Sports Medicine Curricular Recommendations for Undergraduate Medical Education

Abstract

Sports medicine is a unique field encompassing many specialties and aspects of medicine. While musculoskeletal medicine is a significant aspect of sports medicine, the breadth of sports medicine extends beyond the musculoskeletal system and includes the spectrum of care for the patient who is or desires to be physically active. This article provides recommendations for sports medicine education in undergraduate medical education. The framework highlighting these recommendations uses domains of competence. Entrustable professional activities, measures that are endorsed by the Association of American Medical Colleges, were matched to domains of competence to provide objective markers of achievement. In addition to recommended sports medicine educational content, there should be consideration of both methods of assessment and implementation catered to each individual institution’s needs and resources. These recommendations may serve as a guide for medical educators and institutions pursing optimization of sports medicine education.

Introduction

An appropriate breadth of experience during undergraduate medical education (UME) is important in the overall training and education of every physician. Sports medicine (SM) education, including musculoskeletal (MSK) education, within the UME curriculum at most medical institutions constitutes a minority of the focus when compared with other organ systems (¹). The downstream effects of this decreased emphasis are seen in studies demonstrating poor knowledge and confidence in the provision of SM care among physicians (^2–10). Medical students and residents report a lack of confidence in their mastery of MSK medicine (^6–8). A prior study reported 82% of medical school graduates failed a validated MSK examination (¹⁰).

Health care visits for MSK disorders rank second only to visits for routine primary care, such as well-child checks and physicals (¹¹). MSK disorders are the leading cause of disability in the country, and in 2013, 19% of health care visits were for MSK conditions (¹¹). The Accreditation Council for Graduate Medical Education (ACGME) 2022 residency match data reports that primary care specialties (family medicine, internal medicine, pediatrics, and combination programs) offered nearly 50% of the first-year residency positions, and another 11% of first-year residency spots were filled by graduating medical students entering other specialties that routinely care for these conditions (emergency medicine, physical medicine and rehabilitation, and orthopedics) (^12,13); given this information, it is important to ensure adequate MSK education for future physicians during their medical training.

The spectrum of SM encompasses evaluation and treatment of all organ systems, conditions, and injuries in the active individual, as well as application of physiology and exercise science to optimize physical activity, health, and well-being for all patients. Appropriate and safe exercise can prevent chronic disease and improve conditions, such as obesity, diabetes, and cardiovascular disease (¹⁴). As there are numerous health benefits to patients engaging in exercise, from disease prevention to disease reduction, it is important for all medical students to receive ample education in exercise medicine (¹⁵). Awareness of disparities, which may impact the health of the SM patient, is important for effective care and optimizing treatment plans (^16,17).

To address the SM knowledge needs of physicians in various specialties, formal recommendations have been published that provide a guide for resident specialty-specific expectations (^18–22). However, to date, there are no formal recommendations for medical student SM education, and literature surrounding SM education initiatives for medical learners is sparse. The purpose of this article is to provide guidelines and recommendations for medical student educators on SM educational content for UME.

Methods

The AMSSM subcommittee on UME was charged with developing recommendations for SM knowledge and skills that may be applied to medical students and serve as a benchmark of accomplishment prior to graduation. The format for outlining these recommendations comes from the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities for Entering Residency Curriculum Developer’s Guide (²³). The AAMC identifies eight domains of competence (DOCs) as the main competencies for students to achieve upon graduation. These are listed in Table 1 (²³). The DOCs are similar to and reflect the six competencies recommended by the ACGME for evaluation and assessment of all resident physicians (²⁴).

Table 1 - DOCs and Core EPAs from the AAMC (²³).

