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

Using the Novel Musculoskeletal Emergency Medicine Assessment Tool: A Feasibility Study

Background and objective While musculoskeletal (MSK) disorders account for a significant number of primary care and emergency department (ED) visits, there are widely recognized shortcomings and gaps in MSK education throughout medical training. Undergraduate medical education (UME) frequently fails to impart clinically relevant MSK knowledge, while many emergency medicine (EM) residency graduates report feeling unprepared to manage MSK complaints. Existing MSK assessments are not tailored to EM and may inaccurately assess specialty-specific MSK knowledge. The novel validated Musculoskeletal Emergency Medicine Assessment Tool (MEAT) holds great promise in standardizing EM MSK knowledge assessment. This trial of feasibility was conducted to assess the viability and practicality of using MEAT to evaluate MSK knowledge among incoming resident physicians in EM programs. Methods This feasibility study involved 21 incoming EM resident physicians from two programs at a single institution. MEAT was administered online during orientation, and demographic data and survey metadata were collected. UME MSK education details were obtained, and MEAT scores were analyzed. Results Participants reported no difficulties in accessing or understanding the 50-question online MEAT, resulting in a 100% response rate. The average pretest score for all interns was 29.9, with a median of 30. Most participants had documented UME MSK education, but curricular content varied widely. The participants took an average of 32 minutes to complete the assessment. Conclusions MEAT demonstrated successful implementation and high response rates, suggesting a high level of feasibility. The tool can be used to assess baseline MSK knowledge and ultimately track progression during residency with the potential for evaluating educational interventions once further validation studies have been performed. Further adoption of MEAT across multiple EM residency programs will help to enhance the tool's generalizability.

The Musculoskeletal 30-question multiple choice questionnaire (MSK-30): a new assessing tool of musculoskeletal competence in a sample of Italian physiotherapists

BACKGROUND

The prevalence and cost of musculoskeletal diseases increased dramatically over the past few decades. Therefore, several institutions have begun to re-evaluate the quality of their musculoskeletal educational paths. However, current standardized questionnaires inadequately assess musculoskeletal knowledge, and other musculoskeletal-specific exams have limitations in implementation. The musculoskeletal 30-question multiple choice questionnaire (MSK-30) was proposed as a new tool for assessing basic musculoskeletal knowledge.

AIM

To analyse basic musculoskeletal knowledge in a sample of Italian physiotherapists by administering the MSK-30 questionnaire.

METHODS

After a transcultural adaptation process, the MSK-30 was developed and administered to Italian physiotherapists to assess their musculoskeletal knowledge. Participants were invited to participate in the survey via the SurveyMonkey link. Mann-Whitney test and the Kruskal-Wallis test with Bonferroni correction were used to observe the differences between groups in the MSK-30 scores.

RESULTS

Four hundred-fourteen (n=414) physiotherapists participated in the survey. The median MSK-30 value was higher in physiotherapists who attended the International Federation of Orthopaedic Manipulative Physical Therapists postgraduate certification than in those who attended unstructured postgraduate training in musculoskeletal condition or in those who had not completed any postgraduate training in this field (p<0.001).

CONCLUSIONS

This work demonstrates significant differences in the management of musculoskeletal disorders between those with specific postgraduate university education and those without. The findings can contribute to the advancement of the physiotherapy profession in Italy. Authors recommend further research with more robust methodologies to deeper understand this topic. Musculoskeletal conditions will continue to represent a significant portion of primary care visits, and future generations of physiotherapists must be prepared to address this challenge.

Play in the reading room: Utilizing soft modeling compound to teach musculoskeletal anatomy and pathology

PROBLEM DESCRIPTION

Musculoskeletal (MSK) anatomy and pathology from a radiology perspective can be difficult to conceptualize and understand due to the challenge of visualizing 3D structures in stacks of 2D imaging. Consequently, trainees may benefit from inexpensive methods that can help trainees better visualize MSK anatomy and pathology. The purpose of this study is to provide proof of concept for inexpensive methodology to help learners such as radiology residents quickly and inexpensively understand musculoskeletal anatomy and pathology. This can help trainees become better at applying musculoskeletal knowledge to clinical practice.

INSTITUTIONAL METHODOLOGY

Soft-modeling compounds such as Play-Doh® was utilized in a variety of colors with pottery tools to recreate 3D models of challenging MSK anatomy and pathology for trainees. Qualitative feedback from the residents was collected.

RESULTS

Eighteen different pathological conditions across six major bone structures were modeled with a soft modeling compound. Residents qualitatively identified the experience as educational in terms of helping them better understand MSK pathology and positive in terms of making learning fun, less stressful, and memorable due to uniqueness of the learning modality. Residents report challenges modeling complex anatomical features and pathology via this methodology.

CONCLUSION

Radiology residents and other learners can enhance their knowledge of musculoskeletal anatomy and pathology via utilization of inexpensive soft modeling compounds. This may offer a cheaper and more time sensitive alternative to current 3-dimensional hardware and software technologies being developed for educational purposes. Additional work needs to be done to examine the utility of this methodology across larger and diverse groups of learners.

Development of an Orthopedic Surgery Anatomy Curricular Model for Fourth Year Medical Students Using a Modified Delphi Method

OBJECTIVE

The purpose of this study was to develop anatomy-focused learning outcomes that can be used to design a fourth-year elective for students matriculating into orthopedic surgery residencies.

DESIGN

A series of proposed learning outcomes (N=72) was developed using the ACGME Orthopedic Milestones 2.0 as a framework. In 2021, these were converted into a survey asking participants to rate the importance of each outcome on a 5-point Likert scale. The modified Delphi Method was used to refine the list of outcomes until group consensus was achieved. The consensus was defined using a conservative 3-tier approach.

SETTING

Eighteen academic centers with an associated orthopedic surgery residency.

PARTICIPANTS

Twenty-six orthopedic surgeons (ranging from 1 to 42 years in practice).

RESULTS

Of the 72 learning outcomes from the first-round survey, 25 met consensus criteria. Of the 62 learning outcomes from the second-round survey, 45 met consensus criteria. All learning outcomes that met consensus criteria after the second-round survey were stratified into low-yield (n = 8), intermediate-yield (n = 34), and high-yield (n = 28) categories.

CONCLUSION

Using a modified Delphi Method, this study elicited feedback from experts in the field of orthopedic surgery to develop a framework for a fourth-year elective focused on anatomical concepts important for students applying to residencies in orthopedic surgery. The product of this process affords a great deal of flexibility when utilizing the results of this study in institution-specific curricular development.

Emergency Medicine Obstetrics and Gynecology: A Case-Based Curriculum for Residents

Introduction

Millions of patients present to US emergency departments every year with OB/GYN concerns. Emergency medicine trainees must be adequately prepared to care for this population, regardless of how commonly they appear in the training environment. We used active learning and gamification principles in this curriculum to increase learner engagement and participation in the material.

Methods

We chose OB/GYN topics based on review of Tintinalli's OB/GYN content and the American Board of Emergency Medicine's Model of Clinical Practice. Each session comprised a case-based lecture and review questions using the game-based Kahoot! online software. Pre- and postcurriculum surveys assessed residents' confidence in caring for emergent OB/GYN pathologies on a 5-point Likert scale. We designed survey questions assessing the first level of Kirkpatrick's levels of training evaluation; these questions were reviewed and revised by the department's Medical Education Scholarship Committee for validity.

