Musculoskeletal problems including both rheumatologic and orthopaedic pathologies are the primary reason for physician office visits across the United States, with approximately 92.1 million encounters reported annually, according to the 2004 National Ambulatory Medical Care Survey1. Despite the impact that musculoskeletal diseases have on society and the wide range of medical practitioners who treat these conditions, there is compelling evidence that undergraduate medical curricula do not adequately prepare physicians in musculoskeletal medicine2-5. In 2005, the Association of American Medical Colleges (AAMC) issued a Medical School Objectives Project Report on musculoskeletal medicine highlighting the need for medical schools to improve the education of future physicians in this area6. The report outlined educational guidelines to establish a more coherent undergraduate musculoskeletal curriculum.
We conducted a study at our medical school during the 2005-2006 academic year that substantiated the need for improving the musculoskeletal curriculum. Students lacked cognitive mastery, demonstrated low clinical confidence, and were dissatisfied with the amount of time spent learning musculoskeletal medicine. Findings of the study suggested the need to improve the integration of musculoskeletal medicine into the curriculum3. Data from the 2005 Step-1 United States Medical Licensing Examination at our institution also revealed that performance on the musculoskeletal section was the lowest of all the subsections. Thus, both national as well as institutional concerns prompted us to lobby for, develop, and begin implementation of a four-year integrated musculoskeletal curriculum. We focused our initial reform endeavors on the preclinical (first and second-year) curriculum.
The process of curriculum reform and development differs among various medical schools. As such, the purpose of this study was to provide a framework that may assist educators in achieving the adoption of an integrated musculoskeletal curriculum into the preclinical curriculum at their own school. We offer insight from our experience identifying the areas for improvement within an existing curriculum, using results to generate interest and garner support from faculty and administrative stakeholders, and building a consensus on the development of educational objectives. Moreover, we provide guidance about lobbying for curricular time and integrating key objectives into existing courses, tailoring course material and lectures to those objectives, and developing faculty to teach the new curriculum.
Materials and Methods
Identify the Existing Musculoskeletal Curriculum
In 2005, we examined all four years of the 2005-2006 traditional curriculum at Harvard Medical School for musculoskeletal content in each course and clinical rotation. Course objectives and syllabi for all courses were collected and assessed for their relevance to musculoskeletal education. The amount of time devoted to this topic at Harvard Medical School was compared with the national average presented by the Association of American Medical Colleges' AAMC Curriculum Directory7.
Assess Existing Musculoskeletal Curriculum
Once the existing musculoskeletal curriculum was identified, we sought to assess the effectiveness of this curriculum. In that study3, we used a nationally validated basic competency examination in musculoskeletal medicine to measure the students' cognitive mastery of the subject. Moreover, a survey was administered simultaneously to assess the students' clinical confidence and attitudes toward musculoskeletal education.
Identify Key Supporting Educators
Several senior Harvard Medical School administrators and faculty, including deans and associate deans, were contacted regarding the feasibility of administering the above survey and examination. Once institutional review board approval was obtained, the course directors from all courses were contacted for permission to administer the musculoskeletal assessment to their students. Throughout this process, key medical educators at our institution in support of our educational mission were identified.
Initiate Musculoskeletal Reform
Following the survey, the results were presented to the identified key supporting educators who developed and approved a common set of objectives. Further discussions were then initiated regarding how to incorporate these objectives into the existing curriculum.
Lobby for Course Additions
Relevant courses in the traditional curriculum where further musculoskeletal course content would be appropriate were lobbied for addition of their content. Agreed-on musculoskeletal curriculum objectives were elucidated to the relevant course directors. The time frame to address each objective effectively was also considered during these discussions.
Design Course Content
After attaining favorable responses from the course directors and specific time allocations, we considered the best methods for teaching the musculoskeletal curriculum. These methods included identification of specific areas of weaknesses in the traditional curriculum with use of assessment data8 and integration of these areas of weakness into the newly lobbied musculoskeletal course content on the basis of developed objectives.