DOCs

1. Patient care

2. Knowledge for practice

3. Practice-based learning and improvement

4. Interpersonal and communication skills

5. Professionalism

6. Systems-based practice

7. Interpersonal collaboration

8. Personal and professional development

EPAs:

1. Gather a history and perform a physical examination

2. Prioritize a differential diagnosis following a clinical encounter

3. Recommend and interpret common diagnostic and screening tests

4. Enter and discuss orders and prescriptions

5. Document a clinical encounter in the patient record

6. Provide an oral presentation of a clinical encounter

7. Form clinical questions and retrieve evidence to advance patient care

8. Give or receive a patient handover to transition care responsibility

9. Collaborate as a member of an interprofessional team

10. Recognize a patient requiring urgent or emergent care and initiate evaluation and management

11. Obtain informed consent for tests and/or procedures

12. Perform general procedures of a physician

13. Identify system failures and contribute to a culture of safety and improvement

In addition to using DOCs to define competencies necessary for all medical students, the AAMC recognizes 13 entrustable professional activities (EPAs) to describe student responsibilities or tasks to complete which contribute to achieving competence in a specific area (Table 1). Each EPA is intended to be “independently executable, observable, and measurable in their process and outcome” (²³). For example, to display competence in patient care (DOC), a student should be able to appropriately gather a history on a knee injury and perform a focused, appropriate physical examination of the knee (EPA 1). It is important to note, however, that an EPA may contribute to more than one DOC. For instance, that same student performing a history and physical examination (EPA 1) also may demonstrate competence in professionalism (DOC). EPAs allow for a measure of medical student achievement toward a competence and work together with DOCs to serve as a framework for curriculum and assessment.

Upon formatting the SM recommendations for medical education to the DOCs, we assigned and matched EPAs to each DOC. The AAMC previously mapped EPAs to each DOC and calculated how frequently each EPA was associated with each DOC (²³). The most frequently mapped EPAs per DOC (mapped ≥2 times) were considered for inclusion, and the ones determined to be most relevant by the subcommittee to SM education within each DOC were included in this document. Table 2 demonstrates eligible EPAs and selected EPAs for inclusion in this outline. An exception to this selection method was the addition of EPA 1 to the patient care DOC as it was believed by the subcommittee that this EPA was important for inclusion.

Table 2 - List of EPAs included/excluded in recommendations per DOC.

DOC	Included EPAs	Additional EPAs a
Patient Care	1 b , 3, 4, 10, 12	2, 5
Knowledge for Practice	2	3, 7
Practice-based Learning and Improvement	7	4, 8, 13
Interpersonal and Communication Skills	5, 8, 9, 11	1, 6, 10, 12
Professionalism	1, 6	None
Systems-based Practice	13	None
Interpersonal Collaboration	9	None
Personal and Professional Development	6	1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13

EPAs that are mapped at a frequency of ≥2 for each DOC per AAMC (²³).

^a EPAs with high frequency of mapping to each DOC but not included in recommendations.

^b EPA included in recommendations despite low mapping frequency.

To complement the DOC-specific recommendations, the subcommittee compiled a list of suggested educational content and topics for inclusion throughout UME (Appendix A, https://links.lww.com/CSMR/A141). This list was compiled by subcommittee members who are experts in SM education. The content is suggested to be incorporated alongside of the EPAs. A summary of these recommendations, as well as suggested measures for accomplishment and assessment methods, is provided in Table 3.

Table 3 - Summary of SM and MSK education recommendations for medical education.

