While chiropractic doctors address a wide range of health concerns
and disorders in their clinical practices, the profession as a whole
and our formal training obviously emphasize musculoskeletal
diagnosis and treatment. This is appropriate, given that
musculoskeletal disorders are a major burden to individual patients
and the health care system as a whole.1 Since several of
the drug interventions generally employed by allopaths appear to
accelerate joint destruction2-4 and result in more than
100,000 hospitalizations and well over 16,000 deaths per year,5-7
and since some surgical procedures for musculoskeletal pain are not
more effective than placebo or conservative treatment,8-10
the chiropractic profession’s contribution to public health by the
provision of safe and effective nonpharmacologic and nonsurgical
management of musculoskeletal pain is important. With these and
other considerations in mind, the assessment of competence and
comparative competence among front-line health care professionals is
a worthy area of investigation.
The standardized musculoskeletal competency examination was
initially developed and published by Freedman and Bernstein in their
landmark study published in Journal of Bone and Joint Surgery
in October 1998.11 The test has been validated by a
nationwide survey of hospital residency chairs in orthopedics and
internal medicine. The test consists of 25 open-ended, short-answer
questions that survey general orthopedic diagnoses and management on
topics such as acute compartment syndrome, septic arthritis,
scaphoid fracture and lateral epicondylitis. A minimum score of
70%-73% is required for passing.
Just like the original study by Freedman and Bernstein, all
follow-up confirmation studies assessing medical “allopathic”
competence by this validated and standardized examination have shown
that medical school preparation in musculoskeletal medicine is
inadequate and that the vast majority of medical graduates are
incompetent in basic musculoskeletal diagnosis and management.12-16
Generally, these articles have demonstrated that only 20%-30% of
medical graduates are competent in basic musculoskeletal knowledge.
Stated differently, 70%-80% of medical graduates are incompetent in
basic musculoskeletal knowledge, as assessed by this peer-reviewed
and well-researched competency examination. These results are
consistent and reproducible from different study populations and are
thus probably generalizable to the medical profession as a whole.
Until recently, the question remained: “How well would
chiropractic seniors and clinicians perform on this same test of
musculoskeletal competence?” That question was partially answered in
January 2007 by Humphreys, et al.,17 who administered the
standardized musculoskeletal competency examination to 123
chiropractic seniors and 10 experienced clinicians. In contrast to
the 20%-30% success rate achieved by medical students and doctors,
the overall chiropractic success rate (51%-64%) was double or triple
that seen among allopathic and osteopathic graduates. The
chiropractic group showed a 64% success rate using a minimal passing
score of 70%, and a 51% success rate using a minimal score of 73%.
The 10 chiropractic clinicians demonstrated a 100% success rate.
Thus, the performance of this small group of chiropractic doctors
far outshone the results seen among 85 medical doctors working as
first-year hospital residents in surgery, medicine and orthopedics;
these medical doctors had only a 30% success rate.11
While additional data from other chiropractic colleges and from
larger groups of chiropractic clinicians is necessary before firm
and generalized conclusions can be drawn, these results suggest that
chiropractic training in musculoskeletal medicine as evaluated by a
“medical” standardized and validated competency examination is
clearly more thorough and more effective in ensuring minimal
competence among chiropractic graduates than are the comparable
educational programs utilized in allopathic medical schools. The
well-documented and consistently high rate of incompetence in
musculoskeletal medicine among medical graduates and clinicians is a
cause for concern and has implications for state and national public
health policies, as well as insurance reimbursement schedules.
Likewise and conversely, the consistent demonstration of
chiropractic superiority in this field should foster enhanced
utilization of and access to chiropractic clinical services.
However, while these latest findings suggest chiropractic
superiority in musculoskeletal competence, the findings also suggest
we in the chiropractic profession still have a lot of room for
improvement within our own educational programs. The standardized
musculoskeletal competency examination assesses only fundamental,
basic, minimal competence. It is a very weak “standard,” and the
chiropractic profession should set its sights for the attainment of
mastery and excellence, not the achievement of minimal competence.
To foster the achievement of this goal and high educational
standards in general, I publicized a list of more than 50
competencies and 100 questions18 that are reflective of
modern integrative chiropractic orthopedics19 and that
surpass the elementary competence reflected by the standardized
musculoskeletal competency examination.20
Given that the drug-surgical treatments employed by allopaths
cause an estimated 180,000-225,000 iatrogenic deaths per year in
America (range: 493-616 iatrogenic medical deaths per day), result
in millions of injuries, and cost more than $136 billion per year in
drug-induced adverse effects,21-22 the chiropractic
profession should not be satisfied with succeeding at the goal of
parity with the medical profession. Chiropractic clinical standards
must never be lower than allopathic standards. We are capable of far
better than that, and our patients deserve the best we can give
them.
[1] Woolf A, Pfleger B. Burden of major musculoskeletal. conditions.
