In the United States, musculoskeletal complaints are the number one reason for visits to a primary care physician.19 They account for 10-28% of all visits to primary care physicians and emergency departments in North America, Europe, and Great Britain14-16,18,20,22; yet, some investigators have reported that medical school graduates lack basic musculoskeletal knowledge.12,13 In a study by Freedman and Bernstein, incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country.12 Eighty-two percent of students tested failed to show basic competency.12 Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years.3,25 Less than ½ of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than ¼ require a clinical course, and nearly ½ (57/122) have no required preclinical or clinical course.1,10 In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems.8,18 Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system.2,4,7,9,11-13 If more experience leads to a higher percentage of competent students, as suggested by Freedman and Bernstein,12 clinical experience should increase the competence of medical students above a baseline established during a second-year course in anatomy and musculoskeletal medicine.
In a survey of more than 1900 second-year residents, many stated they left medical school poorly prepared for doing musculoskeletal examinations or providing specific evaluations and treatments for musculoskeletal problems, especially for foot pain and back pain.6 Are students better trained in particular topics in musculoskeletal medicine than they are in others?
The musculoskeletal aptitude and competence exam given at the University of Pennsylvania was validated by the test results of their chief residents and by an importance ranking given by more than 100 orthopaedic program directors and 240 internal medicine program directors.12,13 Do the exam deficiencies on basic concepts, principles, and facts suggest a knowledge deficiency that is outside the basic information taught at the medical school level? Are the basic concepts, principles, and facts more appropriately taught in an orthopaedic surgery residency? If so, one would expect that scores on this exam would increase dramatically with each year of orthopaedic residency training, and that the scores of the first-year residents would not differ from the scores of the fourth-year medical students.
To evaluate the acquisition of musculoskeletal knowledge by medical students, we asked ourselves the following questions: (1) do additional experiences in musculoskeletal clinical electives improve performance on an exam designed to assess basic competency in musculoskeletal medicine? (2) breaking down the musculoskeletal curriculum by topic area, are there particular topics that are less understood by University of Washington students? and (3) do the topics and concepts covered in a basic competency exam reflect what would be more appropriate required knowledge for an orthopaedic resident rather than for a medical student likely to go into one of many primary care fields? Answers to these questions may help educators better understand the need to elevate medical school graduates to an adequate level of preparation in musculoskeletal medicine.
MATERIALS AND METHODS
All students enrolled in the University of Washington School of Medicine who were in their second, third, or fourth years during the 2001-2002 and 2002-2003 academic years were invited to participate in the study. All University of Washington residents in orthopaedics and sports medicine in the autumn of 2004 also were invited to participate. Medical students visiting the University of Washington from other institutions for away-rotations were excluded from the study. The University of Washington School of Medicine is known for its musculoskeletal education program, which has been highly regarded for primary care training.24
Approximately 180 students graduate from the University of Washington School of Medicine every year. The major preclinical experience in musculoskeletal medicine takes place during the winter quarter of students’ second year. This course, The Musculoskeletal System, lasts 8 weeks and includes approximately 40 hours of contact time. Sixteen hours are spent in the gross laboratory doing dissection, 4 hours are spent in small group sessions, including limited instruction in physical examination, and 20 hours are spent in anatomy and clinical correlation lectures. During this same quarter of the second year, 25 hours are spent in a problem-based curriculum with an emphasis on musculoskeletal issues, and 2 additional hours are spent learning musculoskeletal physical examination in an introductory clinical medicine course. Clinical rotations in orthopaedics and other musculoskeletal-related clerkships are elective and last for 4 weeks. All students are required to complete a 4-week rotation in rehabilitation medicine. The majority of elective rotations are taken during the fourth year of medical school.
