THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 3 - MARCH 99
Med School Graduates Weak in Musculoskeletal Knowledge
The adequacy of musculoskeletal training in medical schools has long been questioned. Now, despite pressure from managed care organizations for primary care physicians to provide more comprehensive care, there are fresh signs that graduates are still exiting medical schools with a weak background in the field.
The latest piece of evidence is a recent report in The Journal of Bone and Joint Surgery (1). The authors administered a validated musculoskeletal knowledge exam (table 1: not shown) to 85 new residents at the University of Pennsylvania School of Medicine in Philadelphia. Seventy of the 85 failed.
Joseph Bernstein, MD, MS, coauthor of the report, said that because musculoskeletal problems are a major reason patients seek medical care, primary care physicians must know how to treat the simple problems and recognize the conditions that require referral to a specialist. Bernstein is director of sports medicine in the Department of Orthopaedic Surgery at the University of Pennsylvania in Philadelphia.
In 1994, the Group Health Association of America (a coalition of managed care organizations, now known as the American Association of Health Plans), issued a report on the need for medical school reforms and listed 12 competencies needed by primary care physicians who work in managed care organizations (2). Managing acute and chronic musculoskeletal conditions was included in one of the competencies (3).
In the family practice setting, musculoskeletal problems account for about 23% of office visits (4). A recent survey from an urban pediatric clinic found that 6.1% of visits were related to musculoskeletal complaints (5). An estimated 10% of visits to internists are for musculoskeletal complaints (J. Ende, MD, written communication, February 1999).
Authors of the JBJS article found that 28 of the 85 residents had graduated with no rotation in orthopedics, 44 had taken a required rotation, and 20 had taken an elective course. Seven students had taken both a required and an elective course in orthopedic surgery. (The graduates represented 37 medical schools.) Students who took an elective course scored significantly higher on the test. The mean duration of their orthopedics training was 5.6 weeks, whereas the mean duration of the whole group was 2.1 weeks.
A 1993 review article (6) reported that in Canada, less than 3% of preclinical medical school curriculum is devoted to musculoskeletal topics and only 12% of medical schools mandate clinical training in musculoskeletal medicine. "Hopefully, primary care residencies pick up the slack" and make up for the lack of training, Bernstein says, but he believes medical school is the place to learn the fundamentals of musculoskeletal medicine.
The variability in musculoskeletal training in primary care residencies raises doubts about whether those programs make up for the medical school deficit. During residency training, family practice students spend 200 hours in orthopedics; for internal medicine students, orthopedics is advised, but a time requirement is not specified (7). In a survey (8) of primary care pediatric residency graduates, sports medicine/orthopedics was one of two areas in which graduates felt weakest.
Douglas B. McKeag, MD, MS, Arthur J. Rooney chair of sports medicine and a professor of family medicine and orthopedics at the University of Pittsburgh, says he agrees that training in musculoskeletal medicine is lacking. "But you could say that [training is inadequate] about any specialty," he adds.
Effect on Patient Care?
The apparent lack of training in musculoskeletal medicine implies that the quality of patient care suffers. But Bernstein says he believes patients are still getting good care, adding that many of the interns who were tested admitted readily that their musculoskeletal training was lacking. "The main problem may be that extra MRIs or consultations are ordered, but that's a problem for the bean counters to worry about," he says.
A study of 72021 family physicians in Canada (9) showed that management of three common musculoskeletal conditions was consistent with expert recommendations. But the study identified unnecessary use of diagnostic tests, inappropriate prescribing of nonsteroidal anti-inflammatory drugs, infrequent use of patient-centered options such as exercise, and lack of diagnostic suspicion of infectious arthritis. The authors said physicians need increased exposure to musculoskeletal problems during undergraduate and residency training and in continuing medical education.
One problem that contributes to inadequate musculoskeletal medicine training is lack of competent instructors, Bernstein says. At the University of Pennsylvania, he says, all of the orthopedic faculty help teach the musculoskeletal course. "But even so, we still could use more help. Maybe the solution is to have musculoskeletal specialists teach a cadre of generalists enough information so that these 'students' can go and teach others."
So far, the role of managed care organizations in medical education has been small, though some medical leaders have suggested that both medical schools and managed care organizations would benefit from such an alliance (2).
Another obstacle to more musculoskeletal medicine training is competition from other course work demands such as preventive medicine, mental health, and healthcare economics, says Bernstein. "It is a constant Darwinian struggle—survival of the fittest, or at least survival of those who make the best case," he says.
(For discussion of another suggested reason for scant musculoskeletal training—the lack of a standard curriculum—see this month's Editor's Notes, "Musculoskeletal Medicine: How to Strengthen Training," page 5.)
Focus on Clinical Exam
Though the JBJS report did not identify specific changes that need to be made in musculoskeletal medicine training, Bernstein suggests a required 2-week course consisting of didactic and clinical instruction. Both Bernstein and McKeag say the course should deemphasize surgical techniques and focus on the clinical exam. They also say anatomy courses should highlight functional issues instead of surgical dissection. "Musculoskeletal medicine also lends itself to be integrated into other courses such as radiology," McKeag says.
Future courses that focus on the clinical exam should incorporate evidence-based medicine, McKeag says. "We need a firmer anchor in science than in the past. We need to come up with tests that are sensitive and specific enough to have good predictive value."
What about the primary care physicians in practice who have a weak musculoskeletal medicine background? One report suggests that continuing medical education is the most important and modifiable variable for boosting physicians' confidence in their ability to manage musculoskeletal disorders (10).