Clin Orthop Relat Res 2005 (Aug); (437): 251–259 ~ FULL TEXT
Gregory A Schmale, MD
Children's Hospital and Regional Medical Center,
University of Washington,
Seattle, 98105, USA.
In their study, Freedman and Bernstein suggested that 80% of a group of graduates from many of the best medical schools in the United States were deficient in their knowledge of basic facts and concepts in musculoskeletal medicine. How do these results compare with results from students attending a medical school with a long-standing dedicated program to musculoskeletal education? Does additional clinical experience in musculoskeletal medicine improve understanding of the basic facts and concepts introduced in a second-year course? 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. Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective. 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.
From the FULL TEXT Article:
In the United States, musculoskeletal complaints are the number one reason for visits to a primary care physician.  They account for 10-28% of all visits to primary care physicians and emergency departments in North America, Europe, and Great Britain [14-16, 18, 20, 22]; yet, some investigators have reported that medical school graduates lack basic musculoskeletal knowledge. [12, 13] In a study by Freedman and Bernstein, incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country.  Eighty-two percent of students tested failed to show basic competency.  Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. [3, 25] Less than ½ of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than ¼ require a clinical course, and nearly ½ (57/122) have no required preclinical or clinical course. [1, 10] In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. [8, 18] Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system. [2, 4, 7, 9, 11-13] If more experience leads to a higher percentage of competent students, as suggested by Freedman and Bernstein,  clinical experience should increase the competence of medical students above a baseline established during a second-year course in anatomy and musculoskeletal medicine.
In a survey of more than 1900 second-year residents, many stated they left medical school poorly prepared for doing musculoskeletal examinations or providing specific evaluations and treatments for musculoskeletal problems, especially for foot pain and back pain.  Are students better trained in particular topics in musculoskeletal medicine than they are in others?
The musculoskeletal aptitude and competence exam given at the University of Pennsylvania was validated by the test results of their chief residents and by an importance ranking given by more than 100 orthopaedic program directors and 240 internal medicine program directors. [12, 13] Do the exam deficiencies on basic concepts, principles, and facts suggest a knowledge deficiency that is outside the basic information taught at the medical school level? Are the basic concepts, principles, and facts more appropriately taught in an orthopaedic surgery residency? If so, one would expect that scores on this exam would increase dramatically with each year of orthopaedic residency training, and that the scores of the first-year residents would not differ from the scores of the fourth-year medical students.
To evaluate the acquisition of musculoskeletal knowledge by medical students, we asked ourselves the following questions:
(1) do additional experiences in musculoskeletal clinical electives improve performance on an exam designed to assess basic competency in musculoskeletal medicine?
(2) breaking down the musculoskeletal curriculum by topic area, are there particular topics that are less understood by University of Washington students? and
(3) do the topics and concepts covered in a basic competency exam reflect what would be more appropriate required knowledge for an orthopaedic resident rather than for a medical student likely to go into one of many primary care fields?
Answers to these questions may help educators better understand the need to elevate medical school graduates to an adequate level of preparation in musculoskeletal medicine.
The current study examines one medical school’s experience educating its students in musculoskeletal medicine. Efficacy of the curriculum was assessed using an exam of open-ended questions previously used with a group of incoming interns at the University of Pennsylvania.  This instrument was selected because of its wide acceptance by program chairpersons in orthopaedics and internal medicine. [12, 13] The open-ended exam format was especially appealing because it tended to reduce the number of correct answers obtained through guessing and, therefore, more accurately assessed the true knowledge of those tested.
Do our students learn more musculoskeletal medicine as they gain experience in medical school? After a decrease in competency rates during the third year, in which students rotate though medicine, obstetrics and gynecology, psychiatry, pediatrics, and surgery clerkships and receive limited exposure to patients with musculoskeletal complaints, students in the spring of their fourth year (when most students have completed required rotations in physical medicine and rehabilitation along with electives in rheumatology, sports medicine, and orthopaedics) showed a better understanding of musculoskeletal information. Still, less than 50% of fourth-year students reached the minimum competency level of 70% correct on this weighted musculoskeletal exam.
Are students better trained in certain topic areas in musculoskeletal medicine? Although an item analysis identified particularly poor performance in the area of the spine, which suggested inadequate education in this area, only three of 24 questions were identified as being spine-related. Performance in the five remaining broad topic areas (general orthopaedics, trauma, sports, pediatrics, and oncology) varied little.
Are the facts and concepts tested with this exam appropriate for medical students? To answer this question, the competency of orthopaedic residents in years 1-5 of postgraduate training at the University of Washington was examined with identical forms of this test. All residents showed competency, with mean scores increasing with each year in training. This suggests that competency was achieved during the medical school years, by students with an interest in orthopaedics, and that residency in orthopaedics reinforces important musculoskeletal concepts. The discrepancy between the Internet-based survey scores for the third-year and fourth-year students and their mean Step 1 and Step 2 USMLE scores merits concern. One might expect that above-average mean scores on the musculoskeletal subtest of the USMLE Step 2 exam would suggest a high proportion of students with competency in musculoskeletal medicine. The instructors in our musculoskeletal preclinical course would certainly expect it, as ? of the class routinely receives an honors grade. Perhaps the routine use of standardized multiple-choice exams as a measure of competency, such as in our preclinical course, several musculoskeletal clerkships at the University of Washington, and the USMLE, disguises a higher level of misunderstanding than test results suggest. Freedman and Bernstein elected an open-ended response format for their original test “to eliminate the possibility of the examinee scoring points by random guessing.”  This format may have ferreted out students who incompletely understood the concept or facts but who may have been able to recognize the best answer if given enough options on a multiple choice exam.
