Undergraduate orthopedic education: Is it adequate?

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.

A History of Musculoskeletal Medicine and Its Place and Progress in Undergraduate Medical Education

Musculoskeletal diseases are responsible for some of the most prevalent conditions affecting population health in the world. Despite the prevalence of these conditions, musculoskeletal medicine has a fraught history within the world of undergraduate medical education. We review the origins of musculoskeletal medicine, its evolution in undergraduate medical education, and progress that has been made over the last decade as a result of global initiatives such as the Bone and Joint Decade. Understanding the history of musculoskeletal medicine is essential to contextualizing the problems that exist today and creating comprehensive solutions to fill the gaps that persist in musculoskeletal curricula.

Perception and Satisfaction of Undergraduate Medical Students of the Mini Clinical Evaluation Exercise Implementation in Orthopedic Outpatient Setting

PURPOSE

The Mini Clinical Evaluation Exercise (mini-CEX) is a brief and direct observational assessment of trainee-patient interactions that helps to assess several clinical domains. There is limited evidence of mini-CEX implementation in orthopedics and undergraduate perceptions toward such an approach. This study investigated the perception of mini-CEX among undergraduate medical students through a questionnaire-based survey in an orthopedic outpatient setting.

PATIENTS AND METHODS

Undergraduate medical students completing their orthopedic clinical posting were invited to participate in an anonymous, self-administered questionnaire written in English to evaluate their perceptions toward mini-CEX implementation in the orthopedic outpatient setting for the 2016-2017 academic session. The questionnaire comprised 28 closed-ended questions with a five-point Likert rating-scale, and five open-ended questions. The survey responses were analyzed for reliability, validity, and quantitative and qualitative analyses.

RESULTS

A total of 350 students completed the questionnaire; the questionnaire was proven to be valid and reliable. The closed-ended questions were designed to assess the knowledge of the mini-CEX as an assessment tool. The participants demonstrated a satisfactory understanding of the mini-CEX methodology, purpose, clarity, comprehensiveness, and as a self-assessment tool for undergraduate medical students. Instructor support for the implementation of mini-CEX appeared inadequate and was rated with non-confidence among most students. Most participants appreciated better clinical skills, which was reflected through improvements in clinical exam preparation, the Objective Structured Clinical Examination, and clinical judgment.

CONCLUSION

Undergraduate medical students perceived the mini-CEX as an effective tool for clinical teaching in an outpatient orthopedic setting. However, most students indicated suboptimal instructor involvement in the teaching and assessment process; this raises concerns regarding inadequate direct observation and limited feedback for student performance. Additional measures are needed to ensure high quality clinical encounters, teacher training, integration with other assessment tools, and standardized coverage mini-CEX implementation in 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.

Clinical Orthopaedic Teaching programme for Students (COTS)

Introduction

There is a huge variation in the depth and breadth of content taught regarding orthopaedic examinations. Undergraduate students are often confused by the variability in examination teaching, therefore increasing concerns for upcoming objectively structured clinical examinations (OSCEs). Doctors, despite being expected to teach, rarely receive formal preparation, with only a handful of institutions providing necessary training. The Clinical Orthopaedic Teaching programme for Students (COTS) was designed to equip medical students with the knowledge to perform orthopaedic examinations and to synergistically provide senior students with the necessary experience for the future teaching required of them.

Methods

Six fortnightly sessions were delivered, each focusing on a specific joint examination. Student and tutor recruitment were voluntary. Pre-session and post-session multiple-choice questions (MCQs) were provided to students to assess improvement in knowledge. Anonymous feedback forms were provided to both students and tutors.

Results

From 61 student responses, 98.4% of students stated that COTS met the learning outcomes, with content relevant for their medical curriculum. 96.7% supported COTS’ near-peer teaching (NPT) style for OSCE preparation. Based on a five-point Likert scale, students displayed a mean improvement in confidence (1.7±1.2, p<0.001) and MCQ scores (1.3±1.2, p<0.001). All 10 tutors perceived an improvement of their teaching skills and confidence to teach (1.0±0.9, p=0.016).