Results

A mean of 18 residents attended each session. Seventy-six percent of residents (26 of 34) completed the precurriculum survey, 67% (23 of 34) completed the postcurriculum survey, and 44% (15 of 34) completed both. For all respondents, mean reported confidence with curriculum topics increased from 3.5 to 4.0 (p < .05). For residents completing both surveys, confidence increased from 3.4 to 4.0 (p < .01).

Discussion

Application of this curriculum significantly improved learner confidence in targeted OB/GYN topics. Future directions could include evaluating curricular impact at higher levels in the Kirkpatrick model, extending sessions to include more time for interaction, and adding suggested readings.

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.

The Current State of Undergraduate Trauma and Orthopedics Training in Saudi Arabia: A Survey-Based Study of Sixth-Year Medical Students' and Interns' Learning Experience and Subjective Clinical Competence

Background and objective Students frequently complain about the lack of practical skill learning and the poor quality of the medical school curriculum. In light of this, the purpose of this study was to assess the learning experience and subjective clinical competence of final-year medical students and interns in the field of orthopedics in Saudi Arabia (SA). Methods A cross-sectional observational descriptive study utilizing an electronically validated survey was conducted, which included the following six main sections: introduction, demographics, self-assessment of competency regarding certain orthopedic skills, clinical experience in orthopedics, orthopedics curriculum assessment, and choice of future career specialty. Results The total number of participants was 794. Among them, 33% (n=160) and 37.1% (180) had attended no "trauma meetings" or "operating room (OR)" sessions respectively, and only 21.9% (n=106) had attended more than five clinics. Subjective competence in history taking was highest (mean: 8.925 ±1.299) among students who had received more than four weeks of orthopedic rotation and attended more than six clinics. The students who had completed more than four weeks of orthopedic rotation and more than six bedside sessions scored the highest in terms of subjective competence in handling orthopedic patients in primary care settings (mean: 8.014 ±1.931). Conclusion The survey indicates that the amount of orthopedic training provided by institutions varies, with some students receiving less training than recommended. However, longer rotations lead to greater perceived orthopedic competence. Students and interns with more exposure to orthopedics through curriculum and elective rotations demonstrated a greater interest in pursuing orthopedics as a future career.

Sports Medicine Curricular Recommendations for Undergraduate Medical Education

ABSTRACT

Sports medicine is a unique field encompassing many specialties and aspects of medicine. While musculoskeletal medicine is a significant aspect of sports medicine, the breadth of sports medicine extends beyond the musculoskeletal system and includes the spectrum of care for the patient who is or desires to be physically active. This article provides recommendations for sports medicine education in undergraduate medical education. The framework highlighting these recommendations uses domains of competence. Entrustable professional activities, measures that are endorsed by the Association of American Medical Colleges, were matched to domains of competence to provide objective markers of achievement. In addition to recommended sports medicine educational content, there should be consideration of both methods of assessment and implementation catered to each individual institution's needs and resources. These recommendations may serve as a guide for medical educators and institutions pursing optimization of sports medicine education.

Knowledge of Musculoskeletal Medicine in Junior Doctors in Australia: Is It Adequate?

PURPOSE

The incidence of musculoskeletal disease is increasing in Australia and around the world. However, medical student education does not necessarily reflect current and projected trends in musculoskeletal medicine. The aim of this study was to assess junior doctors' competency in musculoskeletal medicine using the Freedman and Bernstein Basic Competency Examination in Musculoskeletal Medicine questionnaire.

METHODS

We conducted a cohort study of interns (first year post medical school) across four teaching hospitals in Australia. Interns were asked to take the Freedman and Bernstein examination during organised intern teaching sessions, and results were analysed using the original Freedman and Bernstein marking criteria and validated pass mark.

RESULTS

The mean score for the 92 interns was 13.9 out of 25 (55%) with scores ranging from 8 to 20.8 (29-83%). Only 8 of the 92 interns (8.7%) achieved a score of greater than 73%, the pre-specified pass mark.

CONCLUSION

Our study identifies inadequacies in musculoskeletal medical knowledge in Australian interns. Review of undergraduate medical education may be required to reflect current and predicted trends in the prevalence of musculoskeletal disease and adequately prepare junior doctors.

Impact of Sports Medicine and Orthopedic Surgery Rotations on Musculoskeletal Knowledge in Residency: An Update and Longitudinal Study

Introduction Musculoskeletal (MSK) complaints and injuries account for a significant percentage of presenting chief complaints to the emergency department in the United States (US). Despite the prevalence of disease 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 study is to determine MSK knowledge acquisition after an orthopedic or primary care sports medicine (PCSM) rotation in three emergency medicine (EM) residency programs at a single institution. Methods A total of 115 EM post-graduate year 1 (PGY-1) residents participated in and completed this study over five academic years. Based on existing residency program curricula, the participants were categorized into two groups. One group completed a traditional four-week Orthopedic Surgery rotation and the other group completed a four-week Sports Medicine rotation. The validated written Freedman and Bernstein MSK examination (FB-MSK) was administered to all participants at the start of residency and at completion of their rotation. Fifty-nine of the participants participated in a longitudinal secondary study over five academic years. The FB-MSK was offered to all participants every year following the completion of their rotation during their residency. Results Post-rotation scores improved regardless of which group the resident belonged to. The orthopedic group improved an average of 3.11 points (p = <0.0001, CI 2.39 to 3.82) and the average improvement in the PCSM group was 3.97 points (p = <0.0001, CI 2.81 to 5.83). The post-rotation scores were similar regardless of the group (p = 0.4287, CI -0.73 to 1.70). The amount of improvement in scores between the two groups was not statistically significant (p = 0.209, CI -0.49 to 2.21). Of the longitudinal participants, PGY-3+ significantly scored higher than PGY-1 (p = 0.0325, 95% CI 0.165 to 3.658). Conclusion Regardless of rotation type, MSK knowledge acquisition appears to significantly improve. EM senior residents demonstrate significant MSK knowledge acquisition during residency. Further studies on a multi-institutional level are needed to account for MSK curriculum variability in residency programs.

Musculoskeletal pain is prevalent in Chinese medical and dental students: A cross-sectional study

Objectives

Musculoskeletal pain (MSP) is a major reason for consultation in primary care and is becoming increasingly prevalent among medical students. There is little research on the current situation of MSP among Chinese medical and dental students. Data on the analysis of risk factors related to MSP are also limited. The objectives of this study were to investigate the prevalence and characteristics of MSP among Chinese medical and dental students and to explore the risk factors for MSP and students' intent to seek medical treatment.

Methods

An anonymous, internet-based, cross-sectional, open survey was distributed to medical and dental students at Fujian Medical University, Fuzhou, China. Data on the demographic information and characteristics of MSP were collected and analyzed. In addition to descriptive statistics, logistic regression was used to analyze significant risk factors contributing to MSP.

Results

A total of 1,178 students responded to the survey (response rate = 79.6%), including 722 medical students and 456 dental students. The age ranged from 16 to 24. There were 553 male students and 625 female students. A total of 523 students reported neck pain (NP, 44.4%), 361 students reported low back pain (LBP, 30.6%), and 182 students reported joint pain (JP, 15.4%). Sixty-six students (5.6%) simultaneously suffered from NP, LBP, and JP. The prevalence of NP (49.1 vs. 41.4%, P = 0.01), LBP (34.6 vs. 28.1%, P = 0.02), and JP (20.2 vs. 12.5%, P < 0.001) was significantly higher in dental students than in medical students. The prevalence of MSP was significantly different among the academic years for NP and LBP (P = 0.02 and P < 0.001, respectively). Univariate and multivariate regression analyses demonstrated that female sex, PSS-10 score, and major of stomatology were risk factors for MSP. Medical and dental students' intention to seek treatment for MSP was low and was significantly associated with the severity of pain.