Once the new course content had been determined, appropriate faculty members needed to be recruited to implement the curriculum. Faculty members from the Orthopaedic Surgery and Physical Medicine and Rehabilitation departments were selected on the basis of their areas of expertise as they related to the course content and, more importantly, their ability to educate effectively. Workshops and seminars educating these faculty members on teaching all medical students, most of whom will not go into orthopaedic surgery as a career, were conducted.
Following the implementation of the new musculoskeletal curriculum, the students' understanding of musculoskeletal medicine was assessed during course final examinations, which had been revised to include questions and cases related to musculoskeletal medicine. The examination questions were specifically designed to demonstrate the students' ability to apply musculoskeletal knowledge broadly.
Identify Existing Musculoskeletal Curriculum
The traditional musculoskeletal curriculum in the first-year Human Body anatomy course consisted of three hours of lecture (one hour on an overview, one hour on the upper extremity, and one hour on the lower extremity), nine hours of limb dissection, two hours of limb radiology laboratory, and 1.5 hours of histology of bone and cartilage, for a total of 15.5 hours. In the second-year Human Systems pathophysiology course, twenty-three hours of lecture were devoted to musculoskeletal medicine and twenty-one of those hours were dedicated to rheumatology and metabolic bone disease. The only orthopaedic lectures focused on bone tumors, rehabilitation, and fractures. We also identified a two-hour session involving a rheumatologic “mock patient” in the second-year Patient-Doctor II physical examination course with no other centralized clinical sessions aimed at educating students about other musculoskeletal examinations. Thus, the total amount of time traditionally dedicated to teaching musculoskeletal medicine at Harvard Medical School was 40.5 hours, well below the national average of five weeks or sixty-five hours of musculoskeletal education as reported in the AAMC Curriculum Directory7.
Assess Existing Musculoskeletal Curriculum and Identify Key Supporting Educators
Despite the limited time exposure allocated to musculoskeletal medicine, some senior medical educators at our institution raised concerns regarding the necessity of additional musculoskeletal curriculum time. Recognizing that hours spent teaching musculoskeletal medicine did not necessarily equal the education quality, we sought to assess the effectiveness of the traditional curriculum3. With the help of the Director of Harvard Medical School Center for Evaluation, the Associate Dean of Student Affairs, and the Vice Chair of the Curriculum Committee, a plan was devised to approach all four years.
We surveyed the current musculoskeletal knowledge of the students using the basic competency examination in musculoskeletal medicine that was nationally validated by Freedman and Bernstein4. Prior to completing the survey, the students also responded to a questionnaire regarding their attitudes toward musculoskeletal medicine at Harvard Medical School. In an effort to reach all students, the survey was administered online through MyCourses, an Internet portal web site that allows medical school students, staff, and faculty to access educational and administrative resources including online examinations. In addition, the survey was administered in person during board review sessions and through individual courses. We achieved an average response rate of 73% across all four years3.
Compared with a nationally validated passing threshold of 70%, only 2%, 6%, and 26% of second, third, and fourth-year students, respectively, passed the musculoskeletal competency examination3. Additionally, the students ranked musculoskeletal medicine of major importance to their future medical career and 86% of the fourth-year students suggested additional curricular time be spent on this topic3. The data from this assessment of the traditional musculoskeletal education at Harvard Medical School provided evidence that a musculoskeletal curriculum change was warranted.
Initiate Musculoskeletal Curriculum Reform
A major supporter of our educational mission was the Vice Chair of the Curriculum Committee who created a Musculoskeletal Task Force whose members shared a common interest in enhancing the curriculum and included two Society Masters, one Human Body course director, one Patient-Doctor II course director, three Patient-Doctor II site directors, one surgical clerkship director, two rheumatologists, and four orthopaedic surgeons. On examining our assessment data, the task force concluded that musculoskeletal medicine was not adequately focused and was poorly integrated at Harvard Medical School.
