Musculoskeletal examination for medical students: the need to agree what we teach

A structured multimodal teaching approach enhancing musculoskeletal physical examination skills among undergraduate medical students

Current evidence indicates that undergraduate medical students display deficits in musculoskeletal physical examination skills (MPES). While various instructional methods are recommended for teaching clinical skills, effective methods for teaching MPES have not been established. This study compared the effectiveness of a multimodal teaching approach incorporating video-based learning, interactive small-group teaching, hands-on practicing, peer-assisted learning, formative assessment, and constructive feedback with traditional bedside teaching in developing undergraduate orthopedic MPES. Participants were 151 fifth-year medical students divided into two groups. One group received multimodal teaching, and the other received traditional bedside teaching. In both groups, the participants learned how to physically examine the knee and shoulder. The primary outcome was objective structured clinical examination (OSCE) scores, while the secondary outcomes included teaching sessions' total durations, facilitator's demonstration time, participants' practice time, and proportion of students with passing checklist scores and global ratings-based assessments for the two teaching approaches. The multimodal teaching group had significantly higher OSCE scores (checklist scores, global ratings, and passing rates; p = 0.02, 0.02, 0.01, respectively) than the comparison group. Individual OSCE component assessments showed significant improvements in the special musculoskeletal physical examination test. The overall duration and amount of participants' hands-on time were significantly longer for the multimodal than for the traditional bedside teaching group (p = 0.01 and 0.01, respectively), and the facilitator's demonstration time was significantly shorter (p = 0.01). The multimodal learner-centered teaching approach evaluated in this study was effective for teaching MPES. It appeared to maximize learner engagement through enhancing interactions and providing increased time to engage in hands-on practice. This teaching approach improved MPES levels, maximized teaching efficiency for scenarios with limited instruction time and resources, and enhanced competency of undergraduate medical students in performing special musculoskeletal physical examinations compared to traditional bedside teaching.

Teaching musculoskeletal examination skills to UK medical students: a comparative survey of Rheumatology and Orthopaedic education practice

BACKGROUND

Specialists in Rheumatology and Orthopaedics are frequently involved in undergraduate teaching of musculoskeletal (MSK) examination skills. Students often report that specialty-led teaching is inconsistent, confusing and bears little resemblance to the curricula. The Gait, Arms, Legs and Spine (GALS) is a MSK screening tool that provides a standardised approach to examination despite it being fraught with disapproval and low uptake. Recent studies would appear to support innovative instructional methods of engaging learners such as patient educators and interactive small group teaching.

METHODS

This comparative cross-sectional survey evaluates the current state of undergraduate teaching in Rheumatology and Orthopaedics, including preferred teaching methods, attitudes towards GALS, and barriers to effective teaching. An electronic questionnaire was sent to specialist trainees and Consultants in the East and West Midlands region, representing 5 UK medical schools. Descriptive statistical data analysis was performed.

RESULTS

There were 76 respondents representing 5 medical schools. There was a request for newer teaching methodologies to be used: multi-media computer-assisted learning (35.5%), audio-visual aids (31.6%), role-playing (19.7%), and social media (3.9%). It is evident that GALS is under-utilised with 50% of clinicians not using GALS in their teaching.

CONCLUSIONS

There is a genuine desire for clinical educators to improve their teaching ability, collaborate more with curriculum planners, and feel valued by institutions. There remains a call for implementing a standardised approach to MSK clinical teaching to supersede GALS.

Teaching musculoskeletal physical diagnosis using a web-based tutorial and pathophysiology-focused cases

OBJECTIVE

To assess the effectiveness of an experimental curriculum on teaching first-year medical students the musculoskeletal exam as compared to a traditional curriculum.

BACKGROUND

Musculoskeletal complaints are common in the primary care setting. Practitioners are often deficient in examination skills and knowledge regarding musculoskeletal diseases. There is a lack of uniformity regarding how to teach the musculoskeletal examination among sub-specialists. We propose a novel web-based approach to teaching the musculoskeletal exam that is enhanced by peer practice with pathophysiology-focused cases. We sought to assess the effectiveness of an innovative musculoskeletal curriculum on the knowledge and skills of first-year medical students related to musculoskeletal physical diagnosis as compared to a traditional curriculum. The secondary purpose of this study was to assess satisfaction of students and preceptors exposed to this teaching method.