Conclusions

The prevalence of MSP in Chinese medical and dental students is high, especially for NP and LBP, and is significantly higher in dental students than in medical students. The prevalence of NP and LBP were significantly different among academic grades. Female sex, PSS-10 score, and major of stomatology were risk factors for MSP. Students' intent to seek treatment for MSP was very low and was determined by the severity of pain.

Referral patterns to a pediatric orthopedic clinic: pediatric orthopedic surgeons are primary care musculoskeletal medicine physicians

In 2004, Reeder and in 2012, Schwend reported that inappropriate nonsurgical referrals to pediatric orthopedic clinics create a misuse of resources. Additional authors have called for re-emphasis and additional training in musculoskeletal medicine for primary care physicians (PCP) to improve the confidence, knowledge and performance when managing musculoskeletal conditions. The current study compares the diagnoses referred to a pediatric orthopedic clinic with diagnoses recommended for referral by the American Academy of Pediatrics (AAP) guidelines to determine if any improvement in the quality of referrals has occurred since Reeder and Schwend's article. A chart review of new referrals to a pediatric orthopedic clinic during a 3-month-period was performed. Data were collected on age, sex, referring diagnosis, referral source, final diagnosis and treatment. In total 230 new consults were evaluated. The referral source was a PCP in 169 (73.5%) cases, 30 (13%) self-referrals by a parent, 19 (8.3%) from another orthopedic surgeon, 9 (3.9%) from a neurologist and 3 (1.3%) from another specialist. Fifty percent of referrals met the criteria outlined in the AAP guidelines for referral to a pediatric orthopedic specialist and 48% were classified as primary care musculoskeletal conditions. During the 15 years since the publication of Reeder's study and despite a limited re-emphasis on musculoskeletal education, the percent of inappropriate referrals to a pediatric orthopedic clinic remains unchanged at 50%. We support an expanded musculoskeletal educational effort aimed at the medical, resident and pediatrician level, online decision-making aids, and implementation of a standardized referral form with the specific criteria of the AAP included.

Difficulties with Learning Musculoskeletal Physical Examination Skills: Student Perspectives and General Lessons Learned for Curricular Design

Phenomenon: The development of foundational clinical skills, such as physical examination, is essential to becoming a competent clinician. Musculoskeletal medicine is often considered a specialized area of practice despite the high prevalence of musculoskeletal conditions in the general population and presenting to general clinical practices. Prior work has shown that medical learners and practicing clinicians have low confidence in these skills but understanding of the student perspective on why these skills are more difficult to acquire is unclear.Approach: Our study was guided by social constructivist learning theory to explore the learner experience and present their perspectives. Qualitative analysis investigated the difference between learning musculoskeletal physical examination versus other body systems, using the voices from 11 semi-structured focus group interviews. Participants included third-year medical students across two academic cohorts at one institution. Our analysis was grounded in the principles of phenomenology and used triangulation and reflexivity to provide rigorous analysis.Findings: Students provided rich and insightful perspectives regarding their experiences in learning musculoskeletal physical examination techniques. Four themes were developed from our data: a) the need for opportunities for both supervised and self-directed practice; b) assessment and competence as motivations for learning; c) the need for a different approach to the content and structure of musculoskeletal medicine and its associated examination techniques; and d) the need for distinct expertise and technical skill from musculoskeletal examination teachers.Insights: This study provides a valuable lens to critically reflect on existing curriculum and pedagogical approaches to musculoskeletal examination skills. Lessons from this study may be applicable to curriculum design in general, especially the teaching of physical examination skills, such as how it is taught and integrated with other content (including anatomy), how much practice is required, who teaches physical examination skills, and what faculty development is needed to standardize teaching. Promoting a learner-centered approach to the teaching and learning of these clinical skills will be beneficial to all stakeholders, especially to our future physicians and their patients.Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1954930 .

Healthcare utilization and costs for musculoskeletal disorders in Ontario, Canada

OBJECTIVE

To examine the magnitude and costs of ambulatory primary and specialist physician care and hospital service use for musculoskeletal disorders (MSDs) in Canada's largest province, Ontario.

METHODS

Administrative health databases were analyzed for fiscal year 2013-2014 for adults 18+ years, including data on physician services, emergency department (ED) visits and hospitalizations. ICD diagnostic codes were used to identify MSD services. A validated algorithm was used to estimate direct medical costs. Person visit rates and numbers of persons and visits were tabulated by care setting, age and sex, and physician specialty. Data were examined for all MSDs combined as well as specific diagnostic groupings.

RESULTS

Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs. These included 5.6 million primary care visits. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, 8.5% to day surgery and 61.2% of total costs associated with inpatient hospitalizations. Costs due to arthritis accounted for 40% of total MSD care costs ($639 million). MSD-related imaging costs were $169 million. Including these costs yields a total estimate of $1.8 billion for all MSDs combined.

CONCLUSION

MSDs place a significant and costly burden on the health care system. Health system planning needs to consider the large and escalating demand for care to reduce both the individual and population burden.

Attitudes toward pediatric rheumatology among residency-trained pediatricians

BACKGROUND

Pediatric rheumatology (PR) is a relatively new and rare subspecialty in emerging countries. This study aimed to investigate physicians' attitudes toward and real-life clinical practice in PR among residency-trained pediatricians in Thailand.

METHODS

An electronic questionnaire was developed and sent via email to pediatricians from Thailand who completed their residency training between 2007 and 2015. Confidence in treating and managing children with rheumatic diseases was rated using a 5-point Likert scale.

RESULTS

The response rate was 281 out of 902 (31%), and the mean ± standard deviation age of respondents was 33.8 ± 2.7 years. Confidence was rated as adequate for history taking of children with rheumatic diseases (mean 2.76, 95% confidence interval [CI]: 2.66-2.91), but low for musculoskeletal (MSK) examination (2.42, 95% CI: 2.29-2.54), arthrocentesis (2.01, 95% CI: 1.91-2.11), and rheumatology investigation (2.49, 95% CI: 2.39-2.60). Confidence was high for diagnosis and management of Henoch-Schönlein purpura (3.83, 95% CI: 3.74-3.92) and Kawasaki disease (3.46, 95% CI: 3.38-3.55), but low for juvenile idiopathic arthritis (JIA) (2.41, 95% CI: 2.30-2.52) and chronic systemic vasculitis (1.97, 95% CI: 1.85-2.08). Confidence to perform an MSK examination and arthrocentesis was significantly higher in respondents who had a full-time pediatric rheumatologist working in their pediatric residency training center (P = 0.02, P = 0.01, respectively), and in those who had experienced a PR rotation (P < 0.001, P = 0.01, respectively). Most respondents agreed that more teaching in PR is essential (95.3%) and that case-based discussion was the preferred teaching method.

CONCLUSION

The self-rated confidence of pediatricians was low in MSK examination, arthrocentesis, and rheumatology investigation and therefore, teaching on PR is needed.