The academic standing of University of Washington medical students may be established by comparing their United States Medical Licensing Examination (USMLE) Step 1 and Step 2 means with national averages. During this study, University of Washington medical students tended to score above the national average on standardized tests. Mean student scores were greater than the national mean (at least two points or 0.1 standard deviation) on five of six Step 1 and Step 2 USMLE tests from 2001-2003. On the musculoskeletal, skin, and connective tissue disorder subtest of the Step 2 USMLE, students at the University of Washington performed above the national mean by 0.1-0.3 standard deviation.
In the autumn of 2004, the University of Washington Department of Orthopaedics and Sports Medicine Residency Program included eight first-year residents doing a primarily nonorthopaedic internship. There were six second-year, third-year, and fourth-year residents, and five chief residents.
Potential study participants were invited to participate via an explanatory E-mail that had a link to the Internet-based survey. The survey instrument was two-formed, anonymous, and consisted of 24 short answer questions on musculoskeletal medicine. The test previously was used for competency testing at the University of Pennsylvania.12 Consent for participation was obtained under the guidelines of the University of Washington’s Institutional Review Board. All responses were kept confidential. The first 24 questions of Freedman and Bernstein’s original 25 question test12 were divided to make up two similar 12-question exams, entitled Forms A and B (Appendix 1). The survey questions were divided into six broad topic areas: pediatric orthopaedics, general orthopaedics (anatomy, infection, arthritis, and metabolic bone disease), trauma, spine, oncology, and sports. Topic areas were distributed between Forms A and B. Approximately ½ of the students and residents tested took Form A and the other ½ took Form B based on the first letters of their last names. Students were tested before and after the second-year course, and once during the spring of their third and fourth years. Most students have completed all required courses and the majority of their elective rotations by the spring of their fourth year, which was when the survey was given. The test form was alternated with each subsequent student testing (Table 1). Splitting a test into two versions, or multiple matrix sampling, used fewer questions, had a higher response rate, and reduced the practice effect often seen with repeat exams so that the data better represented students’ knowledge.23 Only one student group saw the same exam form twice; third-year students in 2003 were examined with the same test that they used in their second year before having taken the course in musculoskeletal medicine (Table 1). The orthopaedic residents were surveyed once, but because the residency program included graduates of the University of Washington School of Medicine, three first-year residents and one second-year resident may have been tested with the same exam that was used when they were in medical school. Test results for each of the two forms were compared to confirm that no differences in difficulty between the forms existed. Responses were graded using the criteria described by the test authors (Appendix 1).12 Scores were weighted using the importance rankings that were given by the orthopaedic program chairpersons in the article by Freedman and Bernstein.12 The two forms of the exam were prepared such that the total importance scores for Forms A and B were comparable (Form A importance score = 86.3; Form B importance score = 85.5). A passing score was set at 70% as suggested by internal medicine program directors.13
;)
Table 1: Form of Test Given by Year in Program and Academic Year
Student weighted scores were sorted by year in program and compared using a one-tailed independent samples Student’s t test; resident scores were compared using a Pearson correlation coefficient. Exam questions were sorted by topic (Appendix 1) and mean values for percent correct responses were compared using one-way analysis of variance. Statistical calculations were done using SPSS 11 software (SPSS, Chicago, IL).
RESULTS
The response rate was 41% (146/356) precourse and 44% (157/356) postcourse for the survey of second-year students during the 2 years, 22% (78/342) for the third-year students, and 29% (100/345) for fourth-year students. The resident response rate was 77% (24/31).
Comparison of student scores by year in medical school suggested that more medical training resulted in higher mean scores on the exams, although there was a decrease in third-year exam results (Table 2) (Fig 1). Second-year students showed improvement (p < 0.005) in their mean scores after the introductory course (mean scores improving from 19% correct to 61% correct). However, only 27% of students showed competency after completing the preclinical course. With another 12 months of medical school, the mean score of third-year students decreased to 54% correct, and only 11 of 78 (14%) showed competency. These numbers improved (p < 0.006) for fourth-year students, most of whom had completed a required 4-week rehabilitation medicine rotation, with a mean score of 67% correct. Forty-three percent of fourth-year students showed competency.
