Musculoskeletal Curricula in Medical Education

Filling In the Missing Pieces

Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH

THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 11 - NOVEMBER 2004

It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment.

This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.¹ While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.

Conditions affecting the musculoskeletal system are the primary reason patients seek medical care from physicians, accounting for nearly 100 million office visits per year.² Musculoskeletal conditions are the most common cause of long-term pain and physical disability.³ As our population ages and becomes increasingly obese, the number of people affected by osteoarthritis will increase significantly.³ Adding to the clinical burden of illness in the United States, an estimated 54% of postmenopausal women have osteoporosis, which increases their risk for bone fracture.³ Osteoarthritis and osteoporosis are just two examples of long-term disabling musculoskeletal conditions that physicians must be competent to diagnose and treat. Yet many physicians feel ill prepared to care for patients who have any number of musculoskeletal conditions.⁴ Why?

Defining the Problem

Surveys and testing of medical students and residents suggest that opportunity and training in musculoskeletal medicine during medical school and residency are woefully inadequate.

Several studies^4-7 have drawn attention to the educational shortcomings in musculoskeletal medicine. Freedman and Bernstein^5,6 found that 82% of recent medical school graduates failed a 25-question, written basic competency examination in musculoskeletal medicine. Among the 85 graduates tested, the average time spent in rotations or courses devoted to orthopedics during medical school was only 2.1 weeks. One third of these examinees graduated without any formal training in orthopedics.

As would be expected, these data suggest that limited educational experience contributes to poor performance. Clawson et al⁷ surveyed nearly 2,000 second-year residents in US allopathic and osteopathic residency programs. They found that up to 60% of allopathic residents felt poorly to very poorly prepared to conduct a musculoskeletal examination of the foot.

Matheny et al⁴ surveyed 351 graduating family practice residents about their confidence in the management of musculoskeletal conditions. They found that the residents were far more confident in making a diagnosis of acute myocardial infarction or treating hypertension than they were in diagnosing musculoskeletal conditions. In the same survey, residents ranked their overall musculoskeletal and orthopedic training as a 5.4 on a 10-point scale of least adequate to most adequate.

Changing Courses

It is imperative that education in musculoskeletal medicine undergoes significant improvement at both medical school and residency levels. In May 2003, the American Medical Association (AMA) passed Resolution 310 on musculoskeletal care in graduate medical education.⁸ The resolution was introduced by the American Orthopaedic Foot and Ankle Society and the American Academy of Orthopaedic Surgeons (AAOS). Resolution 310 recommends that:

• Medical schools formally reevaluate the musculoskeletal curriculum with the input of AAOS and the orthopedic subspecialty societies;
• Medical schools make changes to ensure that their students have the appropriate education and training in musculoskeletal care, and make competence in basic musculoskeletal principles a requirement for graduation; and
• The AMA encourage its representatives to the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education (ACGME), and the various Residency Review Committees (RRCs) to promote higher standards in basic competence in musculoskeletal care.

In the spring 2004 preliminary draft of revision of requirements, the RRC for Family Practice proposed increasing the musculoskeletal experience from 140 hours to 200 hours (or 2 months) of orthopedic and musculoskeletal problems, including sports medicine. If these changes are adopted, they will go into effect in January 2006. We await the other agencies' responses to the recent AMA recommendations.

The American Academy of Family Physicians through the Residency Assistance Program publishes recommended curriculum guidelines for family practice residents.⁹ Two sections, "Conditions of the Musculoskeletal System" and "Sports and Recreational Medicine," provide a framework for the family practice resident to obtain knowledge and skills in musculoskeletal medicine. However, these guidelines do not provide direction as to how the resident should acquire this information.

The RRC for the American Board of Family Practice currently requires that residents complete 140 hours of structured experience in the care of orthopedic disorders, and that this experience must include caring for patients with acute, emergency, and chronic musculoskeletal injuries and disorders. Additionally, residents must be provided with experiences in casting and splinting, and in caring for children who have orthopedic conditions. The RRC specifies that these experiences should occur primarily in the outpatient setting and include a structured didactic component. Nowhere in this document is competency in caring for the patient who has a musculoskeletal disorder addressed.

Curricular goals and content will vary between medical school and residency training. Medical schools should emphasize basic anatomy, physiology, and pathophysiology, as well as musculoskeletal physical exam technique. The orthopedic training in primary care residency programs, such as family medicine, internal medicine, and pediatrics, should include a greater depth of knowledge in a wide variety of topics related to musculoskeletal medicine. These topics include normal anatomy and physiology, normal growth and development, testing and interpretation of laboratory data, pathophysiology, management and therapy of musculoskeletal conditions, prevention principles, and the skills of history taking and physical examination.¹⁰

Building Competency

At a minimum, medical schools must provide dedicated opportunities for students to attain the knowledge and skills of musculoskeletal medicine. Historically, undergraduate orthopedic training has occurred in inpatient and surgical settings that do not correlate with the musculoskeletal conditions commonly seen in outpatient settings. Geyman and Gordon¹¹ described "office orthopaedics" seen in general practice or family practice as involving a relatively small spectrum of traumatic strains, sprains, and fractures, with nontraumatic conditions accounting for more than half the orthopedic visits. Among 2,285 visits to a family practice clinic, 23% involved musculoskeletal conditions, with osteoarthritis and regional joint pain as the most frequently noted problems.¹²

To address the disparity between the content of medical education and the clinical burden of musculoskeletal conditions in outpatient practice, medical schools should require a minimum set of core competencies in orthopedics. Options for elective study are desirable—but not sufficient—to meet this educational need. To adequately prepare students for managing these conditions, Craton and Matheson¹³ recommend that medical school education emphasize outpatient orthopedic training. This experience may be obtained in a variety of outpatient venues, including clinics with sports medicine, rheumatology, physical medicine and rehabilitation, and in the emergency department.