Investigating interest in orthopedic surgery within an entire medical faculty: A cross-sectional study

BACKGROUND

Discrepancies exist between the magnitude of musculoskeletal problems and the competency of physicians practicing musculoskeletal medicine, which likely stems from medical school-level educational deficiencies. Therefore, inadequate orthopedic surgery education during medical school may affect the number of students aspiring to practice orthopedic surgery. However, the motivating factors underlying medical students' selection of a career specialty are largely unknown. This study aims to use a survey to examine the motivations of medical students who consider orthopedic surgery as a potential career specialty.

METHODS

A questionnaire survey was administered to medical students in our medical faculty. The results were stratified on the basis of gender, year, and experience as a patient; results were then compared between students who wished to practice orthopedic surgery and those who did not consider it a potential specialty.

RESULTS

Of the 499 students who responded to the questionnaire, 47% considered orthopedic surgery as their career specialty. Being male and having experienced orthopedic surgery as a patient were significant factors influencing the aspiration to practice orthopedic surgery (p < 0.001). In addition, the motivation for choosing orthopedic surgery was academic interest for 55% of students. In the first and fifth years, more than half of the students preferred an orthopedic surgery specialty. The percentage of fifth-year students who were candidates for orthopedic surgery as their career specialty significantly exceeded that of students in other years (p = 0.03). However, the percentage of students considering orthopedic surgery decreased in the sixth year.

CONCLUSION

Our findings suggest that orthopedic surgeons should provide a clearer, more informative job description to attract female medical students' attention and change their negative perception of orthopedic surgery. Furthermore, including education that incorporates experiences closer to clinical practice at the medical-school level is important for increasing the number of candidates for orthopedics.

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.

Creating an Assessment Tool for Clinical Musculoskeletal Knowledge

ABSTRACT

Studies show that medical school curriculums do not prepare graduates to manage the most common musculoskeletal (MSK) injuries they will encounter in the outpatient setting. The authors proposed a new multiple-choice assessment to identify individual and program deficiencies for curriculum improvement. A multiple-choice MSK assessment tool was administered to learners at various stages of training. Students took the examination after completing their core clerkship year; residents took the examination near the beginning of their respective academic year. Outcome measures included average examination score, percent correct for each question, and overall examination reliability. Average examinees scores were 75.6% with higher scores based on training years. No statistical differences were found between MD/DO, male/female, or military/civilian examinees. The tool was found to be a statistically valid method of determining cognitive knowledge in basic MSK topics, identifying individual deficiencies, and highlighting gaps in training programs' MSK curriculums.

A Required, Combined Neurology-Physical Medicine and Rehabilitation Clerkship Addresses Clinical and Health Systems Knowledge Gaps for Fourth-Year Medical Students

ABSTRACT

This study evaluated the impact of a 4-wk mandatory neurology-physical medicine and rehabilitation advanced-core clerkship for fourth-year medical students. The combined clerkship encouraged an interdisciplinary and function-based approach to the management of common neurologic, musculoskeletal, and pain complaints. Seventy-three fourth-year medical students participated in the rotation over 1 yr. A survey assessing knowledge and skill set topics was conducted before and after the clerkship. Qualitative feedback regarding the rotation was provided by the students and analyzed. Significant gaps in knowledge and skill sets were identified before the clerkship and successfully addressed by combined teaching modalities. These data demonstrate that an integrated neurology-physical medicine and rehabilitation clerkship can improve students' confidence in multiple domains. Integrating physical medicine and rehabilitation into core clerkships at other medical schools may provide an avenue to address curriculum gaps.

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care

IMPORTANCE

Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.

OBJECTIVE

To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.

DESIGN, SETTING, AND PARTICIPANTS

This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.

EXPOSURES

SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).

MAIN OUTCOMES AND MEASURES

Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.

RESULTS

Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.

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.

The impact of the COVID-19 pandemic on the medical care and health-care behaviour of patients with lupus and other systemic autoimmune diseases: a mixed methods longitudinal study

OBJECTIVE

The aim was to explore the self-reported impact of the COVID-19 pandemic on changes to care and behaviour in UK patients with systemic autoimmune rheumatic diseases, to help ensure that patient experiences are considered in future pandemic planning.

METHODS

This was a longitudinal mixed methods study, with a cohort completing baseline surveys in March 2020 and follow-up surveys in June 2020 (n = 111), combined with thematic analysis of the LUPUS UK forum and participant interviews (n = 28).

RESULTS

Cancellations of routine care and difficulties in accessing medical support contributed to some participants deteriorating physically, including reports of hospitalizations. The majority of participants reported that fear of COVID-19 and disruptions to their medical care had also adversely impacted their mental health. Feeling medically supported during the pandemic was correlated with multiple measures of mental health and perceptions of care, including the Warwick-Edinburgh mental well-being score (r = 0.44, P = 0.01). Five themes were identified: detrimental reduction in care; disparities in contact and communication (medical security vs abandonment sub-theme); perceived and actual endangerment; the perfect storm of reduced clinician ability to help and increased patient reticence to seek help; and identifying the patients most vulnerable to reduced medical care.

CONCLUSION

The diversion of resources away from chronic disease care was perceived by many participants to have caused adverse outcomes. Fear about increased vulnerability to COVID-19 was high, contributing to health-care-avoidant behaviours. This study also highlights the influence of clinician accessibility and patients feeling medically supported on multiple measures of physical and mental health.

Assessment of knowledge of junior doctors and non-specialists about musculoskeletal medicine

Objectives:

To assess the knowledge and confidence of junior doctors and non-specialists in examining and making a diagnosis of patients with musculoskeletal (MSK) diseases.

Methods:

This was a Cross-sectional study of 121 doctors working in medical clinics at a tertiary hospital between October and December 2019. Data were collected using a questionnaire. Doctor’s awareness regarding different MSK examination methods including gait, arms, leg, spine (GALS), pediatric gait, arms, leg, spine (pGALS) and regional examination of musculoskeletal system (REMS) was noted. Undergraduate teaching of these methods and use in their daily practice was surveyed.

Results:

Majority of the doctors lacked awareness about different MSK examination techniques. Awareness about GALS, REMS and pGALS was 44.6%, 59.5% and 18.2% respectively. There was significant correlation of GALS/REMS awareness with the undergraduate teaching and doctor’s clinical experience (p-value <0.05). Confidence level of doctors in diagnosing patients with adult MSK pathologies was 55%. Only few doctors were satisfied with their musculoskeletal education (29%).

Conclusion:

The GALS examination is a useful screening tool for junior doctors and non-specialists in a direct access setting to rule out musculoskeletal problems.

Effect of Shortened Preclinical Curriculum on Medical Student Musculoskeletal Knowledge and Confidence: An Institutional Survey

PURPOSE

Musculoskeletal education is underrepresented in American medical school curricula, and many medical schools have recently shifted toward a condensed preclinical period. Given that musculoskeletal diseases represent a large and growing social and economic burden, it is imperative that medical students be properly prepared to care for patients with musculoskeletal disorders, regardless of intended specialty.

