Development and validation of a musculoskeletal physical examination decision-making test for medical students

Musculoskeletal Education in Medical Schools: a Survey in California and Review of Literature

INTRODUCTION

Though musculoskeletal complaints account for roughly one-quarter of primary care and emergency department visits, only 2% of US medical school curriculum is devoted to musculoskeletal disease. Many graduating students demonstrate poor knowledge and report low confidence in treating musculoskeletal disorders. This study defines the current state of musculoskeletal curriculum of medical schools in detail to identify variations and potential shortcomings.

METHODS

All eleven medical schools in California were invited to participate in an in-depth survey detailing the design and content of their musculoskeletal curriculum.

RESULTS

A response rate of 100% was achieved. Overall, schools devoted an average of 58.7 h to musculoskeletal medicine, of which more than half was spent covering anatomy. The primary instructor for musculoskeletal medicine was a clinician in four schools (36.4%). Six schools offered a dedicated musculoskeletal physical exam course. No schools required students to complete a clinical rotation in musculoskeletal medicine. There was high variability among institutions when evaluating core subject coverage.

DISCUSSION

There is large variation in the content and structure of musculoskeletal instruction among California medical schools. Increased curricular time, integration of preclinical and clinical experiences, greater specialist participation, and standardized objectives may provide more consistent and comprehensive musculoskeletal education.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-020-01144-3.

Impact of a Hands-on Knee Exam Workshop on Medical Student Clinical Examination Scores

INTRODUCTION

The goal of this research project was to retrospectively evaluate the effect of a voluntary hands-on musculoskeletal knee exam workshop, presented to medical students in the family medicine rotation at the University of Toledo, on the outcomes of a required objective structured clinical examination (OSCE).

METHODS

We analyzed student OSCE scores for both knee and back exams before (July 2011 to June 2012) and after (August 2013 to June 2015) the workshop was offered. The analysis was based on those who attended the voluntary knee exam workshop and those who did not. We compared scores between the two groups of students using two-tailed t testing and χ ² testing, and assessed the correlation of attending the workshop to passing the knee OSCE.

RESULTS

One hundred eighty-seven students attended the workshop and 279 did not. During the period when the workshop was offered, the overall mean score on the knee OSCE was 59.5% for the 187 who attended the workshop and 35.9% for the 116 who did not, which was significantly different (P<.001). A χ² test with α=0.05 showed that attending the workshop correlated with completing at least 70% of maneuvers acceptably during the knee OSCE (P<.001).

CONCLUSIONS

Our study yielded positive outcomes on OSCE scores, comparable to other studies that investigated the effect of similar teaching techniques. Comparison of the scores of those who attended the knee workshop on the simpler back exam OSCE, in which no workshop was offered, demonstrated the efficacy of the workshop.

Early musculoskeletal classroom education confers little advantage to medical student knowledge and competency in the absence of clinical experiences: a retrospective comparison study

BACKGROUND

Deficiencies in medical student knowledge in musculoskeletal medicine have been well documented. To address these deficiencies, numerous curricular changes at our institution were instituted. The objective of this study was to determine whether medical students in their preclinical years benefit from early exposure to musculoskeletal medicine when compared to students exposed to musculoskeletal medicine just prior to completion of their preclinical curriculum.

METHODS

United States Medical Licensing Examination (USMLE) Step 1 and 2 scores were compared for periods of time before and after institution of the new curriculum. Scores on the previously validated 24-question short answer survey from Freedman and Bernstein were also compared over these same periods of time between these two groups and to established standards for competency, using a student's two-tailed unpaired t-test for significance. Entering Medical College Admission Test (MCAT) scores were used to compare baseline preparation of students.

RESULTS

Overall USMLE scores as well as scores on the USMLE subtest on Musculoskeletal, Skin and Connective Tissue Disease showed no improvement when scores were compared between the two groups of students. There was a statistically significant lower performance on the Freedman and Bernstein knowledge assessment exam for students in the new pre-clinical curriculum as compared to those introduced under the old model, considering both musculoskeletal knowledge (p < 0.001) and proficiency (p < 0.01), though the response rate on the recent survey was low (112/986 or 11%). Spine remained the least understood sub-topic, while a dedicated course in rheumatology likely contributed to increased student knowledge in that area. Additional exposure to musculoskeletal topics during the clinical years increased student knowledge. There was no difference between groups when comparing entering MCAT scores.