However, it is not sufficient to simply require completion of a rotation. The educational experience should be directed by specific learning objectives and outcomes. Curricular content should include a solid foundation in anatomy as well as clinical exposure to the most common musculoskeletal conditions. Finally, evaluation of students' knowledge and skill should follow the training.

Likewise, residents in primary care should receive structured and pertinent orthopedic teaching and evaluation. Kahl¹² recommends that residents receive formal instruction in physical exam techniques and in prescribing exercise programs and assistive devices. Kahl also advocates that residents in a supervised outpatient setting manage a sufficient number of patients who have orthopedic conditions. The outpatient experience should include training in ordering and interpreting laboratory data and in performing proper joint injection and aspiration procedures.

Although medical curricula may be structured in several ways, a relatively recent approach, the "competency-based" method, has several compelling characteristics for orthopedic education. This method begins by assessing the competencies required by a practicing clinician and then tailoring the educational curriculum to meet these competencies.¹³ Once the competencies are defined, they become the learning objectives for the curriculum. After curricular implementation, the students may be evaluated on these competencies. At this point, we cannot presume to know what makes a physician competent in a particular area of medicine. Measuring competency is a vital issue that requires much more study and consensus.

The competency-based approach to developing musculoskeletal curricula is certainly endorsed by the recent mandate from the ACGME to implement core competencies in all residency programs. The challenge with this practical and elegant curricular structure is that it is somewhat labor-intensive to implement the teaching and evaluation components.¹³

Fine-Tuning Educational Methods

Educational methods should complement the educational goal: the competencies. Medical students and residents spend a considerable amount of time in lectures, despite the lack of evidence that classroom lectures change physician practices.^14-16 Instead, learning is successful when the student has the opportunity to rehearse behaviors and reinforce the learned material,¹⁴ and skills are best learned through demonstration, practice, and repetition.^17-19

Teaching the musculoskeletal physical exam can be time- and labor-intensive because of the multiple components of the exam. Residencies may be challenged by a small faculty-to-student ratio that limits the ability to provide hands-on instruction. Several studies^20-22 have shown that senior medical students can teach physical exam skills to underclassmen as effectively as faculty can. With appropriate training, residents-as-teachers could be an innovative way to provide one-on-one instruction for the musculoskeletal exam.

Evaluation methods, likewise, should complement the educational goal. Typically, the "summative evaluation" occurs at the end of a rotation or educational experience and serves primarily to give a score or grade. After the evaluation is given, the learner has no opportunity to correct any deficiencies. In contrast, "formative feedback" provides immediate feedback and evaluation at the point of the encounter.²³ This creates an opportunity for learning and correction in future experiences. Formative feedback can be provided during real clinic experiences or in staged scenarios, such as with simulated patients or objective, structured clinical examinations.

Musculoskeletal curricula designed to meet the needs of future physicians should be competency- based and outpatient-centered. When weighing the goals for the curriculum, matching objectives to competencies is a higher priority than is validation. The curriculum should span both undergraduate and graduate training, and the time devoted to it should reflect the relative clinical burden of musculoskeletal conditions. The challenge for those of us involved in teaching medical students and residents is to create opportunities for participants to learn and understand basic principles in musculoskeletal medicine, to acquire and practice physical exam skills related to the musculoskeletal system, and to evaluate students and residents in a manner that reflects the learning objectives. Each institution will have its own barriers to overcome.

Looking Toward the Future

Curricular change such as we are suggesting requires more time commitment from faculty, more financial support from the institution, and time taken away from other activities. Medical schools must prepare students to apply their knowledge and skills in musculoskeletal medicine during subsequent residency training. Residency programs need to create opportunities for residents to evaluate and treat patients who have a wide variety of musculoskeletal problems. Programs must commit to ensuring the competency of their graduates. The burden of illness in musculoskeletal medicine will only increase in future years. Inadequate preparation of tomorrow's physicians will not meet the demands of the population. It is imperative that we step up the effort in a multidisciplinary fashion and use the knowledge and skills of physicians in orthopedic surgery, rheumatology, physical medicine and rehabilitation, and family medicine to ensure the musculoskeletal education of future physicians.

References

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9. American Academy of Family Physicians: Recommended Curriculum Guidelines for Family Practice Residents. Available at http://www.aafp.org/x16524.xml. Accessed September 29, 2004
10. American Academy of Family Physicians: Recommended curriculum guidelines for family practice residents. Available at http://www.aafp.org/eduguide.xml. Accessed September 29, 2004
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18. McLeod PJ, Steinert Y, Trudel J, et al: Seven principles for teaching procedural and technical skills. Acad Med 2001;76(10):1080
19. Kern DE, Thomas PA, Howard DM, et al: Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, The Johns Hopkins University Press, 1998
20. Haist SA, Wilson JF, Brigham NL, et al: Comparing fourth-year medical students with faculty in the teaching of physical examination skills to first-year students. Acad Med 1998;73(2):198-200
21. Haist SA, Wilson JF, Fosson SE, et al: Are fourth-year medical students effective teachers of the physical examination to first-year medical students? J Gen Intern Med 1997;12(3):177-181
22. Barnes HV, Albanese M, Schroeder J, et al: Senior medical students teaching the basic skills of history and physical examination. J Med Educ 1978;53(5):432-434
23. Quillen DM: Challenges and pitfalls of developing and applying a competency-based curriculum. Fam Med 2001;33(9):652-654

Disclosure information: Drs Joy and Van Hala disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.