KEVIN B. FREEDMAN, M.D. and JOSEPH BERNSTEIN, M.D., M.S., PHILADELPHIA, PENNSYLVANIA
Investigation performed at the
University of Pennsylvania School of Medicine, Philadelphia
A basic familiarity with musculoskeletal disorders is essential for all medical school graduates. The purpose of the current study was to test a group of recent medical school graduates on basic topics in musculoskeletal medicine in order to assess the adequacy of their preparation in this area. A basic-competency examination in musculoskeletal medicine was developed and validated. The examination was sent to all 157 chairpersons of orthopaedic residency programs in the United States, who were asked to rate each question for importance and to suggest a passing score. To assess the criterion validity, the examination was administered to eight chief residents in orthopaedic surgery.
The study population comprised all eighty-five residents who were in their first postgraduate year at our institution; the examination was administered on their first day of residency. One hundred and twenty-four (81 per cent) of the 154 orthopaedic residency-program chairpersons who received the survey responded to it. The chairpersons rated twenty-four of the twenty-five questions as at least important. The mean passing score (and standard deviation) that they recommended for the assessment of basic competency was 73.1 ± 6.8 per cent. The mean score for the eight orthopaedic chief residents was 98.5 ± 1.07 per cent, and that for the eighty-five residents in their first postgraduate year was 59.6 ± 12 per cent. Seventy (82 per cent) of the eighty-five residents failed to demonstrate basic competency on the examination according to the chairpersons’ criterion. The residents who had taken an elective course in orthopaedic surgery in medical school scored higher on the examination (mean score, 68.4 per cent) than did those who had taken only a required course in orthopaedic surgery (mean score, 57.9 per cent) and those who had taken no rotation in orthopaedic surgery (mean score, 55.9 per cent) (p = 0.005 and p = 0.001, respectively). In summary, seventy (82 per cent) of eighty-five medical school graduates failed a valid musculoskeletal competency examination. We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.
From the Full-Text Article:
Second only to upper respiratory illness, musculoskeletal symptoms are the most common reason that patients seek medical attention [12, 16] accounting for approximately 20 per cent of both primary-care and emergency-room visits. [5, 6, 8, 11, 15] Musculoskeletal problems were reported as the reason for 525 (23 per cent) of 2285 visits by patients to a family physician , and musculoskeletal injuries accounted for 1539 (20 per cent) of 7840 visits to the emergency room.  The delivery of musculoskeletal care is spread across a spectrum of practitioners, including not only orthopaedic surgeons but also internists, family physicians, and pediatricians, among others. Moreover, under the so-called gatekeeper model that is prevalent in managed-care systems, physicians other than orthopaedic surgeons will provide an expanding share of this musculoskeletal care. Mastery of the basic issues in musculoskeletal medicine is therefore essential for all medical school graduates.
Despite the imperative for education, there may be a marked disparity between the frequency of musculoskeletal problems seen in medical practice and the adequacy of preparation in musculoskeletal medicine. In one study, 129 (51 per cent) of 255 family-practice physicians subjectively reported that their training in orthopaedics had been inadequate for their current practice.  In another survey, pediatric residents identified orthopaedics as first among the areas in which they believed that their education had been inadequate.  Several studies also have identified deficiencies in the orthopaedic physical-examination skills of medical students and primary-care physicians. [2, 4, 7, 9] Fowler and Regan found that only three (6 per cent) of forty-nine patients who had a chronic tear of the anterior cruciate ligament had been diagnosed properly by their primary-care physician. Ahern et al. reported that only seventeen (10 per cent) of 166 medical inpatients had had a musculoskeletal examination despite the fact that sixty-seven (40 per cent) had had a documented history of musculoskeletal symptoms on admission. These findings suggest that general practitioners may be inappropriately managing patients who have common orthopaedic problems.
Medical school is usually the primary source of formal education with regard to the musculoskeletal system. For 147 (56 per cent) of 264 primary-care physicians who were surveyed, medical school was the only source of formal instruction on the musculoskeletal system.  We conjectured that medical school training in musculoskeletal medicine may nonetheless be inadequate. To test this hypothesis, we constructed and validated an examination that we believed evaluated basic competency in musculoskeletal medicine. The examination then was administered to eighty-five recent medical school graduates.
Given the high prevalence of orthopaedic problems that are encountered in clinical practice, the importance of basic competency in musculoskeletal medicine for all physicians cannot be disputed. Nevertheless, seventy (82 per cent) of eighty-five medical school graduates from thirty-seven different schools failed to demonstrate such competency on a validated examination of fundamental concepts.
The examination questions were validated with use of several criteria. One hundred and twenty-four chairpersons of orthopaedic surgery residency programs in the United States reviewed the questions and rated the importance of each question for all medical school graduates. Twenty-four of twenty-five questions were rated as important to highly important, and the mean recommended passing grade was 73.1 per cent. These data established the content validity of the examination. In addition, the eight orthopaedic chief residents achieved a mean score of 98.5 per cent, thereby establishing the criterion validity.
The current study clearly documents the inadequacy of medical school education with regard to musculoskeletal medicine. The duration of the residents’ preparation in this area was inadequate. For the study population as a whole, the mean duration of instruction in orthopaedics was only 2.1 weeks. In addition, twenty-eight residents (33 per cent) had graduated from medical school with no rotation, required or elective, in orthopaedic surgery; these residents had the lowest mean score (55.9 per cent) on the examination and the highest rate of failure (93 per cent).
Devotion of more time in medical school to rotations in orthopaedic surgery was associated with a better performance on the examination. Residents who had taken an elective course in orthopaedic surgery in medical school (mean duration, 5.6 weeks) had a significantly higher mean score (p = 0.001) on the examination. However, those who had taken a required course in orthopaedic surgery in medical school were not found to have a significantly higher mean score than those who had not, perhaps because the standard required course was too brief for the essential information to be conveyed.
Because additional instructional time alone was insufficient to guarantee a passing score on the competency examination (the mean score for the residents who had taken an elective course in orthopaedic surgery was still lower than the chairpersons’ recommended passing score), we believe that there is a problem with regard to course content as well. Perhaps the elective courses were too narrowly focused. In our experience, many elective rotations stress inpatient experiences in highly specialized areas of orthopaedic surgery rather than common outpatient problems.