Day, Charles S. MD; Ahn, Christine S.
Dr. Day is assistant professor, Department of Orthopedic Surgery, and director of the orthopedic curriculum, Harvard Medical School, Boston, Massachusetts, and chief of hand and upper extremity surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Ms. Ahn is a graduate, Harvard College, Cambridge, Massachusetts, and research assistant, Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center.
Correspondence should be addressed to Dr. Day, Harvard Medical School, 330 Brookline Avenue, Stoneman 10, Boston, MA 02215; telephone: (617) 667-3940; fax: (617) 667-2155; e-mail: email@example.com.
Medical schools in the United States have continued to demonstrate deficiencies in musculoskeletal education. In response to the findings of numerous studies and to the objectives of the U.S. Bone and Joint Decade (an international collaborative movement sanctioned by the United Nations and the World Health Organization for the purpose of promoting awareness of musculoskeletal disease), several institutions, including Harvard Medical School, have reassessed the preclinical musculoskeletal curriculum at their respective medical schools. A cross-sectional survey at Harvard in 2004 found that students lacked clinical confidence in dealing with the musculoskeletal system. In addition, only one quarter of the graduating class of medical students passed a nationally validated exam in basic musculoskeletal competency. In 2005, 33 total hours of musculoskeletal medicine were added to the musculoskeletal blocks of the preclinical anatomy, pathophysiology, and physical examination courses. Alongside this movement toward more musculoskeletal education, there has been continued debate over the relevance and cost-effectiveness of cadaveric and surface anatomy labs. With the advent of advanced imaging technology, some argue that dissection anatomy is outdated and labor-intensive, whereas three-dimensional images are more accessible and time-effective for today's students. However, knowledge of anatomy is a critical foundation to learning musculoskeletal medicine. Thus, making room for more musculoskeletal curriculum time by cutting out cadaveric anatomy labs may ultimately be counterproductive.
In the United States, musculoskeletal conditions were the primary reason for visits to physicians' offices in 1995,1 and more than 30% of the U.S. population sought medical care for musculoskeletal conditions in 1999.2 The current associated annual costs of musculoskeletal care now approach $849 billion, or 7.7% of the U.S. gross domestic product.3 As the population ages, the prevalence and costs of bone and joint diseases are only expected to increase. Thus, now more than ever, musculoskeletal knowledge is important in the fields of internal medicine, family practice, emergency medicine, geriatrics, and pediatrics, in addition to specialties such as rheumatology and orthopedics.
Deficiency in musculoskeletal education has been demonstrated in medical schools in the United States and Canada.4–6 Medical students' lack of knowledge of and clinical confidence in the musculoskeletal system has been partially attributed to the fact that insufficient time is dedicated to musculoskeletal medicine. Of the 122 medical schools existing in the United States in 2003, less than 50% required preclinical courses in musculoskeletal medicine, and less than 25% required a clinical course; nearly 50% had no required course, preclinical or clinical.7 In a 2001 report on Canadian medical schools, the average mandatory musculoskeletal education represented 2.26% of the average medical school curriculum, and only 30% of the schools provided mandatory exposure to musculoskeletal medicine in a clinical setting.6 In 2000, at 21 medical schools in the United Kingdom, only 2% of the clinical years was devoted to trauma and orthopedic surgery.8
A cross-sectional survey conducted at our institution, Harvard Medical School (HMS), in 2004 assessed clinical confidence, cognitive mastery, and attitudes toward musculoskeletal education.5 The results of this survey showed that, despite students' acknowledgment of the importance of musculoskeletal education, students lacked both clinical confidence in performing musculoskeletal examinations as well as cognitive mastery of basic musculoskeletal concepts. On average, the HMS students rated their clinical confidence as inadequate to poor, and only 2%, 7%, and 26% of second-, third-, and fourth-year medical students, respectively, passed a nationally validated musculoskeletal competency examination.5
Task Force Reform Efforts