METHODS

A survey was sent to all medical students enrolled full-time at our institution during the 2018 to 2019 academic year. First year students had not yet received musculoskeletal instruction, second-year students had completed a shortened musculoskeletal curriculum of 49 total hours, and third- and fourth-year respondents had completed a longer 78 hour musculoskeletal curriculum. Respondents were asked to rank their confidence in their musculoskeletal knowledge, their interest in orthopaedics, followed by the well-validated Freedman and Bernstein musculoskeletal knowledge assessment and a demographics section asking had respondents completed an orthopaedic surgery clinical rotation, if they had other clinical orthopaedic experience, class year, intended clinical specialty, and gender.

RESULTS

There were 179 responses to the survey, comprising 53 first-year, 54 second-year, and 72 third- and fourth-year students. The longer musculoskeletal curriculum was associated with significantly improved performance compared to the shorter musculoskeletal curriculum (p < 0.0001). Completion of a clinical orthopedics rotation was associated with significantly improved performance than not completing a rotation (p < 0.001), regardless of if non-rotators had other orthopedic experience (p = 0.001) or if they did not (p < 0.001). There was no difference in score (p = 0.94) or musculoskeletal knowledge confidence (p = 0.09) between males and females. Intending to pursue orthopedics was associated with significantly higher scores (p < 0.001) and significantly higher confidence (p = 0.02).

CONCLUSIONS

As shortening preclinical musculoskeletal curricula worsens musculoskeletal performance, medical schools should consider requiring orthopedic clinical rotations to maintain musculoskeletal competency of graduates.

'But you don't look sick': a qualitative analysis of the LUPUS UK online forum

Lupus is a multi-system autoimmune rheumatic disease with increased morbidity and mortality. Some manifestations are life-threatening with many aspects of living with the disease, difficulties in diagnosis and accessing appropriate medical care, having an impact on quality of life. The disease itself, and these patients’ perspectives, are currently poorly understood and under-researched. The LUPUS UK forum of conversations between over 25,000 members provides a rich environment to explore the views of these patients. Conversations on the LUPUS UK online forum were qualitatively explored using virtual ethnography and thematic analysis. The forum itself and positive medical relationships were widely considered to provide a means of support, understanding and validation. Forum members expressed difficulties in diagnosis, disease management, and the psychological and physical impact of living with an unpredictable, poorly understood disease, often with life-changing symptoms. Invalidating personal, social and medical environments were perceived as exacerbating these difficulties. Delays in diagnosis and misdiagnoses were frequently discussed as causing significant damage, especially when symptoms were disbelieved or dismissed. Invalidation was the key theme with further themes of: Uncertainty, Medical (mis)communications and misunderstandings, Navigating health systems and Resilience and support. Although effective care and support was reported by some members, the negative impact of living with an incurable, life-changing disease was often exacerbated by perceived invalidation, uncertainty, and difficulties in multiple areas of members’ lives. Improved knowledge of the disease and greater support at all stages of the diagnostic journey could improve outcomes and quality of life for these patients.

Identifying and Monitoring Deficiencies in Physical Examination of the Foot and Ankle With Diagnostic Ultrasound: Experience From a Physical Medicine and Rehabilitation Residency Training Program

Despite the high incidence of foot and ankle injuries and their biomechanical importance to more proximal joints, the foot and ankle are some of the most daunting and underemphasized musculoskeletal structures in medical training. This study used musculoskeletal ultrasound to identify a knowledge gap in physical medicine and rehabilitation residents in foot and ankle surface anatomy palpation and to determine whether senior residents had higher examination performance compared with more junior residents. Physical medicine and rehabilitation residents at different levels of training were tested cross-sectionally, and palpation accuracy was compared by class year. There was a trend of improvement across class years, with significant class differences in accuracy for the talonavicular joint, calcaneocuboidal joint, and posterior tibialis and peroneal tendons (P < 0.05). Despite this trend, the accuracy was not consistently higher among the senior residents considering the training they received. For all 30 residents assessed, accuracy within 1 cm was highest for the tibiotalar joint (93.3%), peroneal tendons (83.3%), posterior tibialis tendon (63.3%), and talonavicular joint (50%). It was lower for the calcaneocuboidal joint (26.7%) and the second (13.3%) and fourth for the tarsometatarsal joints (20%). Anatomical knowledge and palpation skills of the foot and ankle, particularly at the midfoot and forefoot, may be an area of improvement for physical medicine and rehabilitation resident training.

Deconstructing the Joint Examination: A Novel Approach to Teaching Introductory Musculoskeletal Physical Examination Skills for Medical Students

Introduction

Musculoskeletal (MSK) disorders are very common, but suboptimal teaching of MSK medicine occurs and expert clinicians agree that MSK physical examination (PE) skills can be confusing and complicated for medical students. An innovative approach in introductory teaching of MSK PE skills was developed using constructivist theory for second-year medical students.

Methods

We implemented the MSK PE curriculum innovation in the second year of a four-year MD program, utilizing a standard framework with spaced practice and clinician coaching. We evaluated this curriculum by comparing the innovation group (n = 123) to a historical control group (n = 134) using an anonymous survey and OSCE station scores. Data analysis included repeated measures analysis of variance comparing students' self-confidence in MSK PE to students' self-confidence in other systems-based PEs, as well as independent t-test comparisons of self-confidence scores and MSK-specific OSCE station scores between the historical and innovation groups.

Results

The mean self-assessed confidence of the historical group was significantly lower for the MSK PE than all other PEs (p < 0.001), except for the neurological PE. Significant improvement in MSK PE self-confidence was noted with the innovation group (t(259) = -4.05, p < 0.001). OSCE scores significantly improved in MSK-specific stations, with medium to large effect size across the different stations.

Discussion

We successfully used a framework of deconstruction, repetition, and spaced practice to develop fundamental MSK PE skills in preclerkship medical students. This curriculum structure provides an effective example for teaching introductory MSK PE skills to early medical learners.

Medically explained symptoms: a mixed methods study of diagnostic, symptom and support experiences of patients with lupus and related systemic autoimmune diseases

Objectives

The aim was to explore patient experiences and views of their symptoms, delays in diagnosis, misdiagnoses and medical support, to identify common experiences, preferences and unmet needs.

Methods

Following a review of LUPUS UK's online forum, a questionnaire was posted online during December 2018. This was an exploratory mixed methods study, with qualitative data analysed thematically and combined with descriptive and statistically analysed quantitative data.

Results

There were 233 eligible respondents. The mean time to diagnosis from first experiencing symptoms was 6 years 11 months. Seventy-six per cent reported at least one misdiagnosis for symptoms subsequently attributed to their systemic autoimmune rheumatic disease. Mental health/non-organic misdiagnoses constituted 47% of reported misdiagnoses and were indicated to have reduced trust in physicians and to have changed future health-care-seeking behaviour. Perceptions of physician knowledge and listening skills were highly correlated with patient ratings of trust. The symptom burden was high. Fatigue had the greatest impact on activities of daily living, yet the majority reported receiving no support or poor support in managing it. Assessing and treating patients holistically and with empathy was strongly felt to increase diagnostic accuracy and improve medical relationships.

Conclusion

Patient responses indicated that timely diagnosis could be facilitated if physicians had greater knowledge of lupus/related systemic autoimmune diseases and were more amenable to listening to and believing patient reports of their symptoms. Patient priorities included physicians viewing them holistically, with more emotional support and assistance in improving quality of life, especially in relation to fatigue.

