Musculoskeletal Medicine: An Assessment of the
Attitudes and Knowledge of Medical Students
at Harvard Medical SchoolThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Academic Medicine 2007 (May); 82 (5): 452–457 ~ FULL TEXT
Charles S. Day, MD; Albert C. Yeh; Orrin Franko; Miguel Ramirez; Edward Krupat, PhD
Musculoskeletal Curriculum,
Harvard Medical School,
Orthopedic Hand Surgery,
Beth Israel Deaconess Medical Center,
Boston, Massachusetts 02215, USA
Purpose: To assess medical students' knowledge and clinical confidence in musculoskeletal medicine as well as their attitudes toward the education they receive in this specialty.
Method: A cross-sectional survey of students in all four years of Harvard Medical School was conducted during the 2005-2006 academic year. Participants were asked to fill out a 30-question survey and a nationally validated basic competency exam in musculoskeletal medicine.
Results: The response rate was 74% (449/608). Medical students rated musculoskeletal education to be of major importance (3.8/5) but rated the amount of curriculum time spent on musculoskeletal medicine as poor (2.1/5). Third-year students felt a low to adequate level of confidence in performing a musculoskeletal physical examination (2.7/5) and failed to demonstrate cognitive mastery in musculoskeletal medicine (passing rate on competency exam: 7%), whereas fourth-year students reported a similar level of confidence (2.7/5) and exhibited a higher passing rate (26%). Increasing exposure to the subject by taking clinical electives resulted in greater clinical confidence and enhanced performance on the exam (P < .001). Students' feedback suggested that musculoskeletal education can be better integrated into the preclinical curriculum, more time should be spent in the field, and more focus should be placed on common clinical conditions.
Conclusions: These findings, which are consistent with those from other schools, suggest that medical students do not feel adequately prepared in musculoskeletal medicine and lack both clinical confidence and cognitive mastery in the field. Implementing a four-year integrated musculoskeletal curriculum is one way that medical schools can address this concern.
From the FULL TEXT Article:
Background
The discrepancy between the widespread impact of musculoskeletal diseases on society and the relative inattention devoted to this subject in the undergraduate medical curriculum has been a subject of increasing concern during the past five years. [1–8] In data reported over the past 15 years, musculoskeletal complaints and injuries have comprised approximately 15% to 30% of primary care visits in the United States and Canada, [4] 20% of emergency room visits in the United States, [9] and 20% of nonroutine pediatric visits in Europe. [10] In 2004, the National Ambulatory Medical Care Survey indicated that musculoskeletal conditions were the number-one reason across the United States for visits to physicians’ offices, with approximately 92.1 million cases reported annually. [11] As part of the global initiative aimed at increasing awareness and reducing societal burden arising from these conditions, the World Health Organization designated the years 2000 to 2010 as The Bone and Joint Decade. [12] The United States later reemphasized this effort by adopting the National Bone and Joint Decade in 2002. [13]
In light of these initiatives, there has been much focus recently on the responsibilities of undergraduate medical institutions in providing adequate musculoskeletal education. In 2005, the Association of American Medical Colleges (AAMC) brought to attention that despite the increasing prevalence of musculoskeletal conditions spread across a broad spectrum of clinical practice, it is not clear that medical schools are effectively educating future physicians in this field. [1] Furthermore, recent studies suggest that the discrepancy between the magnitude of musculoskeletal problems and physician competency in musculoskeletal medicine likely stems from educational deficiencies at the medical school level. [2–8]
Various metrics have been employed to evaluate the adequacy of musculoskeletal training. In 2001, a comprehensive study reviewing the curricula of all Canadian medical schools indicated that directors of undergraduate musculoskeletal programs felt dissatisfied with the curricular time devoted to musculoskeletal education. [4] In the same year, survey responses by over 1,900 second-year residents in United States residency programs revealed that residents felt poorly or very poorly prepared in their training when conducting a musculoskeletal examination on various parts of the body. [5] In 2003, Freedman and Bernstein2 reported first-year residents’ performance on a validated basic competency exam in musculoskeletal medicine. According to a passing standard set by 240 internal medicine residency program directors in the United States, 78% of these first-year residents failed to meet the passing criterion expected from medical school graduates.
In an effort to gain a more comprehensive assessment of students’ overall attitudes toward and knowledge of musculoskeletal medicine, we combined the various approaches from the literature by evaluating medical students’ clinical confidence, cognitive mastery, and perception of education in musculoskeletal medicine.
Discussion
As stated earlier, the high prevalence of musculoskeletal conditions and the impact they have on patients across a broad spectrum of medical practice, including pediatrics, emergency medicine, family practice, and internal medicine, justifies the need for all medical students to have a basic understanding of musculoskeletal medicine. Our study demonstrates that medical students realize both the importance of and the need for effective musculoskeletal education. They considered musculoskeletal conditions to account for nearly 45% of reasons for visits to a primary care office and ranked the field as being of “major importance” to their future medical career. However, the students felt that there was insufficient curriculum time devoted to musculoskeletal medicine.