Limitations of this study include using a test setting that was different from that used in the University of Pennsylvania study, where incoming interns were given the paper exam during their residency orientation.  The exam for this study was administered as an Internet-based survey and allowed for optimal consenting of study participants without the pressure or coercion that might have existed had the study been given during regular class time. It insured anonymity of responses and allowed students unlimited time to complete each survey. Splitting the exam into two forms of comparable difficulty reduced the time necessary to complete the task and reduced any practice effect. Drawbacks to this method of survey administration included the inability for the examiners to proctor the exams; students were on their honor to complete the surveys without assistance. Because the survey was administered as an Internet-based questionnaire through an E-mail invitation for participation, it likely contributed to low response rates, particularly for third-year and fourth-year students who frequently take clinical rotations away from Seattle.
Using a school-wide list-serve to address the E-mail invitations also may have discouraged many students from opening the messages and reading the invitation for participation, as these list-serves often are used for a wide variety of noncritical communication purposes in the School of Medicine. Also, students without access to high-speed Internet connections off-campus may have been discouraged from completing an Internet-based questionnaire because of slow system response. The low response rates also may call these results into question. How representative is a survey of a group of students when the response rate is less than 50%? Assuming that the particularly dutiful students were more likely to complete the surveys, and that dutiful students more often are better students, these results may have exaggerated the level of understanding of the average medical student at the University of Washington.
The design of this study differed in many ways from that of Freedman and Bernstein,  making comparison of results problematic. Nonetheless, our results for all fourth-year students (mean weighted score, 67% ± 17%) were similar to those of Freedman and Bernstein in their survey of 85 incoming interns (mean weighted score, 60% ± 12%).  Does more clinical experience in related areas such as rehabilitation medicine improve competency rates? The results of our study and those of Freedman and Bernstein12 show that students who took elective clinical rotations in orthopaedic surgery scored higher on the competency exams. Students most interested and already skilled in musculoskeletal medicine might have been more likely to take additional elective clinical training in this area, meaning a required orthopaedic clerkship may not necessarily achieve the same results for the average fourth-year student. There was no indication that one, 4-week required rotation in rehabilitation medicine provided enough additional clinical exposure to lead to uniform competency, nor did it make a difference in the study of interns by Freedman and Bernstein.  In our study, however, as the majority of students take the rehabilitation rotation during their fourth year, the rehabilitation clerkship likely contributed to the improvement in exam scores and competency rates for the fourth-year students when compared with third-year students’ scores.
At the University of Washington, a preclinical course in musculoskeletal medicine and a physical medicine and rehabilitation clerkship are required for graduation. Yet, less than ½ of 122 US medical schools surveyed in one study require a preclinical block in musculoskeletal medicine, and only six require a clinical rotation in physical medicine and rehabilitation; none required a clinical rotation in orthopaedics.  Reviews of residency programs in primary care fields suggested that musculoskeletal medicine was an area of low confidence for program graduates. [5, 17, 26]
Of 202 family practitioners surveyed, more than ½ stated that they had not spent enough time in orthopaedics during medical school and residency training, which was a higher percentage than identified for any other surgical subspecialty area.21 Another survey of more than 1900 second-year residents in the United States revealed that 26% of residents in allopathic residencies considered themselves ill-prepared to evaluate a patient with low back pain and 60% considered themselves ill-prepared to evaluate a patient with foot pain. 
What can we do as physicians and educators to better prepare our students in musculoskeletal medicine? Certainly a curriculum requiring a preclinical course in musculoskeletal medicine, a clerkship in rehabilitation and physical medicine, and offering clerkship electives in musculoskeletal medicine would be a good place to start. But, as shown here, that may not be enough. As the scores of the fourth-year students show, repeated exposure to the subject improves understanding and competency. More experiences in musculoskeletal medicine during the third year of medical school might measurably increase competency rates of third-year students, boosting that of fourth-year students as well. How additional musculoskeletal medicine might be integrated into the clinical years remains a challenge. The most useful experiences might be found in a community ambulatory clinic with an unscreened general orthopaedic population. Rotations at specialized, prescreened clinics at a tertiary referral center where most patients have patients with diagnoses requiring surgery may do little to introduce the future primary care physician to the most common nonoperative musculoskeletal problems. Because a large proportion of the patients seen by orthopaedic surgeons are referred from primary care providers, who make up the largest proportion of medical school graduates, it behooves us to optimize the training of these future referrers so that they are competent in basic musculoskeletal anatomy and principles. Such training would better prepare students for residencies where they refine their understanding of appropriate diagnostic and treatment strategies for common musculoskeletal complaints, most of which can and should be treated by the primary care physician.