Bulletin of the World Health Organization 2003;81:646-656 http://www.who.int/entity/bulletin/volumes/81/9/Woolf.pdf
[2] “At…concentrations comparable to those… in the synovial fluid of
patients treated with the drug, several NSAIDs suppress proteoglycan
synthesis… These NSAID-related effects on chondrocyte metabolism …
are much more profound in osteoarthritic cartilage than in normal
cartilage, due to enhanced uptake of NSAIDs by the osteoarthritic
cartilage.” Brandt KD. Effects of nonsteroidal anti-inflammatory
drugs on chondrocyte metabolism in vitro and in vivo. Am J Med. 1987
Nov 20; 83(5A): 29-34
[3] “This highly significant association between NSAID use and
acetabular destruction gives cause for concern, not least because of
the difficulty in achieving satisfactory hip replacements in
patients with severely damaged acetabula.” Newman NM , Ling RS.
Acetabular bone destruction related to non-steroidal
anti-inflammatory drugs. Lancet. 1985 Jul 6; 2(8445): 11-4
[4] Vidal y Plana RR, Bizzarri D, Rovati AL. Articular cartilage
pharmacology: I. In vitro studies on glucosamine and non steroidal
antiinflammatory drugs. Pharmacol Res Commun. 1978 Jun;10(6):557-69
[5] “Conservative calculations estimate that approximately 107,000
patients are hospitalized annually for nonsteroidal
anti-inflammatory drug (NSAID)-related gastrointestinal (GI)
complications and at least 16,500 NSAID-related deaths occur each
year among arthritis patients alone. The figures for all NSAID users
would be overwhelming, yet the scope of this problem is generally
under-appreciated.” Singh G. Recent considerations in nonsteroidal
anti-inflammatory drug gastropathy. Am J Med. 1998;105(1B):31S-38S
[6] Topol EJ. Failing the public health--rofecoxib, Merck, and the
FDA. N Engl J Med. 2004 Oct 21;351(17):1707-9
[7] David J. Graham, MD, MPH, (Associate Director for Science,
Office of Drug Safety, US FDA) estimated that 139,000 Americans who
took Vioxx suffered serious side effects; he estimated that the drug
killed between 26,000 and 55,000 people. http://www.commondreams.org/views05/0223-35.htm
http://www.fda.gov/cder/drug/infopage/vioxx/vioxxgraham.pdf Accessed
November 25, 2006
[8] Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA,
Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled
trial of arthroscopic surgery for osteoarthritis of the knee. N Engl
J Med. 2002;347:81-8
[9] Bernstein J, Quach T. A perspective on the study of Moseley et
al: questioning the value of arthroscopic knee surgery for
osteoarthritis. Cleve Clin J Med. 2003;70(5):401, 405-6, 408-10
[10] “These findings suggest that in most cases there is no clear
reason to advocate strongly for surgery apart from patient
preference.” Carragee E. Surgical treatment of lumbar disk
disorders. JAMA. 2006 Nov 22;296(20):2485-7
[11] Freedman KB, Bernstein J. The adequacy of medical school
education in musculoskeletal medicine. J Bone Joint Surg Am.
1998;80(10):1421-7
[12] Freedman KB, Bernstein J. Educational deficiencies in
musculoskeletal medicine. J Bone Joint Surg Am. 2002;84-A(4):604-8
[13] Joy EA, Hala SV. Musculoskeletal Curricula in Medical
Education: Filling In the Missing Pieces. The Physician and
Sportsmedicine. 2004; 32: 42-45
[14] Matzkin E, Smith ME, Freccero CD, Richardson AB. Adequacy of
education in musculoskeletal medicine. J Bone Joint Surg Am. 2005
Feb;87-A(2):310-4
[15] Schmale GA. More evidence of educational inadequacies in
musculoskeletal medicine. Clin Orthop Relat Res. 2005
Aug;(437):251-9
[16] Stockard AR , Allen TW. Competence levels in musculoskeletal
medicine: comparison of osteopathic and allopathic medical
graduates. J Am Osteopath Assoc. 2006 Jun;106(6):350-5
[17] Humphreys BK, Sulkowski A, McIntyre K, Kasiban M, Patrick AN.
An examination of musculoskeletal cognitive competency in
chiropractic interns. J Manipulative Physiol Ther. 2007
Jan;30(1):44-9
[18] For samples of suggested competencies, see
http://optimalhealthresearch.com/competencies.html
and download the PDF document of more than 100 questions and
competencies.
[19] Vasquez A. Integrative Orthopedics, Second Edition 2007.
http://optimalhealthresearch.com/orthopedics.html
[20] Hammer W. Test Yourself on Med School Musculoskeletal
Education. Naturopathy Digest
http://www.naturopathydigest.com/archives/2006/may/hammer.php
[21] “Recent estimates suggest that each year more than 1 million
patients are injured while in the hospital and approximately 180,000
die because of these injuries. Furthermore, drug-related morbidity
and mortality are common and are estimated to cost more than $136
billion a year.” Holland EG, Degruy FV. Drug-induced disorders. Am
Fam Physician. 1997 Nov 1;56(7):1781-8, 1791-2
[22] "These total to 225,000 deaths per year from iatrogenic
causes." Starfield B. Is US health really the best in the world?
JAMA. 2000 Jul 26;284(4):483-5