Early Diagnosis Of Inflammatory Arthritis By Primary Care Physicians Following Training By A Rheumatologist

Background

Early diagnosis and therapeutic management of inflammatory arthritis (IA) is crucial for minimizing disease progression and improving outcomes. We recently developed the New Early Arthritis Referral Criteria to help improve the detection of suspected early IA via musculoskeletal (MSK) examination. The present study aimed to evaluate the agreement between rheumatologists and primary care physicians (PCPs) trained by rheumatologists in detecting IA when applying the standardized MSK examination techniques used to develop this criteria in a real-world setting in Jeddah, Saudi Arabia.

Methods

This quasi-experimental study was conducted in 4 primary health centers and involved 30 PCPs and 3 rheumatologists. All PCPs were trained by rheumatologists to apply the standardized MSK examination techniques used to develop the New Early Arthritis Referral Criteria. Patients were eligible if they were >18 years of age and presented with small-joint pain that persisted for >6 weeks. Patients were excluded if they had prior diagnosis of osteoarthritis, hand fractures, or rheumatic disease associated with IA. All patients were examined separately by a PCP and a rheumatologist, with the findings compared via kappa statistics and the rheumatologist’s findings considered the “gold standard”.

Results

Data from 202 of the 203 enrolled patients were analyzed. There was fair-to-moderate agreement between PCPs and rheumatologists when assessing swelling of the small joints and wrist of the right side (range of kappa: 0.14–0.41) and low-to-moderate agreement in similar examinations of the left side (range of kappa: 0.04–0.42). Assessments of joint tenderness showed fair-to-moderate agreement for both the right side (range of kappa: 0.22–0.47) and left side (range of kappa: 0.24–0.45). P-values were significant for virtually all comparisons.

Conclusion

MSK examinations by PCPs showed a promising extent of agreement in detecting IA with those by rheumatologists following training. Refinement of the standardized training process could further improve accuracy and help PCPs to confidently identify cases of early IA, thus allowing earlier intervention than is typical in this setting.

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.

Student perceived impact of a physical, kinetic and interactive model

Current instructional tools for anatomy education are insufficient scaffolds for learning abstract visual concepts such as basic biomechanics. Diagrams, illustrations and even computer-generated models may be adequate for identification purposes, but are typically not effective when it comes to demonstrating dynamic functions. Evidence from educational concepts, such as the active learning principle in constructivism, indicate that current tools are ineffective due to a lack of opportunity for hands-on or interactive, learning. To address this, our interdisciplinary team designed an instructional model of the canine thoracic limb which is physical, kinetic and interactive. We hypothesised that the unique combination of these three crucial elements would enhance the student learning experience. In order to test this hypothesis, we asked 126 undergraduate students in a biomedical anatomy course to interact with the model. Students were then invited to complete a survey evaluating their experience using the thoracic limb model. Results from completed surveys showed that students perceived the model as easy to use and helpful with understanding basic biomechanical concepts. These results indicate that there is potential for the model to positively impact the students' learning. Future studies will include quantitative evaluation of student performance and cognitive impact in the biomedical anatomy course.

Teaching anatomy using an active and engaging learning strategy

BACKGROUND

Various evidence-based and student-centered strategies such as team-based learning (TBL), case-based learning (CBL), and flipped classroom have been recently applied to anatomy education and have shown to improve student engagement and interaction. These strategies shift the focus of teaching from knowledge transmission to knowledge construction by students and encourage the use of tasks. This study discusses the use of an active and engaging learning strategy to teach the musculoskeletal system to Year 1 MBBS students (Faculty of Medical Sciences, The University of the West Indies, Cave Hill, Barbados) and examines the correlation between assessment modalities and student performance.

METHODS

The "Active and Engaging Learning Strategy" was used to assess student learning in the form of oral presentations. Students had presentations on muscle attachments, muscle actions, blood and nerve supply, and applied anatomy of the limb musculature. Questions on the limbs (Locomotor System) were included in pre and post-presentation spotters, in-course assessments, and final examinations. Percentages, paired t-test, independent sample t-test, and zero-order correlations were performed to confirm the results for the different objectives of the study.

RESULTS

The main modes of presentation chosen were poems (37.1%), followed by stories (21.2%), songs (11.4%), and skits (10.6%). The majority of students (84%) found the strategies beneficial and recommended such sessions for future cohorts (92%). Students achieved significantly better scores in post-presentation spotters (p < 0.01) and the marks of in-course and final examinations also showed significant improvement (p < 0.01).

CONCLUSION

Our study highlighted that the active and engaging learning strategy can be used as an effective learning tool in anatomy. Students were proactive in preparing the muscle presentations by utilizing their own creativity, curiosity, and intelligence. Further studies should be conducted using randomized controlled trials to assess the effectiveness of various learning strategies which could open a new door to medical education.

MSK30: a validated tool to assess clinical musculoskeletal knowledge

Background

Musculoskeletal (MSK) complaints comprise a large proportion of outpatient visits. However, multiple studies show that medical school curriculum often fails to adequately prepare graduates to diagnose and manage common MSK problems. Current standardised exams inadequately assess trainees’ MSK knowledge and other MSK-specific exams such as Freedman and Bernstein’s (1998) exam have limitations in implementation. We propose a new 30-question multiple choice exam for graduating medical students and primary care residents. Results highlight individual deficiencies and identify areas for curriculum improvement.

Methods/Results

We developed a bank of multiple choice questions based on 10 critical topics in MSK medicine. The questions were validated with subject-matter experts (SMEs) using a modified Delphi method to obtain consensus on the importance of each question. Based on the SME input, we compiled 30 questions in the assessment. Results of the large-scale pilot test (167 post-clerkship medical students) were an average score of 74 % (range 53% – 90 %, SD 7.8%). In addition, the tool contains detailed explanations and references were created for each question to allow an individual or group to review and enhance learning.

Summary

The proposed MSK30 exam evaluates clinically important topics and offers an assessment tool for clinical MSK knowledge of medical students and residents. It fills a gap in current curriculum and improves on previous MSK-specific assessments through better clinical relevance and consistent grading. Educators can use the results of the exam to guide curriculum development and individual education.

Flipped Learning: Can Rheumatology Lead the Shift in Medical Education?

Methods:

The flipped classroom education, 55-students, was conducted in 3 phases. Phase 1: Carried out in the students’ own time. Web links were emailed to assist exposure of the instructional part of the lesson online. Phase 2: Interactive in-class activity to share personal reflection and reinforce the key aspects. Phase 3: A simulated OSCE assessment. A cohort of 56-students, who were taught in the last educational year on the same topics according to standard teaching protocols, were included as control group. The clinical Outcomes were assessed using the scores of the OSCE examination model. Academic outcomes included the engagement measure as well as the students’ answers to perceived effectiveness and satisfaction survey.

Results:

There was no significant difference regarding demographics between the 2 students’ groups. There was a significant improvement (p< 0.05) in the flipped learning, in contrast to the control group, in terms of clinical (OSCE score) as well as communication skills. Student perceived effectiveness and satisfaction was significantly higher among the flipped learning (p< 0.05). Scores from the flipped learning cohort showed a state of engagement significantly higher than the control group (p< 0.01).

Conclusion:

Flipped learning implementation musculoskeletal learning successfully demonstrated a promising platform for using technology to make better use of the students' time, and for increasing their satisfaction. Active learning increases student engagement and can lead to improved retention of knowledge.

