Effectiveness of an Interprofessional and Multidisciplinary Musculoskeletal Training Program

Interprofessional education interventions in undergraduate students of musculoskeletal healthcare professions: a scoping review protocol

INTRODUCTION

Enhancing interprofessional education (IPE) fosters collaborative efforts among healthcare professionals specializing in musculoskeletal (MSK) care. This approach presents a valuable opportunity to address the pressing MSK disease burden in developing countries, with high prevalence rates and limited resources. While an abundance of literature on the various elements of IPE among healthcare students and professionals exists, shared contexts of practice of South African MSK disciplines are not currently developed through IPE at higher education level, establishing a need for South African formalised curricular IPE interventions with an explicit focus on undergraduate students of MSK healthcare professions.

METHODS AND ANALYSIS

The intended scoping review protocol is guided by the framework set out by Arksey and O'Malley, where the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews will guide the process of reporting. English sources (qualitative and quantitative methodological studies, conference papers and proceedings, systematic reviews, grey literature, unpublished materials, theses and dissertations) from the electronic databases PubMed, Scopus, ERIC and ProQuest with no date restriction will be included. A researcher, an independent reviewer and research librarian will search and extract data from abstracts and full texts for this scoping review, where any arising disagreements will be resolved by discussion. Reference lists of relevant literature will be scrutinised. Relevant literature will be recorded on a referencing software and deduplicated. The data collection will take place between May and October 2023. The findings will be reported narratively with the use of tables.

ETHICS AND DISSEMINATION

This scoping review does not require ethical approval as all literature used already exists in the public domain with no involvement of human participants. The findings from this planned review will be submitted to peer-reviewed journals and will be presented at higher education conferences. This scoping review protocol was registered on Open Science Framework with the registration osf.io/c27n4.

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.

Incorporating interactive workshops into bedside teaching: completion of a multi-modal rheumatology rotation significantly increases internal medicine residents' competency and comfort with comprehensive knee examinations

BACKGROUND

Studies have elucidated the lack of competency in musculoskeletal (MSK) examination skills amongst trainees. Various modalities have been studied, however, there remains a dearth of literature regarding the effectiveness of bedside teaching versus dedicated workshops. Our aim was to determine if incorporating a workshop into a rheumatology rotation would be effective in increasing medicine residents' competency and comfort with knee examinations when compared to the rotation alone.

METHODS

Over 16 months, rotators were randomized to workshop plus rotation versus rotation alone. Participants were tested on their knee examination skills using an objective structured clinical examination (OSCE). Surveys were administered assessing to what degree the rotation was beneficial. Comfort and helpfulness were measured using a 5-point Likert scale. Paired and independent samples t-tests were used for comparisons.

RESULTS

Fifty-seven residents participated. For both groups, there were improvements between pre- and post-OSCE scores (workshop p < 0.001, no workshop p = 0.003), and levels of comfort with examination (workshop p < 0.001, no workshop p < 0.001). When comparing groups, there were differences favoring the workshop in post-OSCE score (p = < 0.001), mean change in OSCE score (p < 0.001) and mean change in comfort with knee examination (p = 0.025).

CONCLUSION

An elective in rheumatology augmented residents' MSK competency and comfort. Incorporation of a workshop further increased knowledge, skills and comfort with diagnosis and treatment. Current educational research focuses on alternatives to traditional methods. This study provides evidence that a multi-modal approach, combining traditional bedside and interactive models, is of benefit.

Randomized Controlled Study of a Training Program for Knee and Shoulder Arthrocentesis on Procedural Simulators with Assessment on Cadavers

Objective

The study objective was to assess the efficacy of simulators in improving the competence of students in performing a knee and shoulder arthrocentesis on cadavers and to determine the minimum number of simulator training procedures needed to achieve competence in arthrocentesis.

Methods

Two groups of 15 medical students were each trained to perform a single joint arthrocentesis (“knee group” and “shoulder group”) on a simulator to serve as a control for the other. The two groups received the same theoretical training (anatomy, arthrocentesis techniques, ultrasound, and hybrid simulation). Each student punctured the two joints on a cadaver. A student was considered “competent on the cadaver” if they succeeded at two or more arthrocentesis procedures out of the three tests on the joint on which they were trained. The minimum threshold value to be competent was calculated by a receiver operating characteristic curve and the Youden index. An assessment of theoretical knowledge and confidence level in joint arthrocentesis was carried out at the start and end of the study.

Results

Twenty‐two out of 29 students (75.8%) achieved competence in arthrocentesis at the joint for which they were trained. Of the students in the knee group, 79% were competent on the cadaver’s knee versus 60% of the students in the shoulder group (P = 0.43). Of students in the shoulder group, 74% were competent on the cadaver’s shoulder versus 57% of students in the knee group (P = 0.45). Four training punctures on a simulator are necessary to achieve competence on a cadaver. The students’ confidence level in arthrocentesis increased significantly during the study, as did the students’ theoretical knowledge.