Conclusion

COTS shows that an NPT style can be used to effectively teach orthopaedic examinations, with benefits for students and tutors. With our aim to refine and upscale this programme, we publish our pilot study findings to encourage similar teaching programmes to be adopted at other universities.

Improvement of Orthopedic Residency Programs and Diversity: Dilemmas and Challenges, an International Perspective

BACKGROUND

To date, little has been published comparing the structure and requirements of orthopedic training programs across multiple countries. The goal of this study was to summarize and compare the characteristics of orthopedic training programs in the U.S.A., U.K., Canada, Australia, Germany, India, China, Saudi Arabia, Russia and Iran.

METHODS

We communicated with responders using a predetermined questionnaire regarding the national orthopedic training program requirements in each respondent's home country. Specific items of interest included the following: the structure of the residency program, the time required to become an orthopedic surgeon, whether there is a log book, whether there is a final examination prior to becoming an orthopedic surgeon, the type and extent of faculty supervision, and the nature of national in-training written exams and assessment methods. Questionnaire data were augmented by reviewing each country's publicly accessible residency training documents that are available on the web and visiting the official website of the main orthopedic association of each country.

RESULTS

The syllabi consist of three elements: clinical knowledge, clinical skills, and professional skills. The skill of today's trainees predicts the quality of future orthopedic surgeons. The European Board of Orthopedics and Traumatology (EBOT) exam throughout the European Union countries should function as the European board examination in orthopedics. We must standardize many educational procedures worldwide in the same way we standardized patient safety.

CONCLUSION

Considering the world's cultural and political diversity, the world is nearly unified in regards to orthopedics. The procedures (structure of the residency programs, duration of the residency programs, selection procedures, using a log book, continuous assessment and final examination) must be standardized worldwide, as implemented for patient safety. To achieve this goal, we must access and evaluate more information on the residency programs in different countries and their needs by questioning them regarding what they need and what we can do for them to make a difference.

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.

The perceptions and attitudes of medical students towards trauma and orthopaedic teaching: a cross-sectional study

Objectives: This study aimed to identify how undergraduate students perceive learning opportunities available to them and to determine whether students with an interest in trauma and orthopaedic (T&O) surgery have different perceptions and attitudes towards learning.

Methods: All fourth year medical students from the University of Birmingham Medical School (UK) were surveyed regarding their career intentions and their attitudes towards the teaching received in trauma and orthopaedic surgery. The questionnaire was designed to capture student perception of learning environments, core knowledge and career motivations.

Results: Of the 157 respondents, 35 (22.3%) expressed an interest in a career in trauma and orthopaedic surgery. Medical students who reported educational value for trauma and orthopaedic surgery revealed that bedside teaching with a consultant was perceived extremely useful by 57.8% (n = 89). A similar ranking was awarded to small group teaching seminars and bedside teaching with a junior doctor or trainee by 54.5% (n = 85) and 51.6% (n = 79) of students, respectively. In contrast, trauma meetings and operating theatre learning environments were perceived to be of low educational value. Seeing patients within the clinical setting and the quality of teaching received were reported as the most motivating factors in career interest towards trauma and orthopaedic surgery, rated 43.9% (n = 69) and 35% (n = 55), respectively.

Conclusions: Perceptions of educational benefit derived from each learning environment vary among undergraduate medical students. Overall the most valuable learning environment perceived by the students is formal patient-based teaching. Despite diverging speciality choices students demonstrate similar learning needs.

Inadequacy of Musculoskeletal Knowledge among Undergraduate Medical Students

Background/Purpose

Musculoskeletal disorders (MSDs) are a significant public health problem. It has been observed that after leaving medical school, students are incapable of making a general assessment of the musculoskeletal system.

Methods

Accordingly, a pilot study was planned using the Freedman and Bernstein questionnaire and carried out in medical schools in India. Three hundred and twelve students at different levels were enrolled and administered the questionnaire. The correctness score for each student was obtained in each group and compared with the recommended qualifying score.

Results

For the sixth term and the ninth term, 44.61% and 50.71% students met the criterion, respectively, while interns showed the highest proportion of 71.42%. For the majority of the questions, the awareness level of ninth semester students and interns was better than that of sixth term students.

