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Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 42-46

Impact of a week-long physical medicine and rehabilitation clerkship on rehabilitation knowledge of the 3rd-Year medical students in Singapore

Rehabilitation Medicine Department, Tan Tock Seng Hospital, Singapore

Date of Web Publication22-May-2019

Correspondence Address:
Dr. Shuen-Loong Tham
Tan Tock Seng Hospital Rehabilitation Centre, 17 Ang Mo Kio Avenue 9, 569776
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.jisprm_41_19

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Context: Physical medicine and rehabilitation (PM&R) is often underrepresented and taught inconsistently in medical schools. Medical students' awareness and understanding of disability and PM&R are often poor. Aims: This study aims to study the impact of a week-long structured PM&R clerkship on 3rd-year medical students' rehabilitation knowledge. Design: This was a retrospective analysis of pre- and post-clerkship multiple choice questions (MCQs). Settings: This was a rehabilitation center within a tertiary care teaching hospital. Participants: Seventy-two 3rd-year undergraduate medical students who underwent PM&R clerkships between November 15, 2016, and January 15, 2018. Subjects and Methods: At commencement, undergraduates were administered Best of Five MCQs based on the program content. Clerkship components included tutorials, prepared reading materials on PM&R, and exposure to various clinical work of the rehabilitation center. The same MCQs were readministered at the conclusion of clerkship. Results: Postclerkship MCQs saw improved scores in 98.6% of the students. The mean MCQs score improved from 14.44 to 20.01 (23.2% gain). Students, who had previous PM&R observership, scored higher in their preclerkship MCQs (16.06 vs. 13.98; P = 0.001). They fared better in components delving into PM&R work, concepts and roles (7.56 vs. 6.04, P = 0.01), and stroke rehabilitation (2.38 vs. 1.82, P = 0.01). Following clerkship completion, 52% of the students were able to describe PM&R using key rehabilitation concepts/principles, and 76.4% would consider PM&R as their career. Conclusions: The study suggests that a dedicated and structured PM&R clerkship in undergraduate medical curriculum improves PM&R knowledge and awareness among the medical students.

Keywords: Medical students, physical medicine and rehabilitation, rehabilitation medicine, undergraduate curriculum

How to cite this article:
Tham SL, Kong KH. Impact of a week-long physical medicine and rehabilitation clerkship on rehabilitation knowledge of the 3rd-Year medical students in Singapore. J Int Soc Phys Rehabil Med 2019;2:42-6

How to cite this URL:
Tham SL, Kong KH. Impact of a week-long physical medicine and rehabilitation clerkship on rehabilitation knowledge of the 3rd-Year medical students in Singapore. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2022 Jan 20];2:42-6. Available from: https://www.jisprm.org/text.asp?2019/2/1/42/258767

  Introduction Top

Integration of physical medicine and rehabilitation (PM&R) into undergraduate medical curriculum imparts several benefits.[1],[2],[3] Familiarization of rehabilitation work will foster increased utilization of rehabilitation services when these undergraduates become full-fledged medical practitioners. Heightening the awareness of PM&R among these students will, no doubt, encourage recruitment into the field. The core principles taught in PM&R are also crucial aspects of chronic care and disability management. Medical undergraduates should be schooled in these concepts to cater to an increasing population of people with disabilities and chronic conditions.

Unfortunately, PM&R is often neglected or taught inconsistently in medical schools.[4],[5],[6] This is concerning given the climate of rising rehabilitation needs.[7]

This paper aims to study the impact of a 1-week structured PM&R clerkship on 3rd-year medical students' rehabilitation knowledge in Singapore.

  Subjects and Methods Top

PM&R was previously not an integral component of undergraduate medical curriculum in Singapore. However, over the past 6 years, medical undergraduates from National University of Singapore, Yong Loo Lin School of Medicine (YLLSoM) have been given glimpses into rehabilitation work through short clerkships at PM&R units/departments. Of the three medical schools in Singapore, YLLSoM is the oldest and trains a larger portion of the medical students. Its annual intake of 300 medical students makes up more than 50% of the yearly undergraduate medical cohort.

