247J Contemp Med Sci | Vol. 7, No. 4, July–August 2021: 247–251 Original Knowledge and Misconceptions Regarding SLE among Medical Students at King Abdulaziz University Yasser M. Bawazir1*, , Ibtisam Jali2 1Assistant Professor of Medicine and Rheumatology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. 2Associate Professor of Medicine and Rheumatology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. *Correspondence to: Yasser M. Bawazir (E-mail: ymbawazir@kau.edu.sa) (Submitted: 12 May 2021 – Revised version received: 02 June 2021 – Accepted: 23 June 2021 – Published online: 26 August 2021) Introduction Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects multiple organs and predominantly affects women. This heterogeneous condition has a wide spectrum of clinical manifestations related to drug reactions, associated comorbidities, and the disease itself.1 The diagnosis of SLE is chal- lenging because of the heterogenicity of clinical manifestations and, in some cases, the presentation is quite severe, requiring prompt diagnosis and early immunosuppressive treatment.2 Worldwide, the incidence of SLE is 23.2 per 100.000 people per year, while the highest incidence is seen in North America (241 per 100.000 people per year) and the lower inci- dences are recorded in African countries (0.3 per 100,000 people per year). The disease is mostly prevalent among women, regardless of age and ethnicity.3 These data are similar to those reported in Saudi Arabia, where the estimated preva- lence of SLE is 19.28 per 100.000 people.4 Being a complex disease, SLE requires a multidisciplinary approach, including rheumatology, dermatology, cardiology, pulmonology, and nephrology. Assessing the disease can help identify defects in its treatment. Kerezoudis et al.,5 conducted a study with 260 students – 114 in preclinical and 146 in clin- ical years – at two medical schools to assess the depth of their knowledge using survey assessment. They identified several misconceptions in the perception of SLE and attributed this to the lack of clinical practice and the low number of patients.5 Rheumatology curriculum in our intuition includes lec- tures, clinical based learning sessions and clinical examination sessions. All sixth-year students must undergo a week of intense rheumatology course, at the completion of this week, assessment takes place. The total number of the sixth-year students (final clinical year) is around 350 students. Given the magnitude of this disease, this study aimed to assess the knowledge and misconceptions regarding SLE in sixth-year medical students in order to verify their understanding of the gen- eral aspects of SLE and obtain feedback on their curriculum and learning experience. To this end, a 25-item questionnaire was administered to sixth-year medical students at the Faculty of Medicine at King Abdulaziz University. Based on the questionnaire results, suggestions and recommendations were made to improve the learning experience about SLE at the referred university. Methods Participants Participants in this study were sixth-year medical students at the Faculty of Medicine at King Abdulaziz University. The medicine program at King Abdulaziz University comprises six years, the first three years being preclinical and the last three years clinical. In particular, the sixth year includes medical subspecialties, such as rheumatology. Thus, the inclusion cri- terion for this study was to be in the sixth year of the medicine program, since having obtained specific knowledge related to SLE was mandatory to answer the study questionnaire. The questionnaire was distributed to 350 medical students. Study Design This was an observational cross-sectional study in which a 25-item two-part questionnaire was structured using Google Abstract Introduction Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that requires a multidisciplinary approach. The aim of this study was to assess the knowledge and misconceptions regarding SLE in sixth-year medical students in order to verify their understanding of the general aspects of SLE and provide recommendations to improve their learning experience. Methods We created a two-part 25-item questionnaire of 25 questions to assess students’ knowledge about epidemiology, clinical manifestations, complications, management, and prognosis of SLE, preferred ways of learning, and opinion on which specialties should include learning about the disease. The questionnaire was distributed to the participants through Google Forms. Results A total of 200 students from King Abdulaziz University responded to the questionnaire. The prevalence of adequate knowledge among students was 39.5%. There was a significant statistical difference between students with adequate knowledge and those without adequate knowledge according to the number of cases seen during training. There was a higher prevalence of adequate knowledge among female students and those who had a family history of SLE. Most students answered correctly the basic questions about SLE, while there were weak points in the questions about epidemiology and clinical manifestations. The preferred way of learning about SLE indicated by most respondents was to see patients in the wards and analyze the pathophysiology, diagnosis, and treatment of the disease. Most students chose internal medicine and rheumatology as specialties that should include learning about SLE. Conclusion The findings reflect the need to