The need for musculoskeletal education in primary care residencies

Presence of Orthopedic Residency Decreases Emergency Physician's Confidence in Orthopedic Procedures

Introduction: At present, there exists no standard orthopedic training for emergency medicine (EM) residency programs. Varying residency environments including but not limited to volume, acuity, and competing residency programs will dictate the number of orthopedic procedures a resident is exposed to, ultimately dictating a graduate’s comfort level with orthopedic procedures. Our study set out to investigate further whether training alongside an orthopedic residency affects an attending physician’s perceived procedural comfort.

Methods: This is a cohort study utilizing a 14-question survey distributed to an online community of EM physicians to examine the relationship between training at a residence program alongside orthopedic residents, the utility of an elective orthopedic rotation, and the overall confidence in managing closed reductions.

Results: EM physicians trained at a program that also hosted an orthopedic residency were more likely to train at large academic tertiary care centers (78%). Forty-two percent of these respondents felt that the presence of an orthopedic residency had a negative impact on their overall orthopedic training. The remaining 58% felt that the orthopedic residency had a positive impact on their procedural skills. In our study, the overall mean comfort level was statistically significant (p-value = 0.0024) higher in those who trained without orthopedic residents (8.78) compared to those who trained alongside an orthopedic residency (7.61). Those who had an elective orthopedic rotation found it to be more beneficial if they did the rotation with an orthopedic residency (p-value = 0.0329). Those who reported a beneficial orthopedic rotation also reported a higher level of confidence in the management of non-fracture reductions (p < 0.011, ρ = .25).

Conclusion: Seeing as though both training and practice environments for emergency physicians vary greatly across the country, every effort should be taken to ensure graduating residents are prepared to perform orthopedic procedures without the assistance of orthopedic surgeons. Irrespective of whether a program has in-house orthopedic residents or not, EM residents should take it upon themselves to maximize their time during residency to focus on these core competencies. Graduates at the greatest risk of having low confidence are trained at academic centers that also host orthopedic programs. One should be cognizant of this while going through their EM residency.

Musculoskeletal Conditions in the Emergency Room: A Teaching Opportunity for Medical Students and Residents

OBJECTIVE

Assess the potential value of an emergency room (ER) for the teaching of musculoskeletal (MSK) medicine to medical students and residents in training.

METHODS

Data from all encounters to the ER of a teaching hospital for calendar years 2016-2019 were extracted from an electronic database. Encounters with ICD-10-CM M codes (MSK system) and S codes (injury) were selected (MSK encounters). Frequency distributions were calculated by year, sex, and age group for all encounters and MSK encounters. Annual distributions of encounters involving the shoulder, hip, knee, and ankle joints were assessed.

RESULTS

The number of unique patients seen during the four-year period was 84,094, and the number of encounters was 187,829 (Median: 1 encounter; interquartile range: 1-2). The mean number of encounters per year was 46,957 (range: 45,311- 48,382). There was no seasonal variation. Most patients were women (45,868; 54.6%) and young (20 29 yr.) adults (15,012; 17.8%), and these groups generated the largest numbers of encounters (women: 108,799; 57.9%; young adults: 35,969; 19.1%). A total of 41,353 encounters (22.0% of all encounters) involved the MSK system. The shoulder, hip, knee, and ankle were involved in 2,768 (1.5%), 1,592 (0.8%), 3,082 (1.6%), and 1,718 (0.9%) encounters, respectively. The most common conditions for each joint were shoulder pain, femoral fracture, knee contusion, and ankle sprain.

CONCLUSION

Our findings suggest that ER physicians should have broad knowledge of MSK conditions and injuries. An ER is an excellent location for the teaching of MSK medicine to medical students and residents of other training programs.

Machine Learning Models for Abnormality Detection in Musculoskeletal Radiographs

Increasing radiologist workloads and increasing primary care radiology services make it relevant to explore the use of artificial intelligence (AI) and particularly deep learning to provide diagnostic assistance to radiologists and primary care physicians in improving the quality of patient care. This study investigates new model architectures and deep transfer learning to improve the performance in detecting abnormalities of upper extremities while training with limited data. DenseNet-169, DenseNet-201, and InceptionResNetV2 deep learning models were implemented and evaluated on the humerus and finger radiographs from MURA, a large public dataset of musculoskeletal radiographs. These architectures were selected because of their high recognition accuracy in a benchmark study. The DenseNet-201 and InceptionResNetV2 models, employing deep transfer learning to optimize training on limited data, detected abnormalities in the humerus radiographs with 95% CI accuracies of 83–92% and high sensitivities greater than 0.9, allowing for these models to serve as useful initial screening tools to prioritize studies for expedited review. The performance in the case of finger radiographs was not as promising, possibly due to the limitations of large inter-radiologist variation. It is suggested that the causes of this variation be further explored using machine learning approaches, which may lead to appropriate remediation.

Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears

BACKGROUND AND OBJECTIVES

Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted.

METHODS

We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care.

RESULTS

A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management.

CONCLUSION

The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Integrating Musculoskeletal Education and Patient Care at Medical Student-Run Free Clinics

BACKGROUND

Student-run free clinics (SRFCs) have emerged as an important educational component of United States (U.S.) medical schools. Despite the prevalence of musculoskeletal (MSK) problems presenting to SRFCs, students and clinics are often unprepared to diagnose and to treat common MSK complaints.

OBJECTIVE

We sought to determine the scope of diagnosis and treatment at a medical student-run free clinic specializing in musculoskeletal care using physical medicine and rehabilitation (PM&R) residents. Secondary goals included reviewing student satisfaction and determining the appropriateness of the clinic in medical education.

DESIGN

Retrospective chart review, anonymous online survey.

SETTING

Primary care, free student clinic affiliated with tertiary academic medical center.

PARTICIPANTS

A total of 20 medical student volunteers, 6 PM&R residents, and 91 community patients.

METHODS

We established a musculoskeletal clinic as a specialty referral clinic for the 2 primary care SRFCs with institutional support from a partner medical school. We then reviewed clinical operations retrospectively using electronic medical records and student satisfaction based on an online survey.

MAIN OUTCOME MEASUREMENTS

We analyzed patient demographics and chief complaints, referrals provided, and medical services rendered. We also used a 5-point Likert scale to assess student satisfaction.

RESULTS

A monthly musculoskeletal referral clinic was established with the oversight of PM&R attendings and residents. The clinic received 91 referrals and managed 61 unique patients over a 2.5-year study period. The most common presentations to the clinic involved knee pain (n = 17, 27.9%) and back pain (n = 16, 26.2%). Pro bono relationships with community and institutional partners enabled all patients to receive medical examinations, physical therapy visits, plain film radiographs, and insurance consultations free of charge. Student satisfaction with teaching and patient care was high, with 19 of 20 students reporting their experience as "good" or "excellent."

CONCLUSIONS

SRFCs represent an underused opportunity to enhance MSK education among medical students by treating a variety of common MSK complaints in an underserved population.

LEVEL OF EVIDENCE

Not applicable.

Do Emergency Medicine Residency Graduates Feel Prepared to Manage Closed Fractures After Training?

OBJECTIVES

Fractures comprise 3% of all emergency department (ED) visits. Although emergency physicians are often responsible for managing most of the initial care of these patients, many report a lack of proficiency and comfort with these skills. The primary objective was to assess how prepared recent emergency medicine (EM) residency graduates felt managing closed fractures upon completion of residency. Secondary objectives included whether residency training or independent practice contributed most to the current level of comfort with these procedures and which fractures were most commonly reduced without orthopedic consultation.

METHODS

An anonymous online survey was sent to graduates from seven EM residency programs over a 3-month period to evaluate closed fracture reduction training, practice, and comfort level. Each site primary investigator invited graduates from 2010 to 2014 to participate and followed a set schedule of reminders.

RESULTS

The response rate was 287/384 (74.7%) and included 3-year (198/287, 69%) and 4-year (89/287, 31%) programs. Practice in community, academic, and hybrid ED settings was reported by 150/287 (52.3%), 64/287 (22.3%), and 73/287 (25.4%), respectively. It was indicated by 137/287 (47.7%) that they reduce closed fractures without a bedside orthopedic consultation greater than 75% of the time. The majority of graduates felt not at all prepared (35/287, 12.2%) or somewhat prepared (126/287, 43.9%) upon residency graduation. Postresidency independent practice contributed most to the current level of comfort for 156/287 (54.4%). The most common fractures requiring reduction were wrist/distal radius and/or ulna, next finger/hand, and finally, ankle/distal tibia and/or fibula.

CONCLUSIONS

Although most recent graduates feel at least "somewhat" prepared to manage closed fractures in the ED, most felt that independent practice was a greater contributor to their current level of comfort than residency training. Recent graduates indicate that fracture reduction without orthopedic consultation is common in today's clinical practice. This survey identifies common fractures requiring reduction which EM residencies may wish to consider prioritizing in their emergency orthopedic curricula to better prepare their residents for independent clinical practice.