Competencies and EPAs	Functions	Methods to Accomplish	Assessment Methods
DOC 1: Patient Care
EPA 1	Perform an MSK history and physical examination; Perform a PPE; identify limitations to sports participation through history; participate in mass participation events/sideline coverage when able	–Clinical rotations –Simulated patient experiences	–Clinical scenario-based written tests –OSCEs –DOPS –Patient feedback –Preceptor evaluations –Procedure logbooks
EPA 3	Order and interpret imaging studies; order and interpret ECG; order and interpret laboratory values (serology, joint fluid aspirate)
EPA 4	Determine appropriate treatment regimen for concussion (including treatment protocol); discuss home exercise regimens, therapeutic modalities, immobilization techniques, and medications
EPA 10	Recognize emergent scenarios and management techniques in SM (e.g., unstable fractures, spinal cord injuries, sudden cardiac arrest, etc.)
EPA 12	When available and appropriate, perform landmark-guided injections, bone/joint immobilization techniques, simple reduction techniques
DOC 2: Knowledge for Practice
EPA 2	Understand broad spectrum of SM and MSK conditions (Appendix A) and apply to clinical scenarios	–Preclinical coursework (emphasis on anatomy) –Clinical rotations –Online didactic training	–Short answer questions –Essays –OSCEs –DOPS –Preceptor evaluations
DOC 3: Practice-based Learning and Improvement
EPA 7	Form clinical questions (PICOT) and search for these accordingly with appropriate sources	–Preclinical coursework –Clinical rotations –Online didactic training	–Short answer questions -Essays -Preceptor evaluations
DOC 4: Interpersonal and Communication Skills
EPA 5	Write SOAP or APSO note for a patient encounter; succinctly summarize encounter and synthesize information	–Preclinical coursework –Clinical rotations –Simulated patient experiences	–Preceptor evaluations –Essays –Video assessments –OSCEs –Patient feedback
EPA 8	Exhibit appropriate communication with the transition of care of a patient to anther health care professional
EPA 9	Demonstrate variety of communication skills through written and verbal routes; coordinate care for a patient
EPA 11	Understand risks/benefits of a variety of procedures and tests and obtain informed consent from the patient; display patient-level language in discussing risks/benefits of a procedure
DOC 5: Professionalism
EPA 1	Demonstrate appropriate covering/draping of a patient during examination or procedure; sensitively ask questions regarding social habits	–Preclinical coursework –Clinical rotations –Simulated clinical experiences	–Preceptor evaluations –Patient feedback –OSCEs –Video assessments
EPA 6	Maintain HIPAA confidentiality in presentation; demonstrate appropriate handling of patient information in a variety of settings
DOC 6: Systems-based Practice
EPA 13	Review a patient chart prior to an encounter to review medications and allergies; Exhibit universal precautions and handwashing; Exhibit sterile technique with procedures; understand the reporting of medical error; understand quality improvement processes	–Clinical rotations –Online didactic training –Simulated patient experiences	–Preceptor evaluations -Patient feedback -OSCEs -Video assessments -Short answer questions
DOC 7: Interpersonal Collaboration
EPA 9	Collaborate with SM professionals; understand roles and responsibilities of SM team members	–Clinical rotations	–Preceptor evaluations
DOC 8: Personal and Professional Development
EPA 6	Elicit and incorporate feedback from supervising physicians in the delivery of an oral presentation of a clinical encounter	–Clinical rotations –Simulated patient experiences	–Preceptor evaluations –Essays (self-reflection) –Patient feedback

Domains of Competence

Patient Care

Patient care (PC) is a broad competency necessitating a combination of skill, knowledge, and professionalism to adequately achieve. Students are expected to master basic skills pertinent to PC, including history taking, performing a physical examination, interpreting diagnostic and screening tests, prescribing appropriate treatments, recognizing and managing urgent or emergent situations, and performing basic procedures.

EPA 1: Gather a history and perform a physical examination

Students need to have a basic understanding of MSK conditions and exposure to a patient population presenting with these conditions. This provides the student with an opportunity to perform an MSK history and physical examination of the major joints. There is often limited training on performing examinations of injured or painful body parts commonly encountered in clinical practice, including the low back, knee, and shoulder; as the global burden of MSK disease continues to rise, emphasis should be placed on these high-yield examinations and incorporated within a clinical skills curriculum or clinical rotations (¹¹).

