Congratulations to the chiropractic profession for having the highest level of musculoskeletal competence; but now the time has come to move from competence to excellence.

Integrative Orthopedics reviews history taking, physical examination, and treatment for nearly every outpatient condition that will be encountered in clinical practice.  Integrative Rheumatology reviews more details in laboratory tests, functional assessments, and detailed protocols for the treatment of systemic autoimmune diseases. Emergency conditions are also reviewed so that clinicians will know how to recognize urgent conditions, such as acute compartment syndrome, cauda equina syndrome, and atlantoaxial instability.  See the Orthopedics index and the Rheumatology index for detailed listings of topics that are reviewed, then order your copies now so that you and your patients can begin benefiting from this information.

Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates.

Stockard AR, Allen TW.  Virginia College of Osteopathic Medicine, 2265 Kraft Dr, Blacksburg, VA 24060-6360, USA.

BACKGROUND: Consistent with osteopathic principles and practice, the nation's colleges of osteopathic medicine (COMs) have emphasized the significance of the musculoskeletal system to the practice of medicine. The authors hypothesized that graduating COM students would, therefore, demonstrate superior knowledge and competence in musculoskeletal medicine when compared with graduates of allopathic medical schools. METHODS: The authors asked graduating COM students to complete a standardized and previously validated 25-question basic competency examination on musculoskeletal medicine in short-answer format. Originally developed and validated in the late 1990s, the examination was distributed to allopathic medical residents at the beginning of their residencies. The authors compare their results with those reported by Freedman and Bernstein for allopathic residents. RESULTS: When the minimum passing level as determined by orthopedic program directors was applied to the results of these examinations, 70.4% of graduating COM students (n=54) and 82% of allopathic graduates (n=85) failed to demonstrate basic competency in musculoskeletal medicine. Similarly, the majority of both groups failed to attain the minimum passing level established by the directors of internal medicine programs (graduating COM students, 67%; allopathic graduates, 78%). CONCLUSION: In an examination of competence levels for musculoskeletal medicine, students about to graduate from a COM fared only marginally better than did their allopathic counterparts. To ensure that all graduating COM students have attained a level of basic competence in musculoskeletal medicine, the authors recommend further study as a prelude to evaluation of the didactic and clinical curriculum at all 22 COMs and their branch campuses.

 

 
More Evidence of Educational Inadequacies in Musculoskeletal Medicine.

Schmale GA.  From the Children's Hospital and Regional Medical Center, University of Washington, Seattle, WA.

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.

 
The adequacy of medical school education in musculoskeletal medicine.

Freedman KB, Bernstein J.  University of Pennsylvania School of Medicine, Philadelphia, USA.

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.

 
Educational deficiencies in musculoskeletal medicine.

Freedman KB, Bernstein J. University of Pennsylvania School of Medicine, Philadelphia, 19104, USA.

BACKGROUND: We previously reported the results of a study in which a basic competency examination in musculoskeletal medicine was administered to a group of recent medical school graduates. This examination was validated by 124 orthopaedic program directors, and a passing grade of 73.1% was established. According to that criterion, 82% of the examinees failed to demonstrate basic competency in musculoskeletal medicine. It was suggested that perhaps a different passing grade would have been set by program directors of internal medicine departments. To test that hypothesis, and to determine whether the importance of the individual questions would be rated similarly, the validation process was repeated with program directors of internal medicine residency departments as subjects. METHODS: Our basic competency examination was sent to all 417 program directors of internal medicine departments in the United States. Each recipient was mailed a letter of introduction explaining the purpose of the study, a copy of the examination, and our answer key and scoring guide. There was no mention of the results of the first study. The subjects were requested to rate the importance of each question on the same visual analog scale, ranging from "not important" to "very important," as had been used by the orthopaedic program directors. These ratings were converted into numerical scores. The program directors were also asked to suggest a passing score for the examination, and this score was used to assess the examinees' performance on the examination. The results on the basis of the internal medicine program directors' responses and those according to the orthopaedic program directors' responses were compared. RESULTS: Two hundred and forty (58%) of the 417 program directors of internal medicine residency departments responded. They suggested a mean passing score (and standard deviation) of 70.0% +/- 9.9%. As reported previously, the mean test score of the eighty-five examinees was 59.6%. Sixty-six (78%) of them failed to demonstrate basic competency on the examination according to the criterion set by the internal medicine program directors. The internal medicine program directors assigned a mean importance score of 7.4 (of 10) to the questions on the examination compared with a mean score of 7.0 assigned by the orthopaedic program directors. The internal medicine program directors gave twenty-four of the twenty-five questions an importance score of at least 5 and seventeen of the twenty-five questions an importance score of at least 6.6. CONCLUSIONS: 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.

 
Adequacy of education in musculoskeletal medicine.

Matzkin E, Smith EL, Freccero D, Richardson AB. University of Hawaii and Tripler Army Medical Center, Honolulu 96859, USA.

BACKGROUND: Basic musculoskeletal knowledge is essential to the practice of medicine. A validated musculoskeletal cognitive examination was given to medical students, residents, and staff physicians in multiple disciplines of medicine to assess the adequacy of their musculoskeletal medicine training. METHODS: The examination was given to 334 volunteers consisting of medical students, residents, and staff physicians. Analysis of the data collected and comparisons across disciplines were performed. RESULTS: The average cognitive examination score was 57%. Sixty-nine participants (21%) obtained a score of >/=73.1%, the recommended mean passing score. Of the sixty-nine with a passing score, forty (58%) were orthopaedic residents and staff physicians with an overall average score of 94%. Differences in the average scores for the orthopaedic residents compared with all other specialties were significant (p < 0.001). The average score was 69% for the 124 participants who stated that they had taken a required or an elective course in orthopaedics during their training compared with an average score of 50% for the 210 who had not taken an orthopaedic course (p < 0.001). When the scores of those in orthopaedics were excluded, the average score for the participants who had taken an orthopaedic course was 59%; this difference remained significant (p < 0.001). CONCLUSIONS: Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination. This suggests that training in musculoskeletal medicine is inadequate in both medical school and nonorthopaedic residency training programs. Among the nonorthopaedists, scores were significantly better if they had taken a medical school course or residency rotation in orthopaedics, suggesting that a rotation in orthopaedics would improve the general level of musculoskeletal knowledge.