Musculoskeletal Education in Medical Schools: A Survey of Allopathic and Osteopathic Medical Students

Background:

Musculoskeletal (MSK) disorders are one of the most common causes of disability and emergency department and physician visits in the United States. However, there is very little consistency in how physicians in training are prepared to treat MSK disorders. On the basis of published reports, medical school graduates have a relative lack of cognitive mastery in MSK medicine, even with the recent increase in instruction. This study sought to compare MSK education at an allopathic medical school with that at an osteopathic medical school.

Methods:

An anonymous survey of students in medical school graduate years 2, 3, and 4 at Michigan State University College of Human Medicine (allopathic) and College of Osteopathic Medicine (osteopathic) was conducted. Questions were structured into three main categories: demographic information, content of the current MSK curriculum, and opinions regarding importance, instruction, and assessment of MSK education.

Results:

As of 2010, 83% of medical schools require MSK courses because of the United States Bone and Joint Initiative to incorporate such coursework into core curriculum. Yet only 54% of surveyed students thought that their MSK education was adequate. A greater portion of osteopathic students (57.1%) compared with allopathic students (26.8%) thought that their MSK curriculum is adequate, and as a consequence, 36.6% of allopathic students thought that they were inadequately prepared for the MSK content of US medical licensing examinations compared with 8.1% of osteopathic students. Further curriculum development and improvement is needed to advance physicians' abilities to address and treat MSK disorders. Medical students surveyed feel that this goal can be accomplished by emphasizing MSK education in third and fourth years of medical school.

Conclusion:

These findings highlight differences in MSK education between an allopathic and osteopathic medical school. Further standardization of the curriculum in medical schools may help improve the quality of teaching student comfort levels of new physicians.

Level of Evidence:

Level III

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.

Does Ultrasound-Enhanced Instruction of Musculoskeletal Anatomy Improve Physical Examination Skills of First-Year Medical Students?

OBJECTIVES

Ultrasound imaging is commonly used to teach basic anatomy to medical students. The purpose of this study was to determine whether learning musculoskeletal anatomy with ultrasound improved performance on medical students' musculoskeletal physical examination skills.

METHODS

Twenty-seven first-year medical students were randomly assigned to 1 of 2 instructional groups: either shoulder or knee. Both groups received a lecture followed by hands-on ultrasound scanning on live human models of the assigned joint. After instruction, students were assessed on their ability to accurately palpate 4 anatomic landmarks: the acromioclavicular joint, the proximal long-head biceps tendon, and the medial and lateral joint lines of the knee. Performance scores were based on both accuracy and time. A total physical examination performance score was derived for each joint. Scores for instructional groups were compared by a 2-way analysis of variance with 1 repeated measure. Significant findings were further analyzed with post hoc tests.

RESULTS

All students performed significantly better on the knee examination, irrespective of instructional group (F = 14.9; df = 1.25; P = .001). Moreover, the shoulder instruction group performed significantly better than the knee group on the overall assessment (t = -3.0; df = 25; P < .01). Post hoc analyses revealed that differences in group performance were due to the shoulder group's higher scores on palpation of the biceps tendon (t = -2.8; df = 25; P = .01), a soft tissue landmark. Both groups performed similarly on palpation of all other anatomic structures.

CONCLUSIONS

The use of ultrasound appears to provide an educational advantage when learning musculoskeletal physical examination of soft tissue landmarks.

Simulating the multi-disciplinary care team approach: Enhancing student understanding of anatomy through an ultrasound-anchored interprofessional session

Quality of healthcare delivery is dependent on collaboration between professional disciplines. Integrating opportunities for interprofessional learning in health science education programs prepares future clinicians to function as effective members of a multi-disciplinary care team. This study aimed to create a modified team-based learning (TBL) environment utilizing ultrasound technology during an interprofessional learning activity to enhance musculoskeletal anatomy knowledge of first year medical (MD) and physical therapy (PT) students. An ultrasound demonstration of structures of the upper limb was incorporated into the gross anatomy courses for first-year MD (n = 53) and PT (n = 28) students. Immediately before the learning experience, all students took an individual readiness assurance test (iRAT) based on clinical concepts regarding the assigned study material. Students observed while a physical medicine and rehabilitation physician demonstrated the use of ultrasound as a diagnostic and procedural tool for the shoulder and elbow. Following the demonstration, students worked within interprofessional teams (n = 14 teams, 5-6 students per team) to review the related anatomy on dissected specimens. At the end of the session, students worked within interprofessional teams to complete a collaborative clinical case-based multiple choice post-test. Team scores were compared to the mean individual score within each team with the Wilcoxon signed-rank test. Students scored higher on the collaborative post-test (95.2 ±10.2%) than on the iRAT (66.1 ± 13.9% for MD students and 76.2 ±14.2% for PT students, P < 0.0001). Results suggest that this interprofessional team activity facilitated an improved understanding and clinical application of anatomy. Anat Sci Educ 11: 94-99. © 2017 American Association of Anatomists.

Improving the Clinical Skills Performance of Graduating Medical Students Using "WISE OnCall," a Multimedia Educational Module

INTRODUCTION

"Transitions to residency" programs are designed to maximize quality and safety of patient care, as medical students become residents. However, best instructional or readiness assessment practices are not yet established. We sought to study the impact of a screen-based interactive curriculum designed to prepare interns to address common clinical coverage issues (WISE OnCall) on the clinical skills demonstrated in simulation and hypothesize that performance would improve after completing the module.

METHODS

Senior medical students were recruited to participate in this single group prestudy/poststudy. Students responded to a call from a standardized nurse (SN) and assessed a standardized patient (SP) with low urine output, interacted with a 45-minute WISE OnCall module on the assessment and management of oliguria, and then evaluated a different SP with low urine output of a different underlying cause. Standardized patients assessed clinical skills with a 37-item, behaviorally anchored checklist measuring clinical skills (intraclass correlation coefficient [ICC], 0.55-0.81). Standardized nurses rated care quality and safety and collaboration and interprofessional communication using a 33-item literature-based, anchored checklist (ICC, 0.47-0.52). Standardized patient and SN ratings of the same student performance were correlated (r, 0.37-0.62; P < 0.01). Physicians assessed clinical reasoning quality based on the students' patient encounter note (ICC, 0.55-0.68), ratings that did not correlate with SP and SN ratings. We compared pre-post clinical skills performance and clinical reasoning. Fifty-two medical students (31%) completed this institutional review board -approved study.

RESULTS

Performance as measured by the SPs, SNs, and the postencounter note all showed improvement with mostly moderate to large effect sizes (range of Cohen's d, 0.30-1.88; P < 0.05) after completion of the online module. Unexpectedly, professionalism as rated by the SP was poorer after the module (Cohen's d, -0.93; P = 0.000).

DISCUSSION

A brief computer-based educational intervention significantly improved graduating medical students' clinical skills needed to be ready for residency.

Determining the impact of a new physiotherapist-led primary care model for back pain: protocol for a pilot cluster randomized controlled trial

BACKGROUND

Back pain is a leading contributor to disability, healthcare costs, and lost work. Family physicians are the most common first point of contact in the healthcare system for people with back pain, but physiotherapists (PTs) may be able to support the primary care team through evidence-based primary care. A cluster randomized trial is needed to determine the clinical, health system, and societal impact of a primary care model that integrates physiotherapists at the first visit for people with back pain. Prior to conducting a future fully powered cluster randomized trial, we need to demonstrate feasibility of the methods. Therefore, the purpose of this pilot study will be to: 1) Determine feasibility of patient recruitment, assessment procedures, and retention. 2) Determine the feasibility of training and implementation of a new PT-led primary care model for low back pain (LBP) 3) Explore the perspectives of patients and healthcare providers (HCPs) related to their experiences and attitudes towards the new service delivery model, barriers/facilitators to implementation, perceived satisfaction, perceived value, and impact on clinic processes and patient outcomes.

