Mini-Residency in Musculoskeletal Care: An Interprofessional, Mixed-Methods Educational Initiative for Primary Care Providers

National Needs Assessment of Emergency Medicine Residencies for Musculoskeletal Knowledge

Introduction Musculoskeletal (MSK) complaints and injuries account for a large percentage of presenting chief complaints to the emergency department in the United States (US). Despite the prevalence and economic impact on the US healthcare system, there is a documented deficiency in MSK education at all training and practicing levels in the US medical system. The purpose of this needs assessment is to better determine the state of MSK education in Emergency Medicine residency programs. Methods An online needs assessment form was sent to Emergency Medicine program directors in the US. Summary statistics were performed followed by an exploratory analysis. Results Data from 43 of 272 Emergency Medicine program directors that responded to this needs assessment were analyzed. Respondents ranked the importance of MSK education in Emergency Medicine on a Likert scale of 1-5 (very unimportant to very important) at a mean of 4.2. Additionally, 97.6% of respondents believe that their MSK curriculum could be improved. Seventy-nine percent of respondents were somewhat likely or highly likely to use a standardized method or tool to assess MSK knowledge. Of the top three barriers to MSK education implementation, 94.9% cited time, 56.4% cited interdepartmental relations, and 46.2% cited funding. Conclusion MSK knowledge is taught and assessed in highly variable methods across Emergency Medicine residency programs. Although efforts are being made to address the known deficiency in MSK knowledge, further research is needed to perform a larger needs assessment, study innovative MSK education modalities, and develop a standardized MSK assessment for Emergency Medicine residency training.

Impact of a Musculoskeletal "Mini-Residency" Professional Development Program on Knee Magnetic Resonance Imaging Orders by Primary Care Providers

BACKGROUND

The US Department of Veterans Affairs has created a portfolio of educational programs to train primary care providers (PCPs) in the evaluation and management of common musculoskeletal (MSK) conditions. Appropriate resource utilization for evaluation of knee pain, including limiting unnecessary magnetic resonance imaging (MRI) studies, is an important theme of these initiatives. The objective of this study was to report the utilization of knee MRI by PCP providers before and after the MSK education program and to determine the appropriateness of these MRI orders.

METHODS

Twenty-six PCPs participated in the MSK Mini-Residency educational program held in Salt Lake City between April 2012 and October 2014. Knee MRI orders submitted by these providers 12 months before and 12 months after their participation were reviewed. Magnetic resonance imaging orders were categorized as "inappropriate," "probably inappropriate," or "possibly appropriate," based on accepted guidelines for knee MRI utilization. Differences in the numbers of precourse and postcourse MRI orders for each of these categories were compared using Student t test.

RESULTS

Following our program, MRI orders decreased from 130 (precourse) to 93 (postcourse), a reduction of 28% ( p = 0.04). This reduction was observed entirely within the "inappropriate" and "probably inappropriate" categories; the number of orders categorized as "possibly appropriate" increased, but not significantly.

CONCLUSIONS

The MSK Mini-Residency training program was a successful educational intervention and was associated with a reduction in inappropriate knee MRI utilization for some participants, while keeping appropriate MRI utilization stable.

Impact of Sports Medicine and Orthopedic Surgery Rotations on Musculoskeletal Knowledge in Residency

Introduction

Musculoskeletal (MSK) complaints and injuries comprise 18.7% of emergency department visits. However, only 61% of emergency physicians (EP) pass a validated written Freedman and Bernstein MSK examination (FB-MSK). Educational interventions such as a primary care sports medicine (PCSM) rotation aid in MSK residency education. This study utilizes a validated MSK examination to evaluate and compare MSK knowledge acquisition following a traditional orthopedic rotation and a PCSM rotation.

Methods

Forty-nine interns were recruited to participate in this study over two academic years. The FB-MSK was administered to all participants at the start of residency. Participants were divided into two groups based on their residency sites; one group completed a traditional four-week orthopedic surgery rotation and the second group completed a four-week PCSM rotation. Forty-six of the forty-nine participants were administered the FB-MSK after completion of their rotations.

