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It's Past Time to Reform the Musculoskeletal Curriculum

Clawson, D. Kay MD; Jackson, Douglas W. MD; Ostergaard, Daniel J. MD

Institutional Issues: Commentaries

Dr. Clawson is former dean, College of Medicine, University of Kentucky, and former executive vice chancellor, Kansas University Medical Center; Dr. Jackson is an orthopedist in private practice in Long Beach, California, and former president of the American Academy of Orthopaedic Surgeons; and Dr. Ostergaard is vice president for international and interprofessional activities, American Academy of Family Physicians.

This commentary does not imply endorsement by the represented organizations.

Musculoskeletal conditions now rank number one in the nation among reasons for visits to physicians' offices, among impairments reported in the United States, and among diseases as a measure of disability.1 In 1995, musculoskeletal conditions and injuries accounted for more than 131 million patient visits to health care providers annually,2 and there is no doubt that these numbers are higher now. In 1999, the costs associated with treating these conditions were estimated to be $215 billion each year.1 In addition, many patients have been disenchanted with their care by traditional physicians and feel that practitioners who offer alternative or complementary treatments can more effectively deal with their musculoskeletal disabilities. Finally, as the U.S. population ages, more and more individuals will require care for their musculoskeletal impairments, and the costs of caring for this aging population will escalate. How well are physicians prepared to meet these challenges?

Not nearly as well as is necessary, we maintain. Our view is supported by representatives of several prominent physicians' groups (discussed below). We wrote this Commentary to present their concerns (which we share), some highlights of their research into physicians' preparedness to diagnose and treat musculoskeletal problems, and a summary of their recommendations.

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In 1997, leaders of nine U.S. national physicians' organizations* formed the Steering Committee on Collaboration among Physician Providers Involved in Musculoskeletal Care. Their common concern was the need to improve the diagnosis and treatment of musculoskeletal conditions in a cost-effective manner. The group believed that a common core of musculoskeletal knowledge among physicians would promote high-quality care and cost-effective prevention and treatment of musculoskeletal injuries and impairments.

An outgrowth of their deliberations was an attempt to learn what physicians who were entering their residencies thought of their preparation for diagnosing and treating musculoskeletal problems, and to assess how adequate they felt to handle musculoskeletal problems compared with handling conditions of other body systems. In late 1999 the steering committee mailed a questionnaire to 5,487 second-year residents in the U.S. allopathic and osteopathic residency programs. (Details of the questionnaire and the survey findings are available from the American Academy of Orthopaedic Surgeons.) Although the usable response rate was only 34.7% (a statistical analysis projected an error of 3 to 7%), the responses were suggestive and, for the most part, disturbing.

For example, when asked, “On entering residency, how would you describe your preparation/training to conduct a musculoskeletal examination to assess problems of various areas of the body,” many allopathic physicians felt poorly or very poorly prepared in most areas, ranging from 26% who felt that way for low back pain to 60% for foot pain. Those believing their preparation excellent or very good ranged from 10% for foot pain to 31% for low back pain.

In the same areas, osteopathic physicians felt their preparation to be poor or very poor ranging from 3% for back pain to 14% for foot pain. Those believing their preparation to be excellent or very good ranged from 41% for hand problems to 82% for low back pain. The fact that the osteopathic medical school graduates felt quite well prepared to assess these types of musculoskeletal problems indicates to us that it is possible to provide a musculoskeletal education in medical school that would improve the students' confidence to assess musculoskeletal problems regardless of what specialties they intend to practice.

When the residents were asked, “On entering residency, how would you describe your preparation/training to provide specific evaluations or treatments,” allopathic residents felt poorly or very poorly prepared, ranging from 24% for advising patients of the need for physical or manipulative therapy to 66% for treatment of common fractures. Those believing their preparation to be excellent to very good ranged from 9% for interpreting musculoskeletal radiographs to 27% for advising patients of the need for physical and manipulative therapy. When asked the same questions, osteopathic residents felt their preparation to be poor to very poor, ranging from 3% for assessing sports-related injuries to 40% for treating common fractures and interpreting musculoskeletal radiographs. Those feeling their preparation was excellent to very good ranged from 21% for applying a simple case, splint, or taping to 76% for assessing sports-related injuries.

These findings are similar to those of Friedman and Bernstein, who attempted to assess the adequacy of medical school education in musculoskeletal medicine. They tested 85 residents in their first graduate year using an instrument prepared by orthopedic department chairpersons throughout the United States and found that 82% of the residents failed that musculoskeletal competency examination.3 The survey also revealed that both allopathic and osteopathic residents felt less or much less prepared to evaluate musculoskeletal complaints than complaints involving other systems.

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Representatives on the steering committee agreed that the survey findings strongly suggest that medical students entering their residencies are ill prepared to deal with the more common musculoskeletal conditions. While it is possible that this deficiency could be addressed during the residency period, there is no documentation that this has been done in a way that would allow all physicians, regardless of specialty, to provide the most effective musculoskeletal treatments or to initiate appropriate referrals.

Therefore, the committee members strongly recommended that

  • ▪ a collaborative effort be carried out to assess how well physicians entering practice feel they are prepared to deal with the musculoskeletal problems they will encounter in their specialty practices;
  • ▪ the faculty and administration at U.S. medical schools should use this information, along with other sources, to re-assess the curriculum with respect to the need for more musculoskeletal education within their individual schools; and
  • ▪ because of the burden of musculoskeletal conditions to individuals and to society, medical schools should place more emphasis on these conditions so that young physicians entering their residencies will feel as well prepared to deal with such conditions as they are prepared to deal with problems found in other body systems.

We agree strongly with these recommendations. We hope that the faculty and administration of U.S. medical schools will be guided by them and other sources to re-assess their curricula regarding the need for more musculoskeletal education. With appropriate reforms, all physicians who treat patients with musculoskeletal problems will know the appropriate diagnostic and treatment interventions and how to deliver them in a cost-effective manner. Their patients will benefit, and their health care burdens on society will decrease.

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1. Praemer A, Furmer S, Rice DP. Musculoskeletal Conditions in the United States. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1999.
2. National Center for Health Statistics, National Ambulatory Medical Care Survey. Washington, DC: U.S. Government Printing Office, 1995.
3. Freedman KB, Bernstein J. The adequacy of medical education in musculoskeletal medicine. J Bone Joint Surg. 1998;80:1421–7.
© 2001 Association of American Medical Colleges