improve the teaching of chronic medical diseases treated on an outpatient basis and to modify the medical school curriculum so as to prepare future physicians to deal with such cases. Keywords Systemic lupus erythematous, medical students, medical education, SLE awareness, Saudi Arabia ISSN 2413-0516 https://orcid.org/0000-0002-5060-3884 mailto:ymbawazir@kau.edu.sa 248 J Contemp Med Sci | Vol. 7, No. 4, July–August 2021: 247–251 Knowledge and Misconceptions Regarding SLE among Medical Students at King Abdulaziz University Original Y.M. Bawazir and I. Jali Forms. The first part included 19 questions and aimed to assess students’ knowledge about epidemiology, clinical mani- festations, complications, management, and prognosis of SLE. If the participant answer 13 out of 19 questions correctly he will be considered as having adequate knowledge. The second part included six questions and aimed to obtain general infor- mation about the participants, their preferred ways of learning about SLE, and their opinion on which specialties should include learning about SLE, as well as how many cases of SLE are seen during their training. The questionnaire was con- ducted in English, which is the language of instruction at the Faculty of Medicine at King Abdulaziz University. For the development of the questionnaire items, we con- ducted a search on PubMed and Google Scholar for validated SLE-related questionnaires. As a result, we identified only two non-validated questionnaires to assess knowledge of SLE among medical students. Therefore, we developed questions to assess the fundamentals of SLE based on the King Abdulaziz university curriculum. Study Procedure The questionnaire developed using Google Forms was distrib- uted to medical students by e-mail on the day of completion of the rheumatology rotation assessment. The respondents were allowed to submit the form only once. Since participation was optional, only 200 of the 350 medical students agreed to par- ticipate. All fourth- and fifth-year students were excluded from the study as they don’t rotate in rheumatology. The study did not require ethical approval as per the department of bio- ethics in our institution. Statistical Analysis Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 21 (IBM Inc., Armonk, NY, USA). Categorical variables were presented as numbers and precents and were compared using Chi-square test. Continuous varia- bles were non normally distributed, so presented as median and range (minimum-maximum) and were compared using Mann Whitney U test. All tests were 2-tailed, and a P value <0.05 was considered statistically significant. Results Table 1 shows the demographic characteristics of the partici- pants. Of the 200 respondents, 198 (99%) were 18 to 25 years old and 117 (58.5%) were women. More than half (107, 53.5%) saw only one to three cases of SLE during training and 30 (15%) had a family history of SLE. Table 2 shows the prevalence of adequate knowledge about SLE among the study participants. In order for respond- ents’ knowledge about SLE to be assessed as adequate, 13 of the 19 questions in the first part of the questionnaire must be answered correctly. The prevalence of adequate knowledge about SLE among the study participants was 39.5%. There was a significant statistical difference between stu- dents with adequate knowledge and students without adequate knowledge according to the number of cases seen during training (P < 0.001). As shown in Table 3, as the number of Table 1. Demographic characteristics of the participants (n = 200) Variable Number of participants Percentage of participants Gender Male 83 41.5 Female 117 58.5 Age <18 years old 2 1.0 18-25 years old 198 99.0 Number of cases seen during training 0 55 27.5 1–3 107 53.5 4–9 31 15.5 >10 7 3.5 Family history of SLE Maybe 4 2.0 No 166 83.0 Yes 30 15.0 Note. All variables are summarized in numbers and percentages. Table 2. Prevalence of adequate knowledge about SLE among participants (n = 200) Variable Number of participants Percentage of participants With adequate knowledge 79 39.5 Without adequate knowledge 121 60.5 Total 200 100.0 Note. All variables are summarized in numbers and percentages. Table 3. Prevalence of adequate knowledge about SLE according to number of cases seen during training Adequate knowledge Variable Yes No P-value Number % Number % Number of cases seen during training 0 6 11% 49 89% <0.001 1–3 44 41% 63 59% 4–9 22 71% 9 29% >10 7 100% 0 0% Total 79 39.5% 121 60.5% Note. All variables are summarized in numbers and percentages. 249J Contemp Med Sci | Vol. 7, No. 4, July–August 2021: 247–251 Y.M. Bawazir and I. Jali Original Knowledge and Misconceptions Regarding SLE among Medical Students at King Abdulaziz University cases increases, the prevalence of adequate knowledge also increases. According to Table 3, all students who saw more than 10 cases during training had adequate knowledge. The test of significance was carried out at the 0.05 level. A chi- square test was used to assess the statistical significance of the differences between the two groups according to the number of cases seen during training. Regarding the relationship between prevalence of ade- quate knowledge and gender/family history of SLE, a statisti- cally significant (P < 0.001) higher percentage of adequate knowledge was identified among female respondents and those with a family history of SLE (Table 4). The prevalence of adequate knowledge about SLE was higher