Musculoskeletal Medicine: How to Strengthen Training

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 3 - MARCH 98

Roughly one quarter of visits to primary care physicians are for musculoskeletal problems, but typically less than 3% of the undergraduate medical school curriculum is spent on musculoskeletal medicine. The results? A recent study (1) reveals that 82% of new medical and surgical residents at one major medical school failed to pass a basic knowledge test in musculoskeletal medicine. Postgraduate training is also meager: less than half of family practice residents receive postgraduate training in musculoskeletal medicine (2), and, for those who do, much of the training is in inpatient settings (1,2).

This disparity between the magnitude of the outpatient musculoskeletal clinical burden and the amount of training received is not new. But the problem is growing more acute as the "gatekeeper" model requires family physicians and general internists to be responsible for many musculoskeletal problems they encounter. For more information on this problem, see our News Briefs department, page 15.

In my view, this problem in quality and quantity of training continues because there is no single approved curriculum and training program; there are no existing board-certified specialties that provide an integrated curriculum for outpatient musculoskeletal problems. These problems form the core of sports medicine practice, yet sports medicine is not recognized as the nonoperative complement to orthopedic surgery. The nonoperative/operative parallel exists in almost all fields of medicine, and it should prevail in musculoskeletal medicine as well. If sports medicine were a specialty—as it is in several countries—residents would be taught a uniform curriculum specific to the care of physically active people and athletes. Numbers of trained specialists could then disseminate their knowledge and skills to primary care physicians in the same way cardiology or obstetrics essentials are now taught.

The population to be served by this new specialty isn't just athletes; it's everyone who can benefit from physical activity. We can extend the model of healthcare developed for elite athletes to provide clear benefits to the physically active population. In addition, while musculoskeletal medicine and rehabilitation may be central, sports medicine embraces— from all branches of medicine and science—knowledge that will improve the care of active patients (3). Cardiology, endocrinology, exercise physiology, nutrition, and many other fields contribute to active patients' care. Specialization, by pulling this knowledge together, would contribute to public health by increasing the substance and rigor of our training programs in areas such as exercise and health—benefiting not just the young and healthy, but the disabled, the aged, the ill, and the growing sedentary population.

Two points are critical in this model: first, the increased scientific rigor and knowledge that will develop by centralizing the specialty appropriately; and second, the dissemination of the knowledge to reach the greatest possible number of physicians and their patients.

Progress on this approach will involve:

• Overcoming the "branding" of sports medicine by various specialties (primary care sports medicine, orthopedic sports medicine, pediatric sports medicine, etc)—a current reality that fragments the knowledge base.
• Emphasizing the public health and disease-modifying capabilities of "sports medicine," while continuing to draw on lessons learned from the athletic population.
• Establishing a single governing body to set standards of excellence and accountability.
• Adopting a flexible approach that allows physicians to train in various existing certification programs but receive a standardized curriculum in sports medicine.
• Developing specialist training programs that start with expert supervision and provide clinical experience with a large volume and variety of patients.
• Educating medical students and primary care residents in the thought processes and skills of the field.

Clearly, such goals are now in the stage of visions and dreams. Interim steps such as integration of content into medical school curricula, postgraduate rotations, and expanded and more rigorous sports medicine fellowships are steps toward the long-term goal.

Meanwhile, we at The Physician and Sportsmedicine are making a concerted effort to supply you with educational opportunities in this exciting and growing field. We look forward to expanding our service to you, and we welcome any comments you may have.

Best,
Gordon O. Matheson, MD, PhD
Editor-in-Chief

References

1. Freedman KB, Bernstein J: The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg (Am) 1998;80(10):1421-1427
2. Craton N, Matheson GO: Training and clinical competency in musculoskeletal medicine: identifying the problem. Sports Med 1993;15(5):328-337
3. Matheson GO, Pipe AL: Twenty-five years of sport medicine in Canada: thoughts on the road ahead. Clin J Sport Med 1996;6(3):148-151