The students’ concerns about the inadequacy of musculoskeletal education are consistent with both their lack of clinical confidence in examining the musculoskeletal system as well as their lack of cognitive mastery in basic musculoskeletal medicine. An effective way to address both of these deficiencies is through increased exposure to information about this area of medicine. Results demonstrated that both third- and fourth-year students who had taken musculoskeletal electives in their clinical years performed significantly better on the competency exam (P < .001) and were significantly more confident in examining the musculoskeletal system (P < .05) than those who had taken just the required musculoskeletal curriculum. Furthermore, only fourth-year elective takers exhibited an average score above the suggested passing criterion set by the internal medicine residency program directors.
Relying on clinical electives, however, is not an effective solution. Despite the fact that most students from our study seem to be aware of the importance and prevalence of musculoskeletal conditions, only 79 (48%) of third-year students and 25 (29%) of fourth-year students chose to take electives in the field. One way to guarantee greater exposure would be for medical institutions to increase the amount of mandatory musculoskeletal education in their curricula. Although every academic department could benefit from more curricular time, our study adds to the literature that provides direct evidence that such a need exists for musculoskeletal medicine.
Better integration of musculoskeletal education throughout the preclinical and clinical years is just as important. As the AAMC recommended, fragmentation of musculoskeletal content in the curriculum should be addressed through curriculum design and instructional implementation. [1] Student feedback from our study supports these recommendations. We received a wide range of suggestions for improving the musculoskeletal curriculum, including better integration of musculoskeletal education in human anatomy, human systems, and patient–doctor tutorials; increased coordination with neurology; more focus on common clinical complaints; and a more structured musculoskeletal curriculum in orthopedic surgery rotations. Many of these suggestions do not entail increasing curricular time but, rather, better organization and coordination between courses. Another potential way of integrating musculoskeletal medicine into the clinical years that was not mentioned in student responses is emphasizing the musculoskeletal exam across relevant clerkships, such as family medicine, geriatrics, internal medicine, and pediatrics.
Limitations
Results from our study should be interpreted within the context of several limitations. First, musculoskeletal elective-takers may have performed better on the exam not because they took musculoskeletal electives, but because they have a higher level of interest in musculoskeletal medicine. To address this issue, we looked at the top residency choice for all 25 fourth-year elective takers and found that 7 out of the 25 medical students listed orthopedics as their first residency choice. The remaining 18 students selected their top residencies as follows: internal medicine (6), obstetrics–gynecology (2), general surgery (2), plastic surgery (2), radiology (2), urology (1), radiation oncology (1), neurology (1), and emergency medicine (1), reflecting a wide variety of interest not necessarily biased towards musculoskeletal medicine. When we compared exam scores of the seven students interested in orthopedics with those of the other 18 students, we found no statistical difference between the two groups’ scores. These data suggest that the increase in cognitive mastery of musculoskeletal medicine is more strongly associated with taking musculoskeletal electives than with interest alone.
Second, our assessment was performed at only one medical school. Our study population may not be representative of other medical institutions, and the musculoskeletal medicine curriculum certainly varies from school to school. It could be argued that our institution promotes a disproportionate share of future specialists and researchers and does not focus as much on primary care medicine. Nonetheless, the required two weeks of preclinical instruction focused on musculoskeletal medicine at HMS is consistent with the national average of curricular time devoted to this field. [3] Out of all medical schools in the United States, 47% require neither preclinical nor clinical instruction in musculoskeletal medicine, and 44% require either preclinical or clinical instruction but not both. [3] Out of all Canadian medical schools, 68% do not require musculoskeletal education in the clinical setting. [4] Thus, the amount of time devoted to musculoskeletal medicine at our institution is not atypical. Although individual institutions’ curricula vary in effectiveness, it may still be reasonable to infer that a large portion of U.S. and Canadian medical schools face a similar challenge in effectively addressing musculoskeletal medicine in their curricula.
Future direction
As the AAMC suggests in its Medical School Objectives Project report guidelines, medical schools can and should better address musculoskeletal education by striving to “integrate learning experiences relevant to musculoskeletal medicine throughout the curriculum in ways that explicitly identify the material as part of a coherent curriculum component.” [1] HMS is currently in the midst of a major undergraduate medical education reform. In response to the AAMC’s recommendations and to the findings from this study, HMS is in the process of designing a four-year musculoskeletal curriculum. Preliminary changes have already been implemented for the 2006–2007 academic school year.
Our study adds to the previous literature not only by providing direct measurement of the effectiveness of the undergraduate musculoskeletal education, but also by presenting the medical students’ perspectives towards musculoskeletal medicine and the musculoskeletal curriculum. To our knowledge, this is the largest study so far that has used Freedman and Bernstein’s nationally validated basic competency exam, and the results are consistent with other medical institutions’ findings. [2, 7, 8]
The increasing burden of musculoskeletal problems on individuals and society dictates more focus on musculoskeletal medicine, and medical schools bear a large share of the responsibility in adequately preparing future physicians to deal with these conditions. Implementing a four-year integrated musculoskeletal curriculum with dedicated time spent in both preclinical and clinical years is one way that medical schools can contribute to The Bone and Joint Decade, the global initiative aimed at addressing the impact that musculoskeletal disorders have on society. [12]
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