among women (56%) and among students with a family history of SLE (70%). The test of significance was carried out at the 0.05 level. A chi-square test was used to assess the statistical significance of the differences between the two groups according to gender and family history of SLE. The analysis of the first part of the questionnaire (19 ques- tions) revealed that the majority of students answered cor- rectly the basic questions about SLE. On the other hand, there were weak points in the questions about epidemiology and clinical manifestations (Figure 1). As for the second part of the questionnaire, question 24 asked students to choose their preferred ways of learning about SLE. More than one choice was allowed. The preferred way of learning about SLE indicated by most respondents was to see patients in the wards and analyze the pathophysiology, diagnosis, and treatment of the disease (172 responses), fol- lowed by seeing a patient-actor with SLE during class and dis- cussing symptoms, diagnosis, differential diagnosis, and treatment (77 responses). Watching educational videos with real patients and discussing clinical vignettes during lectures obtained 72 and 63 responses, respectively (Table 5). Finally, the questionnaire asked students their opinion on which medical school specialties should include learning about SLE. More than one choice was allowed. Most students choose internal medicine (130) and rheumatology (127), while 86 choose pathology (Table 6). Discussion Advances in medicine in recent decades have been accompa- nied by a marked increase in the number of chronic diseases worldwide. Such diseases have been managed mainly in the outpatient clinic sitting. Medical education in most medical schools follows the Flexner model, which focuses mainly on inpatient hospital-based training. The problem with this model is that it does not focus on the outpatient training sitting.6 The main barriers to outpatient education are the lack Table 4. Prevalence of adequate knowledge about SLE according to gender and family history of SLE Adequate knowledge Variable Yes No P-value Number % Number % Gender Male 13 16% 70 84% <0.001 Female 66 56% 51 44% Family history of SLE Maybe 0 0% 4 100% <0.001 No 58 35% 108 65% Yes 21 70% 9 30% Note. All variables are summarized in numbers and percentages. Table 5. Frequency of preferred ways of learning about SLE among participants Ways of learning about SLE Number of responses (%) A. See patients in the wards and analyze the pathophysiology, diagnosis, and treatment of the disease. 172 (44.7%) B. See a patient-actor with SLE during class and discuss symptoms, diagnosis, differential diagnosis, and treatment. 77 (20%) C. Watch educational videos with real patients. 72 (18.6%) D. Discuss clinical vignettes during lectures. 63 (16.4%) Total 384 Note. All variables are summarized in numbers. Fig. 1 Frequency of correct answers in each of the 19 questions about SLE in descending order. Table 6. Specialties that should include learning about SLE in the opinion of the participants Specialty Number of responses (%) Internal medicine 130 (32.7%) Rheumatology 127 (31.9%) Pathology 86 (21.6%) Physiology 34 (8.5%) Biology 20 (5%) Total 397 (100%) Note. All variables are summarized in numbers. 250 J Contemp Med Sci | Vol. 7, No. 4, July–August 2021: 247–251 Knowledge and Misconceptions Regarding SLE among Medical Students at King Abdulaziz University Original Y.M. Bawazir and I. Jali of evidence in the literature, conflicts between medical educa- tion and healthcare, and inadequate financial incentives for academic medical staff.7 SLE is a systemic disease treated mainly in the outpatient sitting, whereas few complicated cases are hospitalized.8 This may contribute to students’ lack of exposure to patients with chronic illnesses. At King Abdulaziz University, students must complete three years of preclinical studies before beginning the three clinical years. Clinical teaching in the medicine program is based mainly on inpatient teaching, with limited outpatient exposure.8 Unfortunately, only 39.5% of the respondents in this study showed adequate knowledge about SLE. We attribute this result to the number of cases seen during clinical practice, as most respondents saw only one to three cases. Women showed to be more knowledgeable about SLE, which could be attrib- uted to the higher prevalence of the disease among women.1,3 In addition, students with a family history of SLE showed more adequate knowledge. This may be due to the fact that these students sought to educate themselves more about the disease, as the risk of developing SLE are higher among rela- tives of patients with SLE. To suggest alternatives to improve the teaching of rheu- matology, which is a critical specialty in the treatment of SLE, we analyzed the weak points in the questionnaire responses. We found that there is little awareness among students about the current use of chemotherapy and biological therapy in patients with SLE. This is clearly explained by the low number of cases seen during training, in addition to the majority of assistance to stable patients at the outpatient clinic. Further- more, at the university hospital, chemotherapy and biological therapy is administered at the day care unit, and students do not rotate through this unit. Unlike rheumatoid arthritis, for which we have many approved biologic therapies,9 for SLE, we currently have belimumab approved for treatment.10 Other