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More Bad News For Medical Patients

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More Bad News For Medical Patients

The Chiro.Org Blog

Medical Training For Musculoskeletal Conditions is Inadequate

From Harvard Medical School in the U.S. to medical schools in Europe, medical education related to musculoskeletal conditions is inadequate. A 2009 survey tested physician’s knowledge related to simple low back pain management. [1] The average survey score of family practitioners was 69.7 and the average score of orthopedists was far less at 44.3. Orthopedists were less likely to make the proper radiological referral and appropriate pharmacological prescription based upon the literature.

Another 2009 study from the U.K. found that only 13% of the junior doctors felt they had adequate musculoskeletal medical training. [2] Research from the University of Washington found that less than 50% for the fourth-year student interns were competent in the area of musculoskeletal medicine. A 2007 study of Harvard medical students found that they were not confident in management of musculoskeletal cases and failed to demonstrate cognitive mastery. The study concluded that “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.”

The current failure of modern medicine worldwide to adequately train physicians and the continually growing problems like low back pain is just one more good reason to see a chiropractor when you have musculoskeletal complaints.

REFERENCES: Thanks to ChiroAccess!

1. Orthopaedists’ and Family Practitioners’ Knowledge of Simple Low Back Pain Management
Spine 2009 (Jul 1); 34 (15): 1600-1603

2. The Inadequacy of Musculoskeletal Knowledge After Foundation Training in the United Kingdom
J Bone Joint Surg Br 2009 (Nov); 91 (11): 1413-1418

End Medical Mis-Management of Musculoskeletal Complaints

Q. — Are medical doctors well trained to diagnose or treat musculoskeletal complaints?

A. — Read the unsettling answer in the following series of articles

Educational Deficiencies in Musculoskeletal Medicine
J Bone and Joint Surgery 2002 (Apr); 84–A (4): 604–608
According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.

NOTE: This is a follow-up article to the study cited below, which demonstrated that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. What would the headlines scream if, after 4 years, our profession had failed to improve it’s skills in musculoskeletal assessment and management? Ask your self, why should medicine receive more slack than we are???

The Adequacy of Medical School Education in Musculoskeletal Medicine
J Bone and Joint Surgery 1998 (Oct); 80-A (10): 1421–1427
This is the original article, which found that 82 per cent of medical school graduates failed a valid musculoskeletal competency examination. They concluded that “we therefore believe that medical school preparation in musculoskeletal medicine is inadequate” and that medical students were inadequately trained to diagnose and treat musculoskeletal complaints.

Educating Medical Students About Musculoskeletal Problems: Are Community Needs Reflected in the Curricula of Canadian Medical Schools?
J Bone and Joint Surgery 2001 (Sept); 83-A (9): 1317–1320
Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. (So they conclude:) There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.

A Comparison of Chiropractic Student Knowledge Versus Medical Residents
Proceedings of the World Federation of Chiropractic Congress 2001 Pgs. 255
A previously published knowledge questionnaire designed by chief orthopedic residents was given to a Chiropractic student group for comparison to the results of the medical resident group. Based on the marking scale determined by the chief residents, the Chiropractic group (n = 51) showed statistically significant higher average grade than the orthopedic residents. Expressed in other terms, 70% of chiropractic students passed the knowledge questionnaire, compared to an 80% failure rate for the residents.

We need to reflect on the true differences between these 2 groups. The medical students had already graduated from medical school, received their MDs, had done ALL their residency rotations, and finally had been admitted to a highly-competitive orthopedic residency program (the “pinnacle” of medical training), while the chiropractic students were still completing their pre-doctoral studies. 70% passed vs. 80% failed. Who would YOU rather consult with?

Musculoskeletal Knowledge: How Do You Stack Up?
Physician and Sportsmedicine 2002; 30 (8) August
One of every 4 or 5 primary care visits is for a musculoskeletal problem. Yet undergraduate and graduate training for this burden of illness continues to constitute typically less than 3% of the medical curriculum. This is an area of clear concern, but also one in which sports medicine practitioners can assume leadership.

Musculoskeletal Curricula in Medical Education
Physician and Sportsmedicine 2004 (Nov); 32 (11)
It’s 8:00 pm on a Monday night. Just as you’re getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment. This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.[ 1 ] While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.