METHODS

This quasi-experimental study was conducted at a single LCME-accredited medical school and included a convenience sample from 2 consecutive classes of medical students during the musculoskeletal portion of their physical diagnosis class. We conducted a needs assessment of the traditional curriculum used to teach musculoskeletal examination. The needs assessment informed the development of an experimental curriculum. One class (control group) received the traditional curriculum while the second class (experimental group) received the experimental curriculum, consisting of a web-based musculoskeletal tutorial, pathophysiology-focused cases, and facilitator preparation. We used multiple-choice questions and musculoskeletal OSCE scores to assess differences between knowledge and skills in the 2 groups.

RESULTS

The sample consisted of 140 students in each medical school class. There were no statistically significant differences between the 2 groups. One hundred seven students from the control group and 120 students from the experimental group took the multiple-choice examination. The average score was 66% (95% CI= 59.7-72.3) for the control group and 66% (95% CI = 60.5-71.5) for the experimental group. There was no difference between the median musculoskeletal OSCE scores between the 2 groups. The experimental group was satisfied with the new teaching method and gained the additional benefit of a persistent resource.

CONCLUSIONS

This web-based experimental curriculum was as effective as the traditional curriculum for teaching the musculoskeletal exam. Additionally, users were satisfied with the web-based training and benefited from a persistent resource.

Teaching musculoskeletal physical diagnosis using a web-based tutorial and pathophysiology-focused cases

OBJECTIVE

To assess the effectiveness of an experimental curriculum on teaching first-year medical students the musculoskeletal exam as compared to a traditional curriculum.

BACKGROUND

Musculoskeletal complaints are common in the primary care setting. Practitioners are often deficient in examination skills and knowledge regarding musculoskeletal diseases. There is a lack of uniformity regarding how to teach the musculoskeletal examination among sub-specialists. We propose a novel web-based approach to teaching the musculoskeletal exam that is enhanced by peer practice with pathophysiology-focused cases. We sought to assess the effectiveness of an innovative musculoskeletal curriculum on the knowledge and skills of first-year medical students related to musculoskeletal physical diagnosis as compared to a traditional curriculum. The secondary purpose of this study was to assess satisfaction of students and preceptors exposed to this teaching method.

METHODS

This quasi-experimental study was conducted at a single LCME-accredited medical school and included a convenience sample from 2 consecutive classes of medical students during the musculoskeletal portion of their physical diagnosis class. We conducted a needs assessment of the traditional curriculum used to teach musculoskeletal examination. The needs assessment informed the development of an experimental curriculum. One class (control group) received the traditional curriculum while the second class (experimental group) received the experimental curriculum, consisting of a web-based musculoskeletal tutorial, pathophysiology-focused cases, and facilitator preparation. We used multiple-choice questions and musculoskeletal OSCE scores to assess differences between knowledge and skills in the 2 groups.

RESULTS

The sample consisted of 140 students in each medical school class. There were no statistically significant differences between the 2 groups. One hundred seven students from the control group and 120 students from the experimental group took the multiple-choice examination. The average score was 66% (95% CI= 59.7-72.3) for the control group and 66% (95% CI = 60.5-71.5) for the experimental group. There was no difference between the median musculoskeletal OSCE scores between the 2 groups. The experimental group was satisfied with the new teaching method and gained the additional benefit of a persistent resource.

CONCLUSIONS

This web-based experimental curriculum was as effective as the traditional curriculum for teaching the musculoskeletal exam. Additionally, users were satisfied with the web-based training and benefited from a persistent resource.