Results

Individual post-rotation scores significantly improved regardless of rotation (mean difference 2.78, p<0.001; 95% CI 2.05-3.52). The orthopedic surgery group significantly improved (mean difference 2.84, p<0.001; 95% CI 1.93-3.73) and the PCSM group significantly improved (mean difference 2.64, p=0.002; 95% CI 1.23-4.07). There was no significant difference in pre-rotation scores between the two groups (p=0.86; 95% CI -2.13 to 1.79). There was no significant difference in post-rotation scores between the two groups (p=0.66; 95% CI -1.98 to 1.26). There was no significant difference in mean score improvement between the two groups (p=0.81; 95% CI -1.33 to 1.69).

Conclusion

This study demonstrates significant MSK knowledge acquisition and no difference in the level of knowledge acquisition after completion of either traditional orthopedic surgery or PCSM residency rotation.

Implementing an established musculoskeletal educational curriculum in a new context: a study of effectiveness and feasibility

Background: Musculoskeletal (MSK) problems are common, yet many primary care (PC) providers feel inadequately trained to manage these conditions. Previous studies describe successful MSK educational innovations at single sites, but none have reported on subsequent attempts to replicate or adapt these innovations to new contexts. This article presents a study of a national Veterans Affairs MSK training program modified to fit an existing PC educational program.Objectives: (1) To evaluate the effectiveness and feasibility of an adapted MSK curriculum in a new context. (2) To provide a model for adaptation studies in health professions education.Design: A national MSK shoulder and knee curriculum was adapted for San Francisco VA PC trainees, which included a small-group workshop and workplace learning within a newly-created MSK clinic. Effectiveness was evaluated by assessments of trainee confidence in exam and injection skills (via 5-point Likert scale) and faculty-observed performance of knee and shoulder exams (reported as percent of maximum possible score). Feasibility was evaluated by determining acceptability of the program to PC trainees (via 5-point Likert scale) and ability to implement the curriculum using local resources.Results: 52 trainees completed the training during a 2-year period. Trainees' confidence in MSK exam skills improved from 3.3 to 4.5 for shoulder, and from 3.5 to 4.6 for knee. Confidence performing joint injections improved from 2.6 to 4.2 (shoulder) and 2.5 to 4.5 (knee) (p < 0.001 for all). Observed performance improved markedly - from 50% to 92% for shoulder, and 57% to 90% for knee. Feasibility was evident in high acceptability (5.0 for MSK clinic, and 4.9 for workshops), and successful and sustained implementation.Conclusions: Adapting an established MSK curriculum to a new context was effective and feasible. This may serve as a more efficient model for improving trainee education than de novo curriculum design at individual sites.

Interprofessional Musculoskeletal Education: A Review of National Initiatives from the Department of Veterans Affairs

This article reviews several national programs in musculoskeletal education initiated by the Department of Veterans Affairs over the past decade. These programs have become sustained interprofessional opportunities for learners across disciplines and along the continuum of health professions education (HPE) and training pathways. This article also describes opportunities for leaders in rheumatology and other HPE programs to join these efforts and to collaborate in the scholarship that will be necessary in constructing educational programs fit for the purpose of ensuring a well-trained, competent workforce of health care providers.

Validity evidence for two objective structured clinical examination stations to evaluate core skills of the shoulder and knee assessment

BACKGROUND

We developed two objective structured clinical examinations (OSCEs) to educate and evaluate trainees in the evaluation and management of shoulder and knee pain. Our objective was to examine the evidence for validity of these OSCEs.

METHODS

A multidisciplinary team of content experts developed checklists of exam maneuvers and criteria to guide rater observations. Content was proposed by faculty, supplemented by literature review, and finalized using a Delphi process. One faculty simulated the patient, another rated examinee performance. Two faculty independently rated a portion of cases. Percent agreement was calculated and Cohen's kappa corrected for chance agreement on binary outcomes. Examinees' self-assessment was explored by written surveys. Responses were stratified into 3 categories and compared with similarly stratified OSCE scores using Pearson's coefficient.