All the 3rd-year medical students from YLLSoM undergo 1½ days of observership at a PM&R department/unit, as part of the Family and Community Medicine rotation. A separate half a day of didactic lectures, on various PM&R topics, supplement this observership. This would have been the only mandatory PM&R exposure in the course of a student's undergraduate education.

Since 2013, the 3rd-year YLLSoM medical students, going through general medicine rotations at our hospital, undergo a 1-week mandatory PM&R clerkship. This provides additional exposure to PM&R in their medical curriculum. The PM&R clerkship is conducted at its rehabilitation center, which is responsible for providing tertiary rehabilitation services. Since late 2016, we created a structured program for the 1-week PM&R clerkship. Six students were rotated into the clerkship per week.

The program was designed to focus on neurorehabilitation. At commencement of clerkship, students were administered a series of Best of Five multiple choice questions (MCQs). Following which, the questionnaires were returned to the administrators. At this point, correct responses to the MCQs were not discussed with the students. The questionnaire comprised 24 MCQs (12 on stroke, spinal cord injury, and acquired brain injury rehabilitation topics; 12 on general rehabilitation topics). The questions were written, vetted, and selected in consultation with two physiatrists (PM&R specialists) of the rehabilitation center. The themes were considered important to the understanding of rehabilitative work and principles [Table 1].
Table 1: Subject matters assessed in the multiple choice questions

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At the start of the clerkship, the students were given a 1-h orientation session on the PM&R department, rehabilitation concepts, and principles (provided by a physiatrist). During clerkship, students had supplementary reading materials on the topics of stroke rehabilitation, spinal cord injury rehabilitation, acquired brain injury rehabilitation, and spasticity, in addition to group tutorials on the same subjects. The resource materials were excerpts from the Handbook of Rehabilitation Medicine, a publication produced by the department.[8]

Students were integrated into rehabilitation team ward rounds, attended interdisciplinary patient care meetings and PM&R clinics. These were led and run by physiatrists. Each clinical group was also given the task of clerking a patient undergoing inpatient rehabilitation. The rehabilitation management of these cases was discussed with the rehabilitation center's physiatrists during clerkship.

The students were given opportunities to observe and perform rehabilitative work-related procedures such as intermittent urinary catheterization, urodynamic studies, joint ultrasonography, and intramuscular botulinum toxin injection for spasticity. They had short stints with the center's allied health professionals (e.g. occupational therapists and physiotherapists) to learn about their work and role in the interdisciplinary care of the patients. They were also introduced to rehabilitation-assistive technologies/robotics and learnt about their use in rehabilitative work.

The same MCQs were readministered to the students at the end of the clerkship. Following the repeat attempt, the questions and answers were discussed. The results of the MCQs played no part in their undergraduate formative or summative assessments.

In addition, the students were asked to describe PM&R in a word or phrase as best as they could. Three other personal response questions were posed [Table 2]. The responses to these questions were anonymized.
Table 2: Personal response questions

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This retrospective study analyzed the results of the pre- and post-clerkship MCQs.

Statistical analysis

Statistical analysis was carried out using IBM SPSS statistics version 22.0 (IBM Corp., Armonk, NY, USA). The pre- and post-clerkship MCQ results were compared using the paired t-test. The Chi-square test was used to examine the relationship between previous medical or surgical postings and knowledge of the existence of PM&R discipline. The t-test was used to examine the relationship between student groups and MCQ scores.

  Results Top

Student's responses to the MCQs obtained between November 15, 2016, and January 15, 2018, were sampled. There were 78 sets of MCQs, of which only 72 were complete. Six students did not complete their postclerkship MCQs due to absenteeism on the final day of the clerkship. Thirty-six percent (n = 26) of the students acknowledged that they did not know that PM&R exists as a specialized discipline before the clerkship. As expected, students who had gone through their Family and Community Medicine rotation before the PM&R clerkship were more likely to know the existence of PM&R as a discipline (P = 0.03).