Conclusion

Knee and shoulder arthrocentesis success rates were not statistically different between the two training groups. A minimum number of 4.0 training arthrocentesis on a simulator is needed to achieve competency on a cadaver.

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.

Active Learning Strategies to Improve Progression from Knowledge to Action

Lectures, a form of passive learning, are a modality of teaching used in medical education. Active learning strategies allow learners and teachers to interact and be more engaged with the subject matter in a manner that encourages discussion, critical thinking, and advanced clinical reasoning skills. Learning to be effective requires vigilance, which promotes memory retention and should afford a way for learners to build on preexisting knowledge via scaffolding and concept mapping that uses critical thinking. Educators should also to use evaluation models that seek to improve patient care, health care systems, and community health.

Implementing an established musculoskeletal educational curriculum in a new context: a study of effectiveness and feasibility

Background: Musculoskeletal (MSK) problems are common, yet many primary care (PC) providers feel inadequately trained to manage these conditions. Previous studies describe successful MSK educational innovations at single sites, but none have reported on subsequent attempts to replicate or adapt these innovations to new contexts. This article presents a study of a national Veterans Affairs MSK training program modified to fit an existing PC educational program.Objectives: (1) To evaluate the effectiveness and feasibility of an adapted MSK curriculum in a new context. (2) To provide a model for adaptation studies in health professions education.Design: A national MSK shoulder and knee curriculum was adapted for San Francisco VA PC trainees, which included a small-group workshop and workplace learning within a newly-created MSK clinic. Effectiveness was evaluated by assessments of trainee confidence in exam and injection skills (via 5-point Likert scale) and faculty-observed performance of knee and shoulder exams (reported as percent of maximum possible score). Feasibility was evaluated by determining acceptability of the program to PC trainees (via 5-point Likert scale) and ability to implement the curriculum using local resources.Results: 52 trainees completed the training during a 2-year period. Trainees' confidence in MSK exam skills improved from 3.3 to 4.5 for shoulder, and from 3.5 to 4.6 for knee. Confidence performing joint injections improved from 2.6 to 4.2 (shoulder) and 2.5 to 4.5 (knee) (p < 0.001 for all). Observed performance improved markedly - from 50% to 92% for shoulder, and 57% to 90% for knee. Feasibility was evident in high acceptability (5.0 for MSK clinic, and 4.9 for workshops), and successful and sustained implementation.Conclusions: Adapting an established MSK curriculum to a new context was effective and feasible. This may serve as a more efficient model for improving trainee education than de novo curriculum design at individual sites.

"It's Not Just About Getting Along": Exploring Learning Through the Discourse and Practice of Interprofessional Collaboration

PURPOSE

Interprofessional collaboration (IPC) is a necessary competency for all professionals. However, IPC can be fraught with politics leading to variable uptake and execution. The authors set out to understand how trainees come to appreciate the value of the "team" in their learning and to describe the type of learning related to IPC afforded to trainees in a highly collaborative complex care context.

METHOD

The authors conducted 72 hours of observations of pediatric rheumatology settings at a large pediatric hospital across 18 months. They interviewed 10 health professionals and analyzed an archive of texts to ascertain how the field of pediatric rheumatology conceptualizes the role of IPC. They used the concept of governmentality and critical discourse analysis to describe how values of collaboration enabled learning and theories of expertise to understand how learning was enacted and perceived.

RESULTS

Collaboration was perceived to be a product of providing good rheumatological care, which in this case, aligned well with hospital model of IPC. This alignment afforded trainees learning opportunities beyond preparing them to get along with other health professionals. IPC, when role modeled during problem solving, created the conditions for learning "why" collaboration is important for clinical expertise.

CONCLUSIONS

By critically examining the relationship between discourse, practice, and learning, the authors have described how practices that underpin collaboration as a clinical competency are distinct from collaboration as cultural work contributing to civility within teams and across the organization.

Improving Internal Medicine Resident Comfort With Shoulder and Knee Joint Injections Using an Injection Workshop

INTRODUCTION

Joint injections can be effective treatments for musculoskeletal issues. We examined whether a brief teaching session delivered to residents and faculty would significantly improve resident confidence in performing shoulder and knee joint injections.

METHODS

We implemented a 90-minute workshop instructed by two sports medicine providers. The objectives and content of the workshop included the topics of indications and contraindications, risks and benefits, supplies and setup, and injection techniques, all assessed on 5-point Likert scales. The workshop included a lecture, followed by residents practicing injections on simulation models and identifying key bony landmarks. Outpatient clinic faculty were given the same lecture and practiced on models. The postworkshop questionnaire was administered to the residents 4 months later.

RESULTS

Eighteen residents participated. Mean confidence for performing knee injections increased from 2.2 to 3.8 immediately postlecture (p = .006). Shoulder injection confidence increased from 1.6 to 3.8 immediately postlecture (p = .0002). Confidence in knowledge of the risks and benefits, supplies needed, and indications increased similarly. Four months postworkshop, confidence levels were sustained above pretesting levels for all areas studied. Faculty members appreciated their workshop since they had not often performed injections.