We recommend students obtain exposure in performing evidence-based, age appropriate, and activity-specific preparticipation physical examinations (PPEs) by the end of their training. They should understand the limitations of the PPE as a screening tool and be up to date on current evidence associated with PPEs (^25,26). Students should be familiar with the components of the PPE, conditions that warrant further evaluation prior to clearance, and the indications that restrict athletes from sport. They should demonstrate a basic understanding of the importance of identifying prior MSK and medical issues that may limit sports participation, or that could lead to significant disability (^22,27). Students should familiarize themselves with disease processes and conditions for which participation in physical activity may cause harm to the participant (²⁵). A cardiovascular history and physical examination, with or without electrocardiogram (ECG) or other diagnostic tests, is an important component of the PPE (²⁶). Performing PPEs during rotations with various primary care specialists can provide this experience.

In addition to opportunities for PC in the clinic-based setting, students should be encouraged to participate in providing medical care at mass participation events (e.g., marathon) and sideline events (e.g., high school football game). These events are a forum for further exposure and practice of acute care skills and a means to provide service and interact with the community.

EPA 3: Recommend and interpret common diagnostic and screening tests

Medical students must understand the indications for various radiological studies (radiographs, ultrasound, computerized tomography, magnetic resonance imaging, bone scan, dual-energy x-ray absorptiometry, etc.) (^22,28–32). They should achieve basic competency in ECG interpretation and understand when a patient should be restricted and referred for a cardiologist’s opinion. Students should recognize there are athlete-specific criteria to address physiologic variants that are commonly observed on an athlete’s ECG (³³). Basic interpretation of laboratory values such as those obtained from joint fluid aspirate or serology is recommended.

EPA 4: Enter and discuss orders and prescriptions

Upon completing a thorough history and physical examination appropriate for the chief complaint, students will need to determine next steps in the patient's care including the entering and discussion of orders and prescriptions. In SM, this includes not only communicating efficiently with the patient and the care team regarding recommended workup and treatment strategies, but also incorporating medical knowledge to determine the best treatment. Orders and prescriptions for the multitude of SM conditions may include assigning home exercise regimens for common MSK conditions, immobilization techniques, medications, various therapeutic modalities as well as awareness regarding current postconcussion guidelines as patients return to school, work, and sport (^22,34).

Of importance is the exposure and introduction to exercise prescription. In addition to understanding the role of exercise on cardiovascular fitness, MSK health, and risk reduction of chronic disease states, students should gain experience writing exercise prescriptions for patients with a variety of medical conditions and assist in engaging patients in discussion regarding behavioral change (¹⁵). Exercise prescriptions should consider standard recommendations for physical activity for the general population in addition to recognizing safety concerns and contraindications to exercise (¹⁵). Utilization of the frequency, intensity, type, and timing for prescribing exercise is recommended (¹⁵).

EPA 10: Recognize a patient requiring urgent or emergent care and initiate evaluation and management

Students should recognize a patient requiring urgent or emergent care and initiate evaluation and management while awaiting a higher level of care. These conditions include but are not limited to acute compartment syndrome, dislocations of the hip and knee, unstable fractures of the cervical spine and pelvis, spinal cord injuries, such as cauda equina syndrome, and any injury that results in neurovascular compromise (^22,35–38). Medical students need to recognize life-threatening emergencies and manage appropriately using knowledge and skills obtained through basic life support, such as in the case of sudden cardiac arrest, anaphylaxis, and status asthmaticus (²²).

EPA 12: Perform general procedures of a physician

It is recommended that medical students have exposure to and participate in common MSK procedures, including landmark-guided injections, methods of bone and joint immobilization, and simple common reduction techniques as opportunities present themselves (²²).