Following completion of the PM&R clerkship, 76.4% (n = 55) of the students would consider PM&R as a career choice. All the students agreed that PM&R merits recognition as a clinical specialty.

When asked to describe PM&R in a word or phrase, several common themes emerged: function (26.4%), holistic/comprehensive care (16.7%), interdisciplinary work (6.9%), and patient centricity (4.2%). Fifty-two percent (n = 37) of the students were able to use key concepts and/or rehabilitation principles to describe PM&R at the end of the clerkship.

When the MCQs were administered again postclerkship, 98.6% of the students had improved scores [Table 3]. The mean MCQs score improved from 14.44 to 20.01, representing a 23.2% (5.57 points) gain.
Table 3: Multiple choice questions scores

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Students who had been though a Family and Community Medicine rotation and hence had previous exposure to PM&R, scored higher in their preclerkship MCQs (16.06 vs. 13.98; P = 0.001) [Table 4]. Compared to their counterparts, these students fared better in the components delving into PM&R work, concepts, and roles (7.56 vs. 6.04, P 0.01) and stroke rehabilitation (2.38 vs. 1.82, P = 0.01).
Table 4: Preclerkship multiple choice questions result in medical students previously exposed to physical medicine and rehabilitation

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  Discussion Top

The prevalence of health conditions associated with severe levels of disability has increased dramatically by 23.1% from 2005 to 2015.[9] Aging populations, rising prevalence of chronic diseases, increasing life expectancies, and improved survival rates for previously fatal conditions contribute to this mounting burden.[7] In Singapore, the prevalence of disability in its population was estimated at 3%,[10] as derived from 2010 data. The proportion of the population older than 65 years had increased from 9% to 13%, between the years 2010 and 2017.[11] Our local and regional needs parallel the global increased need for rehabilitation.

Although no consensus exists on the ideal physiatrists to population ratio, the shortage is evident. This is particularly apparent in the low- and middle-income countries. In a survey of 48 countries by the World Health Organization (WHO), Southeast Asian region was reported to have the lowest density of physiatrists per 1 million population.[7] In January 2018, Singapore had 40 registered physiatrists, meeting the rehabilitative needs of a population of 5.61 million (physiatrists-to-people ratio, 1:140,250).[11] In comparison, the ratio of physiatrists to population in the United States of America, in 2013, was 1:35,496. Canada reported a ratio of 1.3:100,000 (1:76,923) in 2015.[12],[13]

There are many reasons for this dearth of physiatrists. Among which, lack of awareness and understanding of rehabilitative work among physicians could be crucial factors. It is necessary and relevant that the principles of PM&R be woven into early undergraduate medical education.

Two decades ago, Kirshblum et al. surveyed the 4th-year medical students (before PM&R clerkship) in the United States of America. Only 67% of the students were aware of PM&R existing as a distinct specialty.[14] This lack of awareness still rings true in the medical undergraduates that we sampled in this study.

In Singapore, the topic of PM&R is primarily incorporated into part of Family and Community Medicine postings in undergraduate medical education. Such collaborative teaching allows students to understand PM&R practice in context.[6] While advantageous, it limits the appreciation of the wide scope of practice in PM&R. Another limitation of such an endeavor lies in it being taught as a cursory subject. As such, the topic of PM&R plays no part in the summative assessment of the medical undergraduate. This has led to variable enthusiasm in students learning the subject.

Our 1-week PM&R clerkship, which started in 2016, provided a structured and longer period of dedicated PM&R teaching. The MCQs were primarily implemented as a tool to facilitate learning.[15] In doing so, we were able to capture the suggestion of acquired PM&R knowledge among the students who completed the clerkship.