Adequacy of Education in Musculoskeletal Medicine
J Bone and Joint Surgery Am 2005 (Feb); 87 (2): 310–314
In this study, 334 medical students, residents and staff physicians, specializing in various fields of medicine, were asked to take a basic cognitive examination consisting of 25 short-answer questions – the same type of test administered in the original JBJS 1998 study. The average score among medical doctors, students and residents who took the exam in 2005 was 2.7 points lower than those who took the exam in 1998. Just over half of the staff physicians (52%) scored a passing grade or higher on the 2005 exam. Only 21% of the residents registered a passing grade, and only 3% of the medical students passed the exam. Overall, Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination.

More Evidence of Educational Inadequacies in Musculoskeletal Medicine
Clin Orthop Relat Res 2005 (Aug); (437): 251–259
A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.

Why is the Bone and Joint Decade Important?
Welcome to the United States Bone and Joint Decade

The Bone and Joint Decade initiative is a global campaign to improve quality of life for people with musculoskeletal conditions and to advance understanding and treatment of these conditions through research, prevention, and education. [ 1 ] The Decade aims to raise the awareness of the increasing societal impact of musculoskeletal injuries and disorders; empower patients to participate in decisions about their care; increase funding for prevention activities and research; and promote cost-effective prevention and treatment of musculoskeletal injuries and disorders.

Doctors Likely to Encounter Children With Musculoskeletal Complaints Have Low Confidence in Their Clinical Skills
Journal of Pediatrics 2009 (Feb); 154 (2): 267–271

Questionnaires, filled out by a broad spectrum of medical providers in England [Primary Care (n = 75), Pediatrics (n = 39), Emergency (n = 39), Orthopedics (n = 40), and experienced doctors in Primary Care (n = 93), and Pediatrics (n = 60).], revealed that 74% of them scored their personal confidence in pediatric musculoskeletal clinical assessment as “no” to “low”.

Orthopaedists’ and Family Practitioners’ Knowledge of Simple Low Back Pain Management
Spine 2009 (Jul 1); 34 (15): 1600–1603

One hundred forty family practitioners and 253 orthopaedists responded to the questionnaire. The mean family practitioners’ score (69.7) was significantly higher than the orthopaedists’ score (44.3) (P < 0.0001). No relation was found between the results and physician demographic factors, including seniority. Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclo-oxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs.

The Inadequacy of Musculoskeletal Knowledge After Foundation Training in the United Kingdom
J Bone and Joint Surgery Br 2009 (Nov); 91 (11): 1413–1418

The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment.

About the Author:

I was introduced to Chiro.Org in early 1996, where my friend Joe Garolis helped me learn HTML, the "mark-up language" for websites. We have been fortunate that journals like JMPT have given us permission to reproduce some early important articles in Full-Text format. Maintaining the Org website has been, and remains, my favorite hobby.


  1. Chiropractor Rockledge January 9, 2010 at 5:59 pm

    I love it when my patients say “My medical doctor told me I shouldn’t have Chiropractic care. MD’s are practicing Chiropractic. I guess we should just say “you dont need to take that prilosec anymore?


    MDs are not trained in chiropractic, so when they say something like that, they speak from ignorance. My favorite quote along those lines is:

    “A patient finally went to a chiropractor for her back pain after finding no relief with the orthopedist. After three adjustments and a week of no symptoms, she had a follow-up visit with her M.D.

    Upon learning about the success of the D.C., the orthopedist stated, “That was just the placebo effect.”

    The patient responded, “If it works so well, why didn’t you use it?”

    Now, that’s what I call logical!

  2. Ken Whidden January 10, 2010 at 4:46 pm

    I’m finding less and less resistance to chiropractic care from MD’s, but patients still will do whatever their MD tells them to. It’s frustrating, but over time I hope our place in the health care environment will be more universally respected.

    Ken Whidden, DC
    Emerald Coast Chiropractic

  3. Ian January 19, 2010 at 8:01 pm

    I’m not going to start an argument on why this article is only a little biased, but I will concur that additional training needs to be had, on various levels. There is also the argument that chiropractors many times are only providing a short term solution, unlike say, a physical therapist who informs a person on how, over time, to improve their aches and pains through proper exercises, rather than a one-time “fix”. We all need to educate the public, and this can be done through various social media networks, including on Twitter and Facebook.

    RESPONSE from Frank:

    Hi Ian,

    I fail to see why citing a long series of peer-reviewed articles from the medical literature could be construed as “biased”?

    I don’t know who’s “argument” you are quoting, but statements like
    “chiropractors many times are only providing a short term solution”

    or your contention that

    “only PTs make recommendations for exercises or pain relief”

    demonstrates a radically mis-informed assessment of my profession.

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