DISCUSSION

This brief workshop-style teaching session can provide meaningful, durable improvements in a trainee's confidence regarding performing shoulder or knee joint injections. The session requires few resources and fits into regular didactic sessions. Further development of this model could increase clinical performance and practice confidence and make these procedures more widely accessible to patients.

SimLEARN Musculoskeletal Training for VHA Primary Care Providers and Health Professions Educators

A simulation-based training curricula applied to the primary care evaluation and management of shoulder and knee pain resulted in improved access to care for veterans and cost savings for the health care system.

Interprofessional Musculoskeletal Education: A Review of National Initiatives from the Department of Veterans Affairs

This article reviews several national programs in musculoskeletal education initiated by the Department of Veterans Affairs over the past decade. These programs have become sustained interprofessional opportunities for learners across disciplines and along the continuum of health professions education (HPE) and training pathways. This article also describes opportunities for leaders in rheumatology and other HPE programs to join these efforts and to collaborate in the scholarship that will be necessary in constructing educational programs fit for the purpose of ensuring a well-trained, competent workforce of health care providers.

The impact of a musculoskeletal training program on residents' recognition and treatment of osteoporosis

BACKGROUND

Osteoporosis is inadequately treated in primary care settings. Under-recognition of the condition among male Veterans may contribute to this problem. In order to improve understanding of bone health in older male patients, we developed the "Musculoskeletal (MSK) Education Week", a multidisciplinary clinical training initiative within a primary care ambulatory rotation for internal medicine (IM) residents at the Salt Lake City VA Medical Center. The objective of this study was to evaluate the impact of this program on trainees' recognition of osteoporosis or treatment of this condition following the training experience.

METHODS

We examined several clinical behaviors of post-graduate year 1 (PGY-1) IM trainees following their participation in the MSK Education Week between July 1-April 30, 2014. To determine the prevalence of these clinical behaviors, we conducted an observational study of patients age 50 and older enrolled at the Salt Lake City VA Healthcare System from July 1, 2013 to May 31, 2014. We used time-dependent multivariable Cox proportional hazard models to evaluate the impact of the training program on 4 osteoporosis-related outcomes: (1) completion of dual energy X-ray absorptiometry (DXA) scan, (2) diagnosis of osteopenia, (3) diagnosis of osteoporosis, and (4) initiation of osteoporosis medications.

RESULTS

Twenty-six PGY-1 IM residents participated in the MSK Education Week, and 43,678 Veterans were identified over these periods of observation. In the Veterans cohort, 1154 had an encounter with a provider who had completed the training (and were therefore "exposed" to the training) and 42,524 Veterans did not. After adjusting for confounders, the effect of the provider training program was significant for DXA (HR = 1.78, 95% CI: 1.11, 2.87), osteoporosis diagnosis (HR = 3.90, 95% CI: 2.09, 7.29), and initiation of medications (HR = 2.87, 95% CI: 2.02, 4.09) outcomes.

CONCLUSIONS

We have shown that IM residents' participation in the MSK Education Week was associated with significantly improvements in their completion of DXA scans, diagnosis of osteoporosis, and initiation of fracture-reducing medications in a population of US Veterans. Long-term follow up is needed to determine whether these initial results are followed by actual reductions in osteoporotic fractures.

Validity evidence for two objective structured clinical examination stations to evaluate core skills of the shoulder and knee assessment

BACKGROUND

We developed two objective structured clinical examinations (OSCEs) to educate and evaluate trainees in the evaluation and management of shoulder and knee pain. Our objective was to examine the evidence for validity of these OSCEs.

METHODS

A multidisciplinary team of content experts developed checklists of exam maneuvers and criteria to guide rater observations. Content was proposed by faculty, supplemented by literature review, and finalized using a Delphi process. One faculty simulated the patient, another rated examinee performance. Two faculty independently rated a portion of cases. Percent agreement was calculated and Cohen's kappa corrected for chance agreement on binary outcomes. Examinees' self-assessment was explored by written surveys. Responses were stratified into 3 categories and compared with similarly stratified OSCE scores using Pearson's coefficient.

RESULTS

A multi-disciplinary cohort of 69 examinees participated. Examinees correctly identified rotator cuff and meniscal disease 88% and 89% of the time, respectively. Inter-rater agreement was moderate for the knee (87%; k = 0.61) and near perfect for the shoulder (97%; k = 0.88). No correlation between stratified self-assessment and OSCE scores were found for either shoulder (0.02) or knee (-0.07).

CONCLUSIONS

Validity evidence supports the continuing use of these OSCEs in educational programs addressing the evaluation and management of shoulder and knee pain. Evidence for validity includes the systematic development of content, rigorous control of the response process, and demonstration of acceptable interrater agreement. Lack of correlation with self-assessment suggests that these OSCEs measure a construct different from learners' self-confidence.