agents such as ustekinumab,11 anifrolumab,12 and Janus kinase inhibitors,13 are still to be approved. Almost half of the respondents were not aware of the worsening of SLE during pregnancy. Since pregnancy with SLE is high risk, the disease must be stable before conception. Risks include SLE flare and the neonatal lupus. Although the prognosis for pregnant women has improved considerably, the fetal risk, although progressively reduced, is still higher in pregnancies of patients with SLE than in pregnancies of healthy women. Miscarriage, premature delivery, and preec- lampsia, as well as heart problems in the baby, are the major complications that can occur.14 We believe that the respond- ents in this study are not adequately aware of the complica- tions of pregnancy with SLE because the university does not have a special clinic for pregnant women with SLE in collabo- ration with obstetrics and the patients are followed in the reg- ular SLE clinics, so that students do not have the opportunity to see such cases in the most appropriate way. Almost half of the students responded that SLE is not life threatening, which is also attributed to the fact that they do not see many inpatient cases. Another important point is that high mortality is more observed in cases of circula- tory diseases and infections15 rather than other SLE compli- cations, and this usually happens when patients are hemodynamically unstable and are referred to intensive care units. Given that SLE is more common in women1 (as men- tioned earlier), there is an obvious misconception among students that the disease is more severe in women as well. In fact, the opposite is true: men with SLE are more likely than women to develop disabilities, hypertension, thrombosis, and renal, hematological, and serological manifestations. Men with SLE are also more likely than women to suffer end-organ damage, including neuropsychiatric, renal, cardiovascular, peripheral vascular diseases, and myocardial infarction.16 The students’ preferred way of learning about SLE was to see patients in the wards and analyze the pathophysiology, diagnosis, and treatment of the disease, followed by seeing a patient-actor with SLE during class and discuss symptoms, diagnosis, differential diagnosis, and treatment. This result is in line with our opinion that students need to be exposed to more inpatient cases to improve their knowledge about this heterogeneous disease. Finally, students indicated that they preferred to study SLE in internal medicine and rheumatology rotations rather than during the basic science years. Given that the integration of the clinical and basic years, students concentrate mainly on ways to obtain good grades rather than on how the knowledge acquired can be applied in clinical settings. Generally, students see learning as a process whereby knowledge is provided to them by the teacher and the curriculum as an aggregate of separate subjects (e.g., pathology and anatomy) rather than a single general topic (e.g., medicine).17 Given the above considerations, we suggest the following changes to improve the learning experience regarding SLE for students at the Faculty of Medicine at King Abdulaziz Univer- sity. First, at this university, rotation in rheumatology used to be merged with rotation in internal medicine. We suggest implementing a separate focused short rotation in rheuma- tology. Second, as we have observed during their busy clinical rotations, students rarely have the time to reflect on their basic science knowledge. For this reason, we suggest introducing clinical-based learning, in which the discussion starts with basic pathology and immunology and ends with clinical diag- nosis and management, in the hope that some of the impor- tant basic information can be provided to senior medical students. Third, to improve students’ awareness about the use of chemotherapy or biological therapy in patients with SLE, we suggest a time dedicated to patients admitted to the day care unit, as well as the acquisition of knowledge about the indica- tions, dosage, and side effects of treatments. Finally, we recom- mend the creation of a rheumatology admission unit and collaboration in the clinic with colleagues from the obstetrics department for high-risk patients. Study Limitation This study assesses the knowledge of 6th year medical students at king Abdulaziz university. The major limitation of this study is the use of non-validated questionnaire which was designed by the authors. As with any survey-based studies, a selection and sampling bias and we overcome this by consulting statistician. Acknowledgments We would like to thank Editage (www.editage.com) for English language editing. 251J Contemp Med Sci | Vol. 7, No. 4, July–August 2021: 247–251 Y.M. Bawazir and I. Jali Original Knowledge and Misconceptions Regarding SLE among Medical Students at King Abdulaziz University Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Declaration of Conflicting Interests The Authors declare that there is no conflict of interest.  References 1. Di Battista M, Marcucci E, Elefante E, et al. One year in review 2018: systemic lupus erythematosus. Clin Exp Rheumatol. 2018;36(5):763-777. 2. Sebastiani GD, Prevete I, Iuliano A, Minisola G. 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Ann Saudi Med. 2011;31(1):58-61. doi: 10.4103/0256-4947.75780 This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. https://doi.org/10.22317/jcms.v7i4.1059