Knowledge for Practice

While the majority of graduating medical students match into primary care residency programs or disciplines where many patients present with MSK complaints, even disciplines not traditionally thought to use SM knowledge would benefit from having a strong educational foundation (¹²). For example, with a specialty, such as psychiatry, exercising fundamental knowledge of SM to guide psychiatrists in prescribing appropriate exercise prescriptions for patients is important to help counter weight gain from medications prescribed and achieve the well documented benefits of physical activity for patients' mental health (^39,40). To meet this need, upon graduation medical students should display an adequate knowledge base in SM to promote healthier lifestyles, including subjects such as anatomy, physiology, and exercise science. Appendix A lists recommended educational topics and content for review and inclusion throughout undergraduate education. Both Table 3 and Appendix A are valuable to establish a minimum requirement of medical student SM knowledge upon graduation.

EPA 2: Prioritize a differential diagnosis following a clinical encounter

With a firm knowledge of MSK anatomy and SM conditions, students may perform an assessment, create an appropriate differential diagnosis, and develop a treatment plan for their patients. Formulating and prioritizing a differential diagnosis after evaluating a patient that is appropriate for the patient's presentation is considered a measure of achievement toward competence in knowledge for practice.

Practice-Based Learning and Improvement

Developing intellectual curiosity, particularly within the breadth of SM, is foundational as UME aims to integrate anatomic and physiologic knowledge in combination with applied biomechanics in education. As the MSK system often receives little attention in UME, creating skills for continued life-long learning and curiosity are paramount.

EPA 7: Form clinical questions and retrieve evidence to advance PC

To form and address clinical questions encountered in the practice of SM, UME instruction in evidence-based medicine (EBM) is foundational. Students should be encouraged to use the patient, intervention, comparison, outcome, and timeframe (PICOT) framework to develop and explore questions (^41,42). Because of changing evidence and evolving discoveries in SM, students must have a curiosity to review new research and information on established practices through the many EBM resources available.

Interpersonal and Communication Skills

Communication with the patient is arguably one of the most important aspects of PC.

Medical students must have a strong foundation in MSK anatomy to minimize the use of medical jargon as many SM conditions have complex pathophysiology that is difficult to describe to patients at a basic level unless the student understands the process well. Inherent in SM visits are conversations around behavior change and exercise prescription, therefore, comfort with motivational interviewing is helpful.

EPA 5: Document a clinical encounter in the patient record

Through documentation, it is important for the student to learn how to summarize SM-specific information from the patient encounter and synthesize that information to form a succinct representation of the patient interaction.

EPA 8: Give or receive a patient handover to transition care responsibility

In SM, transition of care can occur between physicians or other care team members and relies heavily on clear communication. When transitioning a patient's care from one care team member to another, students are expected to sign out that patient in a concise manner, relaying pertinent information imperative to optimal PC.

EPA 9: Collaborate as a member of an interprofessional team

In addition to communication within the patient chart, communication with other members of the health care team is especially important in managing SM concerns, as highlighted later in this article (Interpersonal Collaboration). Recognizing nuances in communication based on various styles and generational, demographic, or cultural differences is important.

EPA 11: Obtain informed consent for tests and/or procedures

We recommend students obtain experience in identifying appropriate patients for a MSK procedure, understand indications and contraindications, recognize possible complications, and counsel patients appropriately (²²). Having a solid foundation in anatomy, basic competence in laboratory test and radiographic interpretation, and the ability to provide guidance on home exercise and rehabilitation routines, is recommended (^43,44). Using patient-level language is valuable when obtaining informed consent from patients for a variety of tests and procedures.

Professionalism

Medical education traditionally looks at professionalism in respect to three frameworks: virtue-based professionalism, behavior-based professionalism, and professional identity formation (⁴⁵). SM provides a unique setting for medical students to be exposed to and learn the tenets of professionalism in medicine through all three of these frameworks.

The practice of SM requires the physician to interact with the community outside of the office. It is a multidisciplinary practice in the truest sense that requires the physician to manage a team of providers in order to offer optimal medical care. SM physicians are regularly faced with decisions regarding return-to-play which may be challenged by the patient, coaches, managers, parents, and even fans. The SM physician must maintain professionalism through a personal set of core values to guide their decision making by moral reasoning.