The group appointed the principal investigator (C.S.D.) who used established guidelines from the 2005 AAMC Medical School Objectives Project Report to develop educational objectives for a four-year musculoskeletal curriculum. Four drafts of these objectives were reviewed in February and March of 2006 by the Harvard Combined Orthopaedic Residency Program Director, the Vice Chair of the Curriculum Committee and the Patient-Doctor II course director, the entire Musculoskeletal Task Force, and finally the Patient-Doctor II faculty at nine sites. This set of objectives was named the Musculoskeletal Task Force Objectives. To incorporate the musculoskeletal curriculum into the preclinical years at Harvard Medical School, the Task Force focused on the objectives presented in Table I.
Lobbying to Add Integration Materials into Existing Courses
Once the musculoskeletal objectives for the first and second year were finalized, we surveyed the curriculum for potential sites of integration and contacted ten preclinical course directors to discuss the inclusion of musculoskeletal learning objectives into case-based tutorials, lectures, and clinical examination sessions. The 2006 Harvard Medical School Curriculum blueprint is provided in Figure 1.
We contacted the directors of the seven courses in the first-year traditional curriculum, and one agreed to incorporate musculoskeletal educational objectives. The Human Body course, an anatomy course required for all first-year medical students, added ten hours to the traditional curriculum. The new Human Body musculoskeletal curriculum included 25.5 hours with an additional six hours of limb dissection time and four hours of small-group sessions on limb surface anatomy in which a 10:1 student-faculty ratio was requested.
Five relevant courses were identified from the second-year curriculum, and we contacted the directors of three (Human Systems, a year-long pathophysiology course; Patient-Doctor II, a year-long physical diagnosis course; and Human Development) to discuss the incorporation of musculoskeletal education.
All three course directors responded with increased structured time devoted to the musculoskeletal educational objectives. We were able to have twenty-seven hours devoted specifically to musculoskeletal education. Beginning in the 2006-2007 academic year, seven hours were added to Patient-Doctor II and four hours were added to Human Development. Starting in the 2007-2008 academic year, sixteen hours were devoted to a new musculoskeletal-orthopaedics pathophysiology block in Human Systems.
Design Course Content
Course content for the preclinical years was designed to address weaknesses in the traditional musculoskeletal curriculum. In a prior study looking for specific deficiencies within musculoskeletal education, Day and Yeh8 found that Harvard Medical School students performed substantially worse on the sections of the Freedman and Bernstein examination that tested the specific anatomic regions of the lower extremity, upper extremity, and back compared with questions that dealt with more “systemic” conditions such as cancer, rheumatoid arthritis, and metabolic bone disorders. In addition, students felt inadequate in examining most anatomic regions. The mean scores were 40% and 50% for third-year and fourth-year medical students, respectively, on anatomic regions compared with 80% on systemic questions8. These issues were addressed in the design of the specific lectures and small-group tutorial sessions implemented in Human Systems and Patient-Doctor II.
The most important course topics were chosen on the basis of the Musculoskeletal Task Force Objectives. We thought that first-year students should develop an understanding of the clinically relevant anatomic structures of the musculoskeletal system as well as its function. Second-year educational objectives build on first-year knowledge and focus on clinical manifestations of common and uncommon but urgent musculoskeletal conditions. We emphasized that second-year students should also practice and feel confident performing a thorough musculoskeletal examination on adults.
Human Systems traditionally covers only dermatology, rheumatology, cardiology, and pulmonary disease. With the additional sixteen hours, a four-day musculoskeletal-orthopaedics pathophysiology block was inserted and consisted of a range of lectures given by eleven different faculty members and three small-group sessions. The lectures covered the pathophysiology of neck pain, back pain, and sciatica; the diabetic foot; fractures; orthopaedic emergencies; acquired and genetic conditions of pediatric orthopaedics; bone tumors; geriatric orthopaedics; musculoskeletal rehabilitation; overuse injuries and soft-tissue trauma; and compressive neuropathies (Table II). The three new small-group sessions entitled Reconstructive Principles of Inflammatory and Noninflammatory Joint Arthritis, Orthopaedic Emergencies, and “The Pitcher” (arm pain) achieved a 20:1 student-to-faculty ratio by recruiting twenty-seven orthopaedics faculty members equally from the four major Harvard-affiliated medical centers, a total of fifty-four faculty hours.