METHODS

This pilot cluster randomized controlled trial will enroll four sites and randomize them to implement a new PT-led primary care model for back pain or a usual physician-led primary care model. All adults booking a primary care visit for back pain will be invited to participate. Feasibility outcomes will include: recruitment and retention rates, completeness of assessment data, PT training participation and confidence after training, and PT treatment fidelity. Secondary outcomes will include the clinical, health system, cost, and process outcomes planned for the future fully powered cluster trial. Results will be analyzed and reported descriptively and qualitatively. To explore perspectives of both HCPs and patients, we will conduct semi-structured qualitative interviews with patients and focus groups with HCPs from participants in the PT-led primary care sites.

DISCUSSION

If this pilot demonstrates feasibility, a fully powered trial will provide evidence that has the potential to transform primary care for back pain. The full trial will inform future service design, whether these models should be more widely implemented, and training agendas.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03320148 . Submitted for registration on 17 September 2017.

Findings Associated With Knee Pathology on MRI in Patients Without Osteoarthritis

INTRODUCTION

We conducted a retrospective study in patients with minimal or no radiographically evident knee osteoarthritis to determine whether presenting signs and symptoms were predictive of knee pathology that was evident on MRI and could be treated with nonarthroplasty knee surgery or could alter nonsurgical treatment.

METHODS

We reviewed records of patients for whom sports medicine orthopaedic surgeons had ordered an MRI of the knee. Univariate analysis identified factors that were associated with positive MRI findings (eg, surgically treatable lesion, meniscal tear) or a finding that could alter treatment. We used multivariate logistic regression to determine independent predictors of evidence of pathology on MRI.

RESULTS

Of the 434 patients in the study, 281 (64.7%) had evidence of knee pathology on MRI. Acute injury, effusion, and ligamentous instability were among the independent predictors of positive MRI results. Patients with evidence of knee pathology on MRI were more likely to have undergone surgery.

DISCUSSION

Specific aspects of patient history and physical examination are associated with evidence of knee pathology on MRI.

CONCLUSIONS

In patients without osteoarthritis, positive findings on knee MRI could be associated with a number of presenting signs and symptoms, and this information could aid physicians in deciding which patients should undergo knee MRIs. Additional prospective research is needed to validate the relationships discovered in our study.

LEVEL OF EVIDENCE

Level III retrospective study.

Competency based clinical shoulder examination training improves physical exam, confidence, and knowledge in common shoulder conditions

BACKGROUND

Deficiencies in musculoskeletal knowledge are reported at every stage of learning. Medical programs are looking for effective ways to incorporate competency-based training into musculoskeletal education.

AIM

To evaluate the impact of bedside feedback on learner's shoulder examination skills, confidence, and knowledge of common shoulder conditions.

SETTING

Four-week musculoskeletal clinic rotation.

PARTICIPANTS

UCSD third year medical students and internal medicine residents.

PROGRAM DESCRIPTION

Learners completed three baseline evaluations: videotaped shoulder examination, attitude survey, and knowledge test. During the 4-week intervention learners received bedside observation and feedback from musculoskeletal experts while evaluating patients with shoulder conditions. Post-intervention learners repeated the three assessments.

PROGRAM EVALUATION

Eighty-nine learners participated. In the primary outcome measure evaluating the pre/post videotaped shoulder examination, significant improvement was seen in 21 of 23 shoulder examination maneuvers. Secondary outcomes include changes in learner confidence and knowledge. Greatest gains in learner confidence were seen in performing the shoulder examination (61.5% improvement) and performing injections (97.1% improvement). Knowledge improved significantly in all categories including anatomy/examination interpretation, diagnosis, and procedures.

DISCUSSION

Direct observation and feedback during clinical evaluation of patients with shoulder pain improves shoulder examination competency, provider confidence, and knowledge of common shoulder conditions.

Comparison of physical examination performance of medical students trained by musculoskeletal versus non-musculoskeletal specialists

AIM

To compare the musculoskeletal (MSK) physical examination skills, knowledge acquisition and performance of first-year medical students trained by MSK specialist tutors to students trained by non-MSK specialist tutors, after a 6-week MSK physical examination tutorial program.

METHODS

Twenty-first year medical students took part in the study. They were recruited into two groups, according to their exposure to either an MSK specialist or a non-MSK specialist tutor during their 6-week MSK training block. Knowledge acquisition was measured via a pre- and post-training objective structured clinical examination (OSCE). We assessed students' self-belief and confidence levels regarding their newly acquired skills via a questionnaire. Independent t tests were used to examine mean group differences of OSCE scores and perceived level of confidence.

RESULTS

Both groups demonstrated a significant improvement (3.9 and 3.8 points, respectively, on an eight-point scale for shoulder assessment, P < 0.01, 3.3 and 3.5, respectively, on a five-point scale for spine assessment, P < 0.01) in OSCE scores compared to baseline after completing the 6-week MSK physical examination tutorial program. There was no between-group difference in the OSCE scores from pre- to post-training (P = 0.92 for shoulder, P = 0.66 for spine) or for perceived level of confidence in performing a basic MSK examination after training (P = 0.91).

CONCLUSION

Students exposed to MSK specialist tutors did not demonstrate increased skill levels or knowledge in the area of MSK physical examination compared to those receiving the same training under the supervision of non-MSK specialist tutors. Both student groups demonstrated improvement.

Using Objective Structured Clinical Examinations to Assess Intern Orthopaedic Physical Examination Skills: A Multimodal Didactic Comparison

Patient care is 1 of the 6 core competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). The physical examination (PE) is a fundamental skill to evaluate patients and make an accurate diagnosis. The purpose of this study was to investigate 3 different methods to teach PE skills and to assess the ability to do a complete PE in a simulated patient encounter.

DESIGN

Prospective, uncontrolled, observational.

SETTING

Northeastern academic medical center.

PARTICIPANTS

A total of 32 orthopedic surgery residents participated and were divided into 3 didactic groups: Group 1 (n = 12) live interactive lectures, demonstration on standardized patients, and textbook reading; Group 2 (n = 11) video recordings of the lectures given to Group 1 and textbook reading alone; Group 3 (n = 9): 90-minute modules taught by residents to interns in near-peer format and textbook reading.

RESULTS

The overall score for objective structured clinical examinations from the combined groups was 66%. There was a trend toward more complete PEs in Group 1 taught via live lectures and demonstrations compared to Group 2 that relied on video recording. Near-peer taught residents from Group 3 significantly outperformed Group 2 residents overall (p = 0.02), and trended toward significantly outperforming Group 1 residents as well, with significantly higher scores in the ankle (p = 0.02) and shoulder (p = 0.02) PE cases.

CONCLUSIONS

This study found that orthopedic interns taught musculoskeletal PE skills by near-peers outperformed other groups overall. An overall score of 66% for the combined didactic groups suggests a baseline deficit in first-year resident musculoskeletal PE skills. The PE should continue to be taught and objectively assessed throughout residency to confirm that budding surgeons have mastered these fundamental skills before going into practice.