Students should ideally have opportunities to work with SM physicians in a variety of settings, where they can begin developing a personal ethical and moral code through observations of interactions between physicians and patients, parents, coaches, and other members of the SM team. SM involves interacting with physically active people of all levels of sport, gender, race, ethnicity, and fitness level.

A student's selection of appropriate professional attire for the variety of settings in which SM education occurs is important; communication with the supervising physician is advised as the recommended attire for clinic may differ from what is worn in an athletic training room or at an athletic event. Students are expected to behave the same way they would in an office when they are at an athletic event or in the training room.

EPA 1: Gather a history and perform a physical examination

Asking questions about employment, social habits such as alcohol consumption and smoking, sports and activities enjoyed, and other recreational activities can be perceived as intimate information to a patient; therefore, it is important that such questions are asked in a professional manner. In performing a physical examination, we recommend a student be aware and respectful of cultural and societal considerations when draping a patient, exposing a body part for a MSK evaluation, or touching a patient. Asking for permission prior to beginning an examination is advised.

EPA 6: Provide an Oral presentation of a clinical encounter

Confidentiality is an important aspect of professionalism in medicine, and plays a particularly unique role in the world of SM. For example, students helping with PPEs should advise the athlete with whom they will be discussing their findings and may wish to explicitly state that only the athletic trainers and physicians directly involved will be privy to this. Awareness of Health Insurance Portability & Accountability Act (HIPAA) and associated confidentiality issues is a fundamental aspect of professionalism and becomes paramount in sports that attract public attention. What information can and cannot be shared comes into sharp focus when the media or public ask questions about an injury they may have witnessed from the sidelines; students assisting on the medical team must follow the lead of their supervising physician and defer any questions regarding information that could be regarded as confidential to senior members of the medical team.

Systems-Based Practice

Students are recommended to be able to identify patient safety concerns and optimize processes and procedures to mitigate breaches in safety. They should understand how to report adverse outcomes and events and recognize the importance of this process.

EPA 13: Identify system failures and contribute to a culture of safety and improvement

Universal precautions and hand washing are an important safety issue, especially with SM procedures. Medical students can help apply and practice sterile technique with topical antiseptic agents and learn about needle safety and the appropriate way to discard “sharps.”

The SM attending should serve as a role model in establishing a systems-based approach in the event of medical error, concern, or complication, which often starts with data collection of what might have or did go wrong. Plan-do-study-act cycles are one example of a system that fosters quality improvement, or audit (⁴⁶). SM faculty should be familiar with this approach and be able to have conversations with students about anticipated outcomes from procedures and potential risks.

Familiarity with the expected benefit of use of a medication or an interventional procedure (e.g., corticosteroid joint injection) should be balanced with the risk of intervention (e.g., infection, glucose elevation, bleeding, steroid flare). Such knowledge is anticipated to be covered in the preclinical pharmacology curriculum and can be retrieved from online databases or from memory.

Interprofessional Collaboration

Effective interprofessional collaboration is key to the delivery of high-quality comprehensive PC. Medical students must understand and appreciate the roles, responsibilities, and contributions of all the members of the SM medical team.

EPA 9: Collaborate as a member of an Interprofessional team

In SM, as in most practice settings, the medical team includes nurses, medical assistants, and front office staff. However, the SM experience can be a unique opportunity for students to have more in-depth exposure to a variety of individuals involved in the care of the athlete: other physicians, athletic trainers, exercise physiologists, nutritionists, occupational/physical therapists, personal trainers, radiology technologists, and sports psychologists, as well as coaches and administrators of high school, collegiate, and professional teams. Students should understand both what these professionals can do in a clinical setting and their limitations. They must be able to effectively communicate with them and develop a relationship of mutual professional respect. They should be comfortable seeking their input and help as needed and should know how to include them in the care of their patients. Students should have a wide variety of interprofessional experiences and witness highly effective teams so that they fully comprehend and embrace the value that teamwork adds to PC.