The second-year course Patient-Doctor II previously had only one two-hour combined session with a rheumatologic “mock patient.” The additional seven hours achieved for the 2007-2008 academic year focused on examining four major regions: the knee, back, shoulder, and hand and wrist. A twenty-minute didactic session about the examination itself was followed by a fifty-minute hands-on practical and a thirty-minute case presentation for each of the four examinations (Table III). During the case presentation, a hypothetical patient with true pathology was used for students to repeat the same physical examination on and provide a possible diagnosis on the basis of the examination. A student-to-faculty ratio of 6:1 was requested and met through the recruitment of twenty-eight faculty members for each Patient-Doctor II hands-on practical examination session for a total of ninety-three faculty hours.
The second-year Human Systems orthopaedic block was integrated with the rheumatology block by means of lectures and small-group discussions on arthritis. We were also able to establish horizontal integration with the Human Systems lectures in the morning, which were followed by Patient-Doctor II physical examination sessions in the afternoon.
Although the design of course content is vital to address the educational needs exhibited by medical students, recruiting the right faculty member to teach the students effectively is of equal importance. The Executive Committee of the Harvard Combined Orthopaedic Residency Program, comprising the chairmen of all four major orthopaedic departments of the Harvard Medical School hospitals (Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Children's Hospital Boston, and Massachusetts General Hospital), reviewed the new musculoskeletal curriculum and enthusiastically supported this endeavor. With their encouragement, orthopaedic faculty from all four hospitals readily agreed to participate in teaching the medical students. In addition, we presented data from the initial study along with the proposed musculoskeletal curricular additions at individual departmental faculty meetings held at each of the four hospitals to elicit faculty involvement.
Eighteen orthopaedics faculty members were recruited to meet a suggested 10:1 student-to-faculty ratio to teach limb surface anatomy sessions in Human Body. A 20:1 student-to-faculty ratio for the three Human Systems small groups was achieved by recruiting a total of twenty-seven orthopaedic faculty equally from the four medical centers. For each Patient-Doctor II examination, a student-to-faculty ratio of 6:1 was requested and met through the recruitment of twenty-eight faculty members. For the curricular changes that we implemented, total faculty participation hours included seventy-eight, sixty-four, four, and ninety-seven hours for Human Body, Human Systems, Human Development, and Patient-Doctor II, respectively.
Up to this point, the majority of the faculty was responsible for teaching residents or fellows in the orthopaedic surgery departments or medical students who were interested in pursuing orthopaedics, not for teaching first and second-year students. A teaching faculty orientation led by a senior medical educator (D.H.R.) on giving effective lectures and leading small-group discussions was arranged. Faculty members were encouraged to increase student learning in lectures by planning the lecture to highlight key aims and encouraging student interaction during the lectures9. Faculty members' lectures were peer-reviewed by the course director (C.S.D.) whose comments allowed instructors to focus on areas of improvement while identifying their strengths as a presenter.
Faculty training for leading small-group sessions centered on case-based teaching methods that facilitate interactive discussions. Flexibility, time-management, and efficient usage of the blackboard during these sessions were also emphasized. To aid in the preparation of cases, faculty were given suggested teaching criteria to keep in mind, such as getting to know the learners, establishing a learning agenda, focusing the learning on the needs of the students, and directing students to additional resources and further applications.
At the end of the Human Body course, students were given oral examinations to identify all structures from the skin to the bone on each limb during anatomy laboratory. A written examination was also administered to the students.