CONCLUSIONS

Classroom curricular changes, including moving the introductory musculoskeletal course to the first year, intended to optimize musculoskeletal medicine education in the pre-clinical years of medical school did not appear to improve student musculoskeletal knowledge at any year of training. Further efforts to improve the education of medical students in musculoskeletal medicine should be directed towards providing more clinical experiences with patients having musculoskeletal concerns. This was a retrospective comparative study, level III evidence.

Near-peer emergency medicine for medical students in Port-au-Prince, Haiti: an example of rethinking global health interventions in developing countries

BACKGROUND

During a 3-year time frame, a partnership between medical trainees in Haiti and the United States was forged with the objective of implementing an emergency response skills curriculum at a medical school in Port-au-Prince. The effort sought to assess the validity of a near-peer, bidirectional, cross-cultural teaching format as both a global health experience for medical students and as an effective component of improving medical education and emergency response infrastructure in developing countries such as Haiti.

METHOD

Medical students and emergency medicine (EM) residents from a North American medical school designed and taught a module on emergency response skills in PAP and certified medical students in basic cardiac life support (BLS) over 2 consecutive years. Five-point Likert scale self-efficacy (SE) surveys and multiple-choice fund of knowledge (FOK) assessments were distributed pre- and postmodule each year and analyzed with paired t tests and longitudinal follow-up of the first cohort. Narrative evaluations from participants were collected to gather feedback for improving the module.

FINDINGS

Challenges included bridging language barriers, maintaining continuity between cohorts, and adapting to unexpected schedule changes. Overall, 115 students were certified in BLS with significant postcurriculum improvements in SE scores (2.75 ± 0.93 in 2013 and 2.82 ± 1.06 in 2014; P < 0.001) and FOK scores (22% ± 15% in 2013 and 41% ± 16% in 2014; P < 0.001). Of 24 Haitian students surveyed at 1-year follow-up from the 2013 cohort, 7 (29.3%) reported using taught skills in real-life situations since completing the module. The US group was invited to repeat the project for a third year.

CONCLUSIONS

Near-peer, cross-cultural academic exchange is an effective method of medical student-centered emergency training in Haiti. Limitations such as successfully implementing sustainability measures, addressing cultural differences, and coordinating between groups persist. This scalable, reproducible, and mutually beneficial collaboration between North American and Haitian medical trainees is a valid conduit for building Haiti's emergency response infrastructure and promoting global health.

The TROJAN Project: Creating a Customized International Orthopedic Training Program for Junior Doctors

Musculoskeletal problems account for a vast proportion of presentations encountered by doctors globally, with figures ranging from 15-36%. However, the time medical schools allocate to learning orthopedics is by no means proportional to this. This study aims to bridge this gap by developing an international orthopedic teaching program tailored to the specific knowledge and skills required by junior doctors in different countries. This prospective study asked fifty junior doctors, who had recently completed an orthopedics job, what three orthopedic teaching topics taught retrospectively would have benefitted their clinical practice. The most requested topics were used to design educational workshops for junior doctors and these consequently comprised the TROJAN (Teaching Requested by Orthopaedic Juniors And Novices) training program. Data was collected from twenty-five junior doctors in KwaZulu-Natale State, South Africa, and twenty-five in London, UK. It is therefore in these two countries that the TROJAN program was subsequently made available. Participants who selected topics were within two years of graduating medical school and had worked an orthopedic or Accident and Emergency job within the last year. 49% of topics chosen by SA doctors were practical skills such as wrist and ankle fracture reduction techniques, and management of open fractures. The most requested topic by UK doctors (11 out of 25) was management of neck of femur fractures. This is rationalized by the fact South African doctors require more hands-on responsibility in their daily practice whereas in the UK greater emphasis is placed on optimizing patients for theatre and making sound management plans. TROJAN currently develops orthopedic skills and knowledge in junior doctors in South Africa and United Kingdom with teaching customized based upon location. Feedback has been exceptionally positive with every candidate thus far rating the usefulness of TROJAN as the highest option, very useful.