From retrospective analysis of the results, we observed some favorable effects of prior, albeit short, PM&R observerships (during the Family and Community Medicine rotation). These students had better baseline understanding of PM&R concepts/principles and possessed greater awareness of PM&R as a specialty. They demonstrated greater understanding of PM&R topics (stroke rehabilitation and PM&R work, roles, and general concepts), as reflected in better preclerkship scores compared to their counterparts. This is likely due to stroke rehabilitation being covered to a greater degree during the PM&R observership in their Family and Community Medicine rotation.

Almost all students had improvements in overall MCQs score. This is hardly surprising, considering that medical students were generally underexposed to PM&R. When the students were asked to describe PM&R postclerkship, slightly more than half were able to articulate themes which are congruent with PM&R concepts and principles.

It may be beneficial to introduce PM&R early into undergraduate curriculum, as this will allow further development in later years.[16] As alluded by Bloch et al., virtually, all physicians treat patients with rehabilitative needs.[1] Hence, rehabilitative principles should be taught to medical students regardless of their ultimate career paths.[1]

The importance of educating medical students in care of individuals with chronic disease and disabilities cannot be understated. It is recognized that essential aspects of chronic care and disability management share commonalities with core principles in PM&R. These include concepts such as interdisciplinary teamwork, treatment of patients across the continuum of care, and assessment and treatment of functional health.[3] Hence, physiatrists are ideal educators of undergraduate medicine to this end.

For those who may decide on a career in the PM&R, early exposure such as this may be when the first seed of interest is sown. In our survey, 76.4% of the students were willing to consider PM&R as a possible career choice after spending a week with us. This is encouraging given the backdrop of low number of physiatrists in Singapore and within the region.

Following the WHO World Report on Disability in 2011, the call to increase human resources for rehabilitation is resounding.[17] It is necessary to expand education/training in rehabilitation, build training capacity, and to take action in recruitment. Weaving concepts of PM&R and disability into undergraduate curricula is a step in the right direction.


There are several notable limitations to our study. First, this study had a relatively small sample size. Each year, only 12 clinical groups representing a total of 72 students will be rotated to our PM&R department. This represents 24% of the annual medical student cohort in YLLSoM. The second limitation is the differing curricula between the three medical schools in Singapore. Our study population may not accurately represent the medical students of the other medical schools, who may receive PM&R exposure in a different manner. However, as previously mentioned, YLLSoM is the major institution of learning in undergraduate medical education, and its curriculum prepares more than half of the medical undergraduates for medical practice in Singapore. Third, the design of certain components of the MCQs was not sensitive enough to demonstrate a significant acquisition of knowledge after the clerkship. Notably, the spinal cord injury rehabilitation questions were possibly too generic. A good number of students had obtained correct responses to these questions on the preclerkship MCQs. The questions will need to be refined in terms of difficulty and number to better estimate baseline knowledge and/or subsequent acquisition.

MCQs measure factual knowledge. As described in Miller's pyramid of clinical competence, this forms the base of the pyramid. Admittedly, they are unsuitable for use to assess the higher level of clinical competence.[18] However, given the short clerkship, the MCQs-based assessment was able to sample a wide range of PM&R topics, while allowing for better objectivity and ease in marking.

  Conclusions Top

Having a structured PM&R clerkship in the undergraduate medical curriculum improves rehabilitation knowledge and awareness of the discipline among the medical students. This is a program that should be extended to other parts of undergraduate medical curriculum where the students would not, otherwise, have the opportunity to experience such PM&R education. Similar mandatory teaching programs must be pursued by all medical schools, particularly those within the region, to prepare their medical undergraduates for practice in a climate of growing rehabilitative needs and unmet rehabilitation demands.