Personal and Professional Development

Medical students should develop the skills and routines necessary to sustain lifelong personal and professional development. SM physicians working with these students must model qualities such as self-awareness, and skills such as coping with stressful situations and managing conflict so that students may learn through observation. Students should be aware of health disparities in the care of underrepresented communities in the provision of surgical interventions, receiving advanced imaging, and pain management (^16,17). This awareness can facilitate fair and impartial care across the spectrum of SM.

Numerous EPAs overlap and are associated with personal and professional development. The development of self-awareness in both abilities and limitations in knowledge and skills, trustworthiness to reassure colleagues and patients, and self-confidence are common when pursuing competency in this domain (²³). Students are encouraged to develop strategies and skills supporting the pursuit of these qualities, both independently and with the guidance of a SM preceptor.

EPA 6: Provide an Oral presentation of a clinical encounter

For the presentation of a SM patient, a student will need to be well versed in appropriate history taking skills based on the clinical concern (e.g., mechanism of injury for an MSK complaint or history of migraine for a concussion evaluation). Through the deliberate practice of delivering an oral presentation of a clinical encounter, students may display trustworthiness, dependability, and self-confidence, while continuing to develop self-awareness.

Assessment Methods

Assessment is instrumental to evaluate competency in knowledge and clinical skills. Knowledge-based assessments include short answer questions, essays, and clinical scenario-based written tests. Tools for hands-on and procedural skills include objective structured clinical examinations (OSCEs), logbooks, direct observation of procedural skills (DOPS), simulated patient experiences, video assessments, standardized patients, and preceptor evaluations. Due to the broad range of competencies for UME in SM, a mixed model approach for evaluation is best. Critically appraising these tools as to feasibility of utilization and implementation, appropriateness of content for assessment, reason for assessment, and validity of method help in making these decisions.

There are studies assessing evaluation tools for utilization in UME (^47,48). Some of these tools help to identify gaps in learner education. Self-assessments frequently highlight the need for opportunities that may be provided through SM experiences to practice clinical skills. One study asked third year medical students to evaluate their competence in clinical skills such as talking to patients, interpretation of radiographs, history taking, physical examination, suturing, and ability to diagnose and select treatment independently (⁴⁷). On a scale from 1 (excellent) to 6 (insufficient) the average score did not exceed 4.7 for any subfactor and only improved to 3.3 for students in their final year (⁴⁷). A review on methodological evidence of the teaching and learning of basic practical skills in UME found literature analyzing seven basic practical skills through fifteen different teaching methods (⁴⁸). Structured skills training, feedback, and self-directed learning demonstrated the most consistent results when looking at effective teaching and learner acquisition of basic practical skills (⁴⁸). Simulation was effective with specific teaching methods as well as less frequently encountered or rare situations, but interestingly in several studies there was no significant difference in teaching effects when taught by expert or peer instructors (⁴⁸).

The evaluation of SM skills relies on the ability of the student to obtain a thorough MSK and injury history, as well as perform a physical examination specific to the area of injury or provide appropriate exercise prescription and counseling. Examination skills are best evaluated through structured skills training combined with an in-person patient experience either through OSCEs or standardized patients (⁴⁸). In addition, standardized patients can provide feedback, another effective assessment tool, to the medical student on their skills acquisition as well as professionalism during the encounter (⁴⁹).

Implementation

Given the prevalence of MSK problems in medicine, and with the applicability of SM to physicians across almost all specialties (e.g., importance of exercise counseling for promotion of exercise as medicine and physical activity), dedicated time should be provided for a SM curriculum (¹⁵). This should be implemented longitudinally throughout all 4 years, as recommended by the AAMC (⁵⁰). Implementation should be multidisciplinary and allow exposure to MSK and SM professionals in different fields, incorporating lectures, clinical experiences, and mentorship.