Development of the Australian Core Competencies in Musculoskeletal Basic and Clinical Science project - phase 1

Musculoskeletal conditions are a major contributor to the burden of disease globally and their impact is predicted to increase. Consistent with findings in other countries, the current standard of musculoskeletal education in Australian medical schools is inadequate to meet today's musculoskeletal care requirements. A national multidisciplinary approach unifying the key musculoskeletal clinical and basic science disciplines has been adopted to provide clear, evidence-based education guidelines that are specifically aimed at priority musculoskeletal conditions; a direct link is therefore established between community health care needs and education at a national level. This "top-down" approach provides the potential for a far more effective and efficient delivery of musculoskeletal education by allowing the identification of the key basic knowledge and skills required to achieve core competencies and by providing appropriate direction for students. The Australian Core Competencies in Musculoskeletal Basic and Clinical Science are being developed for medical schools to incorporate into their curricula, with the ultimate aim of improving the standard of health care for Australians with musculoskeletal conditions.

Validation of the GALS musculoskeletal screening exam for use in primary care: a pilot study

Background

As the proportion of the Canadian population ≥65 grows, so too does the prevalence of musculoskeletal (MSK) conditions. Approximately 20% of visits to family physicians occur as a result of MSK complaints. The GALS (Gait, Arms, Legs, and Spine) screening examination was developed to assist in the detection of MSK abnormalities. Although MSK exams are primarily performed by rheumatologists or other MSK specialists, expanding their use in primary health care may improve the detection of MSK conditions allowing for earlier treatment. The primary goal of this study was to evaluate the use of the GALS locomotor screen in primary care by comparing the results of assessments of family physicians with those of rheumatologists. The secondary goal was to examine the incidence of MSK disorders and assess the frequency with which new diagnoses not previously documented in patients' charts were identified.

Methods

Patients ≥65 years old recruited from an academic family health centre were examined by a rheumatologist and a family physician who recorded the appearance of each participant's gait and the appearance and movement of the arms, legs and spine by deeming them normal or abnormal. GALS scores were compared between physicians with the proportion of observed (P_obs), positive (P_pos) and negative (P_neg) agreement being the primary outcomes. Kappa statistics were also calculated. Descriptive statistics were used to describe the number of "new" diagnoses by comparing rheumatologists' findings with each patient's family practice chart.

Results

A total of 99 patients consented to participate (92 with previously diagnosed MSK conditions). Results showed reasonable agreement between family physicians and rheumatologists; P_obs = 0.698, P_pos = 0.614 and P_neg = 0.752. The coefficient of agreement (estimated Kappa) was 0.3675 for the composite GALS score. For individual components of the GALS exam, the highest agreement between family physicians and rheumatologists was in the assessment of gait and arm movement.

Conclusion

Previously reported increases in undiagnosed signs and symptoms of musculoskeletal conditions have highlighted the need for a simple yet sensitive screening exam for the identification of musculoskeletal abnormalities. Results of this study suggest that family physicians can efficiently use the GALS examination in the assessment of populations with a high proportion of musculoskeletal issues.

An examination of musculoskeletal cognitive competency in chiropractic interns

OBJECTIVE

This study investigates the cognitive competency of final-year chiropractic students in musculoskeletal medicine.

METHODS

The face, content, and criterion validity of the Basic Clinical Examination (BCE) for musculoskeletal medicine were tested for use in chiropractic education. After validity testing, the BCE was administered in a cross-sectional design to all fourth year students (154) attending the Canadian Memorial Chiropractic College.

RESULTS

Twenty percent (5 questions) of the BCE was deemed not relevant or outside of the scope of practice by criterion experts. One hundred twenty-three (80%) fourth year chiropractic interns participated in the cross-sectional study. Interns achieved a 51.2% passing rate (mean score, 73.2%; 95% confidence interval, 82%-71.8%) for the 25-item BCE, whereas the criterion experts achieved a 100% passing rate. For the modified 20-item BCE, the interns' mean score was 80.8%, whereas the criterion experts' mean score rose to 92.8%.

CONCLUSIONS

Most final-year chiropractic interns at this college were [corrected] found to be competent in musculoskeletal medicine as assessed by the Basic Competency Examination. This is in contradiction to previous work with medical students, recent medical graduates, nonorthopedic staff physicians, osteopathic students, and physical therapy students. Chiropractic clinicians with postgraduate training showed considerably better results than chiropractic interns. Problems pertaining to the content validity (relevance and scope of practice for chiropractors) of the BCE need to be addressed.