In response to these findings, a musculoskeletal task force and relevant course directors embarked on an effort to reform the musculoskeletal curriculum at HMS. The group lobbied for additional class hours, and the school recruited additional faculty members, steps that ultimately resulted in the integration of musculoskeletal learning objectives into three preclinical courses: anatomy, pathophysiology, and physical examination. The new curriculum, which HMS implemented in 2006, consisted of an additional 10 hours of mandatory class time in the first-year anatomy course: These 10 hours were divided into 6 hours of limb dissection and 4 hours of small-group sessions on limb surface anatomy. The second-year pathophysiology course incorporated an additional 16 hours for a musculoskeletal orthopedics block. The new course consisted of lectures and small-group sessions on topics such as back pain, tendonitis, compartment syndrome, and peripheral neuropathies. These classes were taught by 11 faculty members. The second-year physical examination course, which had originally consisted of only a 2-hour combined session with a rheumatologic “mock patient,” incorporated an additional 7 hours. This additional time allowed for the study of four anatomic regions—the knee, the back, the shoulder, and the hand and wrist—each of which was covered in a three-part structure, consisting of a 20-minute lecture, a 50-minute hands-on practical, and a 30-minute case presentation.9
The Importance of Anatomy
Over the past few decades, the emphasis for anatomy sessions has shifted from hands-on dissection in laboratories to the analysis of digital images on a computer. Proponents of learning by these new teaching tools believe that much of the traditional anatomy curriculum is now irrelevant to medical practice and that it often can be unnecessarily time-consuming. This may be true in certain clinical scenarios because of the advancements in radiologic diagnostic tests, but this approach cannot be applied to all aspects of medical care.
Without a strong anatomical foundation, it is difficult to teach students how to perform musculoskeletal physical examinations and to instruct them in the pathophysiology of musculoskeletal diseases. The use of computerized images, no matter how clear and colorful or how limitless the zoom function, can never equal the sense of touch involved in cadaveric and surface anatomy. Knowledge of internal cadaveric anatomy is critical to a full understanding of surface anatomy during palpation. How can we teach the McMurray test for meniscal injuries when students are unable to palpate for the meniscus at the joint of the knee? During the past 30 years, there have been continuous reductions in the time and teaching staff allocated to dissection in anatomy courses, and numerous studies indicate that knowledge may now be below acceptable levels. With physicians reporting inadequate confidence in musculoskeletal medicine, and with a sevenfold increase in legal claims associated with anatomical errors in the United Kingdom, as reported by Ellis10 in 2002, it has become increasingly apparent that doctors are not meeting the expectations of their patients.
Even more compelling may be the call from medical students themselves for more training in anatomy. In a study of the attitudes toward anatomical dissection on the part of students at a medical school in Ireland, despite the negative impact of both physical and psychological effects associated with experiences in cadaver dissection labs, an overwhelming majority of student respondents (77%) rated dissecting rooms as very or extremely important to their medical education, and 42% reported that not enough time was spent in the dissecting room.11 This attitude has been further confirmed in the musculoskeletal curriculum evaluation at HMS. After the 2007–2008 pathophysiology musculoskeletal block, second-year students had the opportunity to complete a course evaluation that provided space in which to comment on any of the course's weaknesses. Responding students focused on one specific area of weakness. Four of their comments follow:
* It was very difficult to learn a lot of the [musculoskeletal] material with [a] poor anatomy background in orthopedics.
* Anatomy must be better taught at this medical school for this [musculoskeletal] course to have any value.
* Not knowing anatomy is not very conducive to understanding [musculoskeletal] pathology.
* We are coming into this [musculoskeletal] course with a limited knowledge of limb anatomy from first year. Improving anatomy will help a lot with this course.
Course directors found that nearly three- quarters of the students' comments pointed directly to inadequate knowledge of anatomy as a major obstacle to their understanding of the musculoskeletal material in the preclinical courses. Musculoskeletal medicine is a field that particularly relies on a foundation of knowledge of both internal and surface anatomy. Course directors, curriculum developers, and students alike seem to agree on one thing, succinctly stated by one of the students on the evaluation: “Unless we know anatomy better, four days of orthopedics is never going to be sufficient.”
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