Implementation of this curriculum should include an emphasis on anatomy as a foundation during the preclinical years, and then in context of clinical experiences in the clinical years. If available, ultrasound should be used to assist MSK anatomy learning as research has demonstrated an educational advantage in demonstrating physical examination skills when incorporated to standard learning methods (⁵¹).

As physical examination skills are paramount for the practice of SM and the evaluation of MSK conditions, we believe that hands-on training must be included along with didactic education to optimally educate students. This is best initiated in the preclinical years so that a basic level of proficiency is achieved by the clinical years. Introductory physical examination skills may be taught through a clinical skills course and incorporate faculty well-versed in MSK examinations. If resources are present for standardized patient models and OSCE-style instruction, it is recommended to use these to mimic commonly encountered conditions such as low back, knee, and shoulder pain.

Physical activity education should be incorporated throughout the preclinical and clinical years through teaching the role of exercise on health, chronic disease states, and wellness of communities (¹⁵). In one study, only 8 h of curricular time, on average, was dedicated toward physical activity education at U.S. medical schools (⁵²). Given the importance of such education to a broad patient base, increasing exposure throughout the preclinical years and incorporating physical activity education within the systems-based curricula may provide a strong foundation for future physicians in all specialties. Recommendations for exercise medicine and physical activity promotion within medical school education have been published and serve to outline specific content (¹⁵).

Electronic resources are increasingly used among students as a means of learning (⁵³). These may be used as an adjunct to maximize learning when hands-on learning time is limited. Electronic learning should not be the sole method of teaching or replace hands-on training and should only be seen as a supplemental tool.

Clinical exposures should be emphasized in medical schools. This is supported by a previous survey of medical students that showed a desire for MSK education to be emphasized or added during the third or fourth years (⁵⁴). The following are suggestions for ways to implement SM clinical exposures:

• A required, interdisciplinary clinical rotation in SM may be provided, when possible. Participating in a focused rotation as short as 2 wk has been shown to significantly improve MSK knowledge (⁵⁵).
• If a dedicated SM rotation is not possible, another option is to incorporate this curriculum within the currently required core clerkships. Relying on exposures in core rotations can be inconsistent or inadequate, so additional dedicated SM and/or MSK instruction and clinical experiences should be integrated.

As there is variability among schools, there will not be a uniform, “one size fits all” approach to implementation. There needs to be flexibility and an understanding that the SM experience may not look the same at each institution. It may not be feasible to implement an entire curriculum all at once; however, schools should implement as much as possible based on available resources. Previously published resources for resident SM education may prove useful in supporting implementation at the UME level (^18–22).

Potential challenges to implementing a SM curriculum include the need for a large commitment of resources both in the form of instructional materials as well as time, availability, and commitment of faculty; institutional support; quantity and quality of clinical opportunities; and faculty development to ensure consistent quality of teaching. If additional formal SM education is not feasible, MSK faculty physicians should be integrated into various aspects of the current longitudinal curriculum. These faculty members may provide additional optional sessions, resources, and educational opportunities to students.

For students with particular interest in SM, electives should be available with additional opportunities in SM such as sideline coverage. SM interest groups can provide exposure through webinars, workshops, or guest lectures. If a SM interest group is not available at a given school, a startup guide can be found at amssm.org. Students also can seek resources and mentorship through national organizations, such as the AMSSM Mentor Program.

Conclusions

The suggested curriculum outlined here provides a standardized and comprehensive educational template for UME. While the resources presented at each institution will vary and therefore will influence the types of experiences and opportunities available to students, implementation of these recommendations will ensure that UME graduates will acquire a solid foundation in SM education.

Future exploration into SM education opportunities for medical students on an institutional level is needed. Conducting a national needs assessment may provide insight into this question. Identification of barriers to implementation and optimization of SM education among medical institutions also will be helpful in planning for future initiatives.