At the end of the four-day musculoskeletal-orthopaedics block in Human Systems, students were given a written examination specific to the pathophysiology of musculoskeletal conditions covered during this block. At the end of the entire Human Systems course, there was an integrated study week. Students were given multidisciplinary questions and were presented with three clinical cases covering multiple organ systems and incorporating all different pathophysiologies as a class exercise. Following the curriculum changes to this course, musculoskeletal topics were incorporated into the questions and clinical cases. In addition, during this integrated study week, orthopaedic faculty members served as consultants and discussants. Musculoskeletal topics were also incorporated into the integrated final examination, which presented complex cases similar to those presented as a class exercise during the integrated study week.
While the assessment data from the Freedman and Bernstein examination were essential in driving curricular reform, the limitation in administering the examination was that students were not graded on their performance, which may have resulted in lower reported scores. However, a nationally validated examination was necessary as the initial assessment instrument to achieve credibility and national comparison, especially since no other similar assessment tool existed at the time. After a comprehensive assessment of the Harvard Medical School curriculum on musculoskeletal medicine was conducted, consensus was reached to enhance musculoskeletal teaching across all four years of the medical school experience and a curriculum in musculoskeletal medicine was created.
Despite differences across curricula, integration of these established education objectives can also be accomplished at other institutions. Our approach was unique in that the curricular changes involved the collaboration of multiple courses from both the first and second years. Saleh et al., at the University of Minnesota, addressed the fragmentation of musculoskeletal education through the creation of a single integrated multidisciplinary musculoskeletal disease course in which faculty from the departments of Anatomy, Orthopaedics, Rheumatology, and Physical Medicine and Rehabilitation contributed to the content of a single course10. While the creation of a single integrated course might facilitate the coordination of learning objectives as well as faculty teaching, the use of a longitudinal approach carries the advantage of reinforcing and building on prior course material.
The methodology we used to implement curricular change employed several underlying concepts for successful curricular reform that were established by Bland et al.11. The three major features are “context,” “curriculum,” and “process.” Our institution was undergoing a substantial overall preclinical reform of the curriculum at the time of our proposal, and this “context” likely contributed to its reception, as our efforts aligned with institutional goals. Stakeholder buy-in, both in terms of internal support (backing by the Vice Chair of the Curriculum Committee) and external support (the AAMC report on musculoskeletal medicine and the national declaration of 2002-2011 as the U.S. Bone and Joint Decade), was favorable as well. By contacting individual course directors, we tailored our efforts at longitudinal integration according to our institution's organizational structure.
For “curriculum,” we were able to demonstrate a need for change through our assessment of the existing curriculum. With the results from the Freedman and Bernstein examination, we showed that the need was not trivial and we established a concrete set of educational objectives to organize and present our proposal.
Our “process” involved gathering key institutional members in the creation of the Musculoskeletal Task Force and meeting with course directors to discuss our findings as well as the proposed objectives. The development of human resources by generating support from the orthopaedics faculty was facilitated by support of the four orthopaedic department chairmen.
One of the most important factors that determine the success of institutional change is leadership11. As our medical school has a relatively dispersed power structure, the leadership style must cater to varied and unique institutional needs. To create the appropriate conditions for reform, one of us (C.S.D.) spent a considerable amount of time and effort to generate enough interest and support for the reform of the musculoskeletal curriculum by using concrete data to persuade educators about the need for improvement, by obtaining support from the curriculum committee (political currency), and by establishing shared interest in working toward the overarching institutional goal of improving medical education. Concurrently, it was important for our efforts to be championed by a senior educator (R.A.) who helped to establish and maintain momentum by providing a strong voice within our institution.
The development of an integrated musculoskeletal curriculum within the medical school curriculum can be an effective way to address the need for newly trained physicians to be knowledgeable about the growing demand and burden of musculoskeletal conditions on society. Medical educators involved in all aspects of musculoskeletal medicine should take the initiative to ensure that students are adequately trained in this interdisciplinary field. Future directions in this project consist of evaluating the effectiveness of the new curriculum and refining the newly integrated musculoskeletal curriculum through direct student and faculty assessment and feedback.
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.