RESULTS

A multi-disciplinary cohort of 69 examinees participated. Examinees correctly identified rotator cuff and meniscal disease 88% and 89% of the time, respectively. Inter-rater agreement was moderate for the knee (87%; k = 0.61) and near perfect for the shoulder (97%; k = 0.88). No correlation between stratified self-assessment and OSCE scores were found for either shoulder (0.02) or knee (-0.07).

CONCLUSIONS

Validity evidence supports the continuing use of these OSCEs in educational programs addressing the evaluation and management of shoulder and knee pain. Evidence for validity includes the systematic development of content, rigorous control of the response process, and demonstration of acceptable interrater agreement. Lack of correlation with self-assessment suggests that these OSCEs measure a construct different from learners' self-confidence.

"Mini-Residency" in Musculoskeletal Care: a National Continuing Professional Development Program for Primary Care Providers

INTRODUCTION

A cost-effective professional development program enhancing musculoskeletal (MSK) skills of physicians and allied health providers working in primary care settings has been reported at a single site. This article describes the first 2 years of the national expansion and implementation of a 3-day "MSK Mini-residency."

METHODS

Faculty from Veterans Affairs (VA) medical centers worked in partnership with national program faculty from the Salt Lake City VA to present an intensive, integrated, multidisciplinary program to strengthen the skills of primary care providers in evaluating and managing MSK conditions common in primary care. Course assessments included written surveys and a two-station observed structured clinical examination (OSCE) evaluating the physical examination of the shoulder and knee.

RESULTS

In the first 2 years of the program, 13 VA facilities participated. Two hundred twenty-seven health care providers, including 135 physicians, were trained. Two hundred seven participants (91 %) completed all pre- and post-course written assessments and the two-station OSCE.

DISCUSSION

The MSK Mini-residency program is an effective and well-received mixed-method educational initiative to strengthen the skills of primary care physicians and other health care providers in evaluating and managing patients with MSK complaints and to document their competence in performing physical examinations of the shoulder and knee. The 2-year experience in implementation suggests that this model of educational partnerships is a feasible approach to disseminating innovative educational programs in a way that preserves curricular consistency yet is adaptable to local needs.

Effectiveness of an Interprofessional and Multidisciplinary Musculoskeletal Training Program

BACKGROUND

Musculoskeletal (MSK) problems are common, and a recent US Bone and Joint Initiative calls for new models of education and professional collaboration. Evidence of feasibility and acceptability of innovative methods are needed.

OBJECTIVE

We assessed if an experimental immersion interdisciplinary MSK curriculum would be acceptable to residents from different specialties, be feasible within existing rotations, and be effective in strengthening clinical skills.

METHODS

Through funding from the Veterans Affairs Office of Academic Affiliations and the Office of Specialty Care, we developed a Center of Excellence in MSK Care and Education. A core element is the monthly MSK Education Week, which teaches skills and provides opportunities to apply these in clinical settings. Participants include internal medicine, physical medicine and rehabilitation, and orthopaedic surgery residents, as well as students and residents from other health professions programs. All were assigned to the MSK week in lieu of other clinical experiences. Faculty encompassed primary care, rheumatology, endocrinology, orthopaedics, and physical medicine and rehabilitation. Assessments include surveys and a 2-station objective structured clinical examination (OSCE).

RESULTS

Since 2012, a total of 176 trainees have participated. Percentage of trainees reporting ability to evaluate and manage MSK complaints increased (9% to 87% for shoulder; 18% to 86% for knee), and confidence performing MSK injections increased from 10% to 70%. Competency in evaluation of shoulder and knee pain was confirmed by OSCEs.

CONCLUSIONS

The MSK week program was accepted by residents from the 3 specialties, with learners reporting improved ability to perform shoulder and knee examinations, as demonstrated by OSCEs.