Competence levels in musculoskeletal medicine: comparison of
osteopathic and allopathic medical graduates.
J Am Osteopath Assoc. 2006; 106(6):350-5 (ISSN: 0098-6151)
Stockard AR ; Allen TW
Virginia College of Osteopathic Medicine, 2265 Kraft Dr, Blacksburg, VA 24060-6360, USA. astockard@vcom.vt.edu

BACKGROUND:  Consistent with osteopathic principles and practice, the nation's colleges of osteopathic medicine (COMs) have emphasized the significance of the musculoskeletal system to the practice of medicine. The authors hypothesized that graduating COM students would, therefore, demonstrate superior knowledge and competence in musculoskeletal medicine when compared with graduates of allopathic medical schools.

METHODS:  The authors asked graduating COM students to complete a standardized and previously validated 25-question basic competency examination on musculoskeletal medicine in short-answer format. Originally developed and validated in the late 1990s, the examination was distributed to allopathic medical residents at the beginning of their residencies. The authors compare their results with those reported by Freedman and Bernstein for allopathic residents.

RESULTS:  When the minimum passing level as determined by orthopedic program directors was applied to the results of these examinations, 70.4% of graduating COM students (n=54) and 82% of allopathic graduates (n=85) failed to demonstrate basic competency in musculoskeletal medicine.  Similarly, the majority of both groups failed to attain the minimum passing level established by the directors of internal medicine programs (graduating COM students, 67%; allopathic graduates, 78%).

CONCLUSION:  In an examination of competence levels for musculoskeletal medicine, students about to graduate from a COM fared only marginally better than did their allopathic counterparts. To ensure that all graduating COM students have attained a level of basic competence in musculoskeletal medicine, the authors recommend further study as a prelude to evaluation of the didactic and clinical curriculum at all 22 COMs and their branch campuses.

Musculoskeletal medicine
An assessment of the attitudes and knowledge of medical students at Harvard Medical School

From the May 2007 issue of Academic Medicine

Day CS, Yeh AC, Franko O, Ramirez M, Krupat E. Musculoskeletal medicine: An assessment of the attitudes and knowledge of medical students at Harvard Medical School. Acad Med 2007; 82(5):452-457.

PURPOSE:  To assess medical students’ knowledge and clinical confidence in musculoskeletal medicine as well as their attitudes toward the education they receive in this specialty.

METHOD:  A cross-sectional survey of students in all four years of Harvard Medical School was conducted during the 2005-2006 academic year. Participants were asked to fill out a 30-question survey and a nationally validated basic competency exam in musculoskeletal medicine.

RESULTS:  The response rate was 74% (449/608). Medical students rated musculoskeletal education to be of major importance (3.8/5) but rated the amount of curriculum time spent on musculoskeletal medicine as poor.

Third-year students felt a low to adequate level of confidence in performing a musculoskeletal physical examination and failed to demonstrate cognitive mastery in musculoskeletal medicine  (passing rate on competency exam: 7%), whereas fourth-year students reported a similar level of confidence (2.7/5) and exhibited a higher passing rate (26%).

Increasing exposure to the subject by taking clinical electives resulted in greater clinical confidence and enhanced performance on the exam (P < .001). Students’ feedback suggested that musculoskeletal education can be better integrated into the preclinical curriculum, more time should be spent in the field, and more focus should be placed on common clinical conditions.

CONCLUSIONS:   These findings, which are consistent with those from other schools, suggest that medical students do not feel adequately prepared in musculoskeletal medicine and lack both clinical confidence and cognitive mastery in the field. Implementing a four-year integrated musculoskeletal curriculum is one way that medical schools can address this concern.

Notes: Dr Day is assistant professor in orthopedic surgery and director, Musculoskeletal Curriculum, Harvard Medical School, and chief, Orthopedic Hand Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts Mr Yeh is a fourth-year undergraduate, Harvard College, Cambridge, Massachusetts Mr Franko is a second-year medical student, Harvard Medical School, Boston, Massachusetts Mr Ramirez is a third-year medical student, Harvard Medical School, Boston, Massachusetts Dr Krupat is director of evaluation and associate professor of psychology, Center for Evaluation, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts

More evidence of educational inadequacies in musculoskeletal medicine
Clin Orthop Relat Res. 2005; (437):251-9 (ISSN: 0009-921X)
Children's Hospital and Regional Medical Center, University of Washington, Seattle, 98105, USA

In their study, Freedman and Bernstein suggested that 80% of a group of graduates from many of the best medical schools in the United States were deficient in their knowledge of basic facts and concepts in musculoskeletal medicine.

How do these results compare with results from students attending a medical school with a long-standing dedicated program to musculoskeletal education?

Does additional clinical experience in musculoskeletal medicine improve understanding of the basic facts and concepts introduced in a second-year course?

A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington.

Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency.

Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective.

These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient  and that competency increased when learning was reinforced during the clinical years.