Conclusion

Compared to studies in other countries, the situation in India is not different. Medical institutions should place stress on orthopaedic education to provide better physicians.

Musculoskeletal education in medical school: deficits in knowledge and strategies for improvement

➤ Improvements in medical student physical examination skills and performance on validated musculoskeletal competency examinations correspond with undergraduate curricular reform.➤ Curricular reform success in the United States has been achieved by multidisciplinary collaboration.➤ International efforts are focused on improving medical student physical examination skills through patient partners and structured clinical examinations.➤ Technologies such as simulators and online learning tools are effective and well received.

Pre-internship Nigerian medical graduates lack basic musculoskeletal competency

PURPOSE

Our aim was to assess the basic musculoskeletal competency of pre-internship graduates from Nigerian medical schools.

METHODS

We administered the Freedman and Bernstein basic musculoskeletal competency examination to 113 pre-internship graduates from seven Nigerian medical schools over a three year period from 2008 to 2010 at the University of Uyo Teaching Hospital. Five specialist residents took the examination to test criteria relevance.

RESULTS

All graduates failed this test, obtaining scores ranging from 7% to 67%. The duration of the orthopaedic posting, and observation of operative fracture fixation, were not significant determinants of the score. The two final-year specialist residents each had a marginal pass in the examination.

CONCLUSION

Basic musculoskeletal competency among pre-internship Nigerian medical-school graduates is inadequate.

Evaluation of knowledge of common hand surgery problems in internal medicine and emergency medicine residents

Musculoskeletal disorders are the principal reason for primary care outpatient visits and make up 14% of visits to emergency departments, with the upper extremity as the most common site affected. However, formal musculoskeletal education is inconsistent in medical school and primary care residencies, with many first-year residents reporting a lack of confidence in examination and diagnosis of musculoskeletal conditions. The authors evaluated the level of knowledge of common upper-extremity conditions with a validated examination taken by internal medicine and emergency medicine residents. A 38-question upper-extremity examination was created by a group of hand and upper-extremity surgeons from the Resident Education Committee of the American Society for Surgery of the Hand. The examination was reviewed by 30 hand fellowship directors, who rated each question on a Likert scale and determined a recommended passing percentage. The Web-based examination was taken by emergency and internal medicine residents from multiple institutions. The fellowship directors' recommended passing grade averaged 73%. The majority of respondents were in their first (33%) or second (33%) year of training. The average scores were 56% and 46% for the internal and emergency medicine residents, respectively. This evaluation of a cross-section of internal and emergency residents indicates a deficiency in knowledge of common upper-extremity conditions.

Musculoskeletal examination--an ignored aspect. Why are we still failing the patients?

Over the past two decades, rheumatologists from around the world have not only championed the musculoskeletal system examination but also modified the undergraduate teaching curriculum. This has led to the development and adoption of the gait, arms, legs and spine (GALS) screening along with regional examination techniques. The purpose of this study is to review current practice, determining the frequency of patient exposure to appropriate examination and confidence of junior doctors when dealing with MSK conditions. Two district-general hospitals (non-teaching) and one teaching hospital in North-East London were chosen. At each site, 50 patient notes were reviewed from the acute admission wards for medicine and surgery and the medical assessment unit. Factors considered included whether GALS screenings had taken place, documentation of MSK examinations and assessment of confidence of junior doctors in assessing MSK conditions. GALS screenings were performed for 4% of patients on the medical assessment unit, 7% of acute medical and 0% of acute surgical patients on admission. Examination of the MSK system yielded better results with 16%, 22% and 10% on each of the respective wards. Interviews with junior doctors found 10% routinely screening for MSK conditions, despite 87% feeling confident in taking MSK histories. This prospective audit of clinical practice highlights that patients failed to have a minimal assessment of the MSK system through GALS screenings. When examining the MSK system, results were somewhat better, although still fewer than expected. It is curious that the majority of junior doctors in training felt confident in dealing with MSK disease but few did it in practice. This begs the question of whether current teaching curricula and strategies are adequate. At a time where there is ever-increasing national momentum to address issues on obesity and cardiovascular health, our patients are still deprived of a standard MSK examination by the medical faculty.