience. Knowledge according to experience. Practicing rheumatologists Rheumatology trainees.

In practicing rheumatologists: r = 0.216, p=0.115

0-5 years 6-10 years > 10 years 8.59 (95CI 6.94-10.24) 7.67 (95CI 5.2-10.21) 9.7 (95CI 8.2 -11.2) ANOVA p=0.363 Mean difference -1.53 (95%CI -2.8 to -0.05), p=0.049

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Knowledge according to type of Knowledge according to type of anatomical structure evaluation

Type of anatom. Total evaluated Correct % Correct Odds for structure items answers answers correct Type of evaluation Total evaluated Correct % Correct Odds for Muscle 1846 908 49.1 0.97 items answers answers correct Identification 1295 538 41.5 0.71 Joint 612 298 48.6 0.95 Bones 360 162 45.0 0.82 Demonstration of 2278 1120 49.1 0.97 action Tendons 610 236 38.6 0.63 Cognitive 24 10 41.6 0.71 Ligaments 145 54 37.2 0.59 knowledge Vascular 24 10 41.6 0.71 Total 3597 1668 46.3 0.86 Total 3597 1668 46.3 0.86

Knowledge by anatomical region Discusion

Anatomical Total evaluated Correct % Correct Odds for • A substantial deficit in knowledge of MSK Region items answers* answers correct clinical anatomy was found in our study Hand 1489 596 40.0 0.67 – Deficit was similar Shoulder 360 146 40.5 0.68 • In all countries Foot 214 97 45.3 0.83 • Among trainees and rheumatologists Spine 360 166 46.1 0.86 • Seniority had a positive influence among Elbow 360 176 48.8 0.96 trainees, but not in practicing Knee 360 187 51.9 1.08 rheumatologists Pelvis 454 300 66.0 1.95 Total 3597 1668 46.3 0.86

Discussion Conclusion

• Surprising results on anatomical • The severity in knowledge deficit was knowledge by region paralleled by the interest of participants in – Pelvis > Knee > Elbow > Spine > Foot > Shoulder > Hand the workshops (data not shown) • Basic anatomy for rheumatologists consensus: – Willingness to mend this gap in their formation – Hand and Shoulder: most important regions

• Based on our data a more balanced • The knowledge base according to type of education process in rheumatology is structure showed no substantial warranted differences – Musculoskeletal physical exam skills

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