Educational deficiencies in musculoskeletal medicine
J Bone Joint Surg Am. 2002; 84-A(4):604-8 (ISSN: 0021-9355)
Freedman KB ; Bernstein J
University of Pennsylvania School of Medicine, Philadelphia, 19104, USA

BACKGROUND:  We previously reported the results of a study in which a basic competency examination in musculoskeletal medicine was administered to a group of recent medical school graduates. This examination was validated by 124 orthopaedic program directors, and a passing grade of 73.1% was established.

According to that criterion, 82% of the examinees failed to demonstrate basic competency in musculoskeletal medicine.  It was suggested that perhaps a different passing grade would have been set by program directors of internal medicine departments. To test that hypothesis, and to determine whether the importance of the individual questions would be rated similarly, the validation process was repeated with program directors of internal medicine residency departments as subjects.

METHODS:  Our basic competency examination was sent to all 417 program directors of internal medicine departments in the United States. Each recipient was mailed a letter of introduction explaining the purpose of the study, a copy of the examination, and our answer key and scoring guide. There was no mention of the results of the first study.

The subjects were requested to rate the importance of each question on the same visual analog scale, ranging from "not important" to "very important," as had been used by the orthopaedic program directors. These ratings were converted into numerical scores. The program directors were also asked to suggest a passing score for the examination, and this score was used to assess the examinees' performance on the examination. The results on the basis of the internal medicine program directors' responses and those according to the orthopaedic program directors' responses were compared.

RESULTS:  Two hundred and forty (58%) of the 417 program directors of internal medicine residency departments responded. They suggested a mean passing score (and standard deviation) of 70.0% +/- 9.9%.

As reported previously, the mean test score of the eighty-five examinees was 59.6%.

Sixty-six (78%) of them failed to demonstrate basic competency on the examination according to the criterion set by the internal medicine program directors.

The internal medicine program directors assigned a mean importance score of 7.4 (of 10) to the questions on the examination compared with a mean score of 7.0 assigned by the orthopaedic program directors.

The internal medicine program directors gave twenty-four of the twenty-five questions an importance score of at least 5 and seventeen of the twenty-five questions an importance score of at least 6.6.

CONCLUSIONS:  According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination.

It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.

Chronic Low Back Pain in Older Adults:
What Physicians Know, What They Think They Know, and What They Should Be Taught

Danelle Cayea, MD, MS; Subashan Perera, PhD; Debra K. Weiner, MD
J Am Geriatr Soc. 2006; 54(11):1772-1777. ©2006 Blackwell Publishing
Posted 01/16/2007

Abstract
Chronic low back pain (CLBP) is a common and debilitating problem in older adults.  Little exists in the literature about primary care physicians' (PCPs') knowledge of and confidence in managing this problem.

A self-administered survey was mailed to PCPs in western Pennsylvania to measure knowledge of the evaluation and treatment of common contributors to CLBP in older adults, confidence in diagnosing these contributors through physical examination, and the association between confidence levels and knowledge.

The survey combined items with an ordinal scale on which PCPs ranked their confidence in detecting various contributors to CLBP (e.g., fibromyalgia) using physical examination and patient vignettes followed by multiple choice questions designed to assess knowledge.

One hundred fifty-three of 634 surveys were returned (24.1%). Overall, the majority of PCPs did not feel "very confident" in their ability to diagnose any of the contributors of CLBP listed  (most items <40%). PCPs felt most confident in detecting scoliosis and least confident detecting myofascial pain of the piriformis muscle.

There was a wide range in the number of respondents answering all questions related to a particular topic correctly (3.9% for sacroiliac joint syndrome to 70.4% for hip osteoarthritis). There was no relationship between knowledge scores and confidence ratings (P >.05 for all comparisons).

The results point to a need for more PCP education about CLBP in older adults . It also suggests that accurate needs assessment should not rely on physician confidence ratings alone.

Improved education in musculoskeletal conditions is necessary for all doctors
2008 - World Health Organization
Avenue Appia 20
1211 Geneva 27
Switzerland

ABSTRACT
It is likely that everyone will, at some time, suffer from a problem related to the musculoskeletal system, ranging from a very common problem such as osteoarthritis or back pain to severely disabling limb trauma or rheumatoid arthritis. Many musculoskeletal problems are chronic conditions.

The most common symptoms are pain and disability, with an impact not only on individuals’ quality of life but also, importantly, on people’s ability to earn a living and be independent. It has been estimated that one in four consultations in primary care is caused by problems of the musculoskeletal system and that these conditions may account for up to 60% of all disability pensions.

In contrast, teaching at undergraduate and graduate levels — and the resulting competence and confidence of many doctors — do not reflect the impact of these conditions on individuals and society.

Many medical students do not have any clinical training in assessing patients with bone and joint problems.

Under the umbrella of the Bone and Joint Decade 2000–2010, experts from all parts of the world with an interest in teaching have developed recommendations for an undergraduate curriculum to improve the teaching of musculoskeletal conditions in medical schools.

The goal for each medical school should be a course in musculoskeletal medicine concentrating on clinical assessment, common outpatient musculoskeletal problems and recognition of emergencies.

Improving competency in the management of musculoskeletal problems within primary care settings through improved education is the next aim, but there are needs for improvement for all professionals and at all levels within the health care system.