Based on these findings, the content of the clerkship could be widened to include musculoskeletal rehabilitation components to give the students an even broader exposure. Undoubtedly, a longer period of clerkship will be helpful to provide breadth and depth to the medical students' understanding of the topic. Given the rising relevance of rehabilitation principles in current and future medical practice, due consideration should be given to making the topic a part of formalized assessments in the university's undergraduate medical education.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Bloch RM, Blake DJ, Fiedler IG. Integration of physical medicine and rehabilitation into the undergraduate medical curriculum. The Undergraduate Education Committee of the Association of Academic Physiatrists Workgroup. Am J Phys Med Rehabil 1996;75:242-3.  Back to cited text no. 1
Faulk CE, Mali J, Mendoza PM, Musick D, Sembrano R. Impact of a required fourth-year medical student rotation in physical medicine and rehabilitation. Am J Phys Med Rehabil 2012;91:442-8.  Back to cited text no. 2
Esselman P, Berbrayer D, Friedly J, Granger C, Mayer RS. Chronic care education in medical school: A focus on functional health and quality of life. Am J Phys Med Rehabil 2009;88:798-804.  Back to cited text no. 3
Laskowski ER, Moutvic M, Smith J, Newcomer-Aney K, Showalter CJ. Integration of physical medicine and rehabilitation into a medical school curriculum: Musculoskeletal evaluation and rehabilitation. Am J Phys Med Rehabil 2000;79:551-7.  Back to cited text no. 4
Vlak T, Boban M, Franulović-Golja N, Eldar R. Teaching disability and rehabilitation medicine at the medical school in Split, Croatia. Croat Med J 2004;45:99-102.  Back to cited text no. 5
Gibson J, Lin X, Clarke K, Fish H, Phillips M. Teaching medical students rehabilitation medicine. Disabil Rehabil 2010;32:1948-54.  Back to cited text no. 6
World Health Organization. Rehabilitation 2030 a Call for Action: The Need to Scale up Rehabilitation. World Health Organization. Available from: http://www.who.int/disabilities/care/NeedToScaleUpRehab.pdf?ua=1. [Last accessed on 2018 Feb 01].  Back to cited text no. 7
Kong KH, Yap SGM, Loh YJ. Handbook of Rehabilitation Medicine. Singapore: World Scientific; 2016.  Back to cited text no. 8
GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: A systematic analysis for the global burden of disease study 2015. Lancet 2016;388:1545-602.  Back to cited text no. 9
Raghunathan R, Balakrishnan B, Smith CJ, Md Kadir M. People with Physical Disabilities in Singapore: Understanding Disabling Factors in Caregiving, Education, Employment and Finances. SMU Change Lab. Lien Center for Social Innovation Reports; 2015.  Back to cited text no. 10
Population Trends. Department of Statistics Singapore; 2017. Available from: http://www.singstat.gov.sg/docs/default-source/default-document-library/publications/publications_and_papers/population_and_population_structure/population2017.pdf. [Last accessed on 2018 Jan 31].  Back to cited text no. 11
Association of American Medical Colleges. Physician Specialty Data Book – Workforce – Data and Analysis. Association of American Medical Colleges; 2014. Available from: https://www.aamc.org/. [Last accessed on 2018 Feb 01].  Back to cited text no. 12
Physical Med and Rehabilitation Profile. Canadian Medical Association. Available from: https://www.cma.ca/. [Last accessed on 2018 Feb 01].  Back to cited text no. 13
Kirshblum SC, DeLisa JA, Campagnolo DI. Mandatory clerkship in physical medicine and rehabilitation: Effect on medical students' knowledge of physiatry. Arch Phys Med Rehabil 1998;79:10-3.  Back to cited text no. 14
Little JL, Bjork EL. Pretesting with Multiple-Choice Questions Facilitates Learning. Vol. 33. Boston, MA: Proceedings of the Annual Meeting of the Cognitive Science Society; 2011. p. 294-9.  Back to cited text no. 15
Currie DM, Atchison JW, Fiedler IG. The challenge of teaching rehabilitative care in medical school. Acad Med 2002;77:701-8.  Back to cited text no. 16
von Groote PM, Bickenbach JE, Gutenbrunner C. The world report on disability – implications, perspectives and opportunities for physical and rehabilitation medicine (PRM). J Rehabil Med 2011;43:869-75.  Back to cited text no. 17
Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990;65:S63-7.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3], [Table 4]


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