Table 2: Examination Results on Forms A and B by Year
Fig 1.:
Student scores are compared by year in medical school, revealing improvement in mean scores after the preclinical course in musculoskeletal medicine. A decrease in scores of third-year students is followed by an increase in scores of fourth-year students. The highest scores are seen in fourth-year students having taken a clinical elective in musculoskeletal medicine. *2 pre and 2 post indicate before and after the second-year introductory musculoskeletal medicine course. **4+ isolates those fourth-year students who took a clinical elective in musculoskeletal medicine
Elective clinical experience in musculoskeletal rotations improved score results. For fourth-year students who completed an elective in musculoskeletal medicine during the 2002-2003 academic year (Rheumatology, Sports Medicine for the Primary Care Physician, or any one of many orthopaedic electives), the mean scores (77% correct) and competency proportion (14/18, 78%) were higher (p < 0.006) than the mean scores of students who had not completed a musculoskeletal elective. The 2001-2002 students were not asked about their participation in electives.
The scores on questions related to disc disease and low back pain were lower (p = 0.001) than scores in all other topic areas across all years of students. The percent correct for these spine-related questions was 43% while the mean percent correct for all questions was 61% (Fig 2). An item analysis revealed no differences in mean number of correct answers for students when comparing types of questions, anatomic versus clinical, by year in medical school. There were no differences in frequency of correct answers when comparing questions by year in medical school. Despite the third-year students in 2002-2003 taking the same tests as they had during their second year in 2001-2002, there was no difference in the mean third-year exam scores comparing the 2001-2002 and 2002-2003 results.
Fig 2.:
The frequency of students’ correct answers is compared between topic areas. The lowest frequency of correct answers was seen in spine-related questions. *Averaged across all years of medical students (second year post-course, third, and fourth years).
The mean scores for the orthopaedic residents increased (r = 0.47; p = 0.19) incrementally by year in the program, with mean weighted scores for all years in the program well above the 70% passing levels (Fig 3). All residents who were tested exceeded the level of minimum competency. These results supported the supposition that the 24 questions making up Forms A and B appropriately test for a level of competency that can and should be achieved during the medical school years.
Fig 3.:
Orthopaedic resident scores are compared by year in residency. Mean scores increased with each year of training, and scores for all residents exceeded 70%.
DISCUSSION
The current study examines one medical school’s experience educating its students in musculoskeletal medicine. Efficacy of the curriculum was assessed using an exam of open-ended questions previously used with a group of incoming interns at the University of Pennsylvania.12 This instrument was selected because of its wide acceptance by program chairpersons in orthopaedics and internal medicine.12,13 The open-ended exam format was especially appealing because it tended to reduce the number of correct answers obtained through guessing and, therefore, more accurately assessed the true knowledge of those tested.
Do our students learn more musculoskeletal medicine as they gain experience in medical school? After a decrease in competency rates during the third year, in which students rotate though medicine, obstetrics and gynecology, psychiatry, pediatrics, and surgery clerkships and receive limited exposure to patients with musculoskeletal complaints, students in the spring of their fourth year (when most students have completed required rotations in physical medicine and rehabilitation along with electives in rheumatology, sports medicine, and orthopaedics) showed a better understanding of musculoskeletal information. Still, less than 50% of fourth-year students reached the minimum competency level of 70% correct on this weighted musculoskeletal exam.
Are students better trained in certain topic areas in musculoskeletal medicine? Although an item analysis identified particularly poor performance in the area of the spine, which suggested inadequate education in this area, only three of 24 questions were identified as being spine-related. Performance in the five remaining broad topic areas (general orthopaedics, trauma, sports, pediatrics, and oncology) varied little.
Are the facts and concepts tested with this exam appropriate for medical students? To answer this question, the competency of orthopaedic residents in years 1-5 of postgraduate training at the University of Washington was examined with identical forms of this test. All residents showed competency, with mean scores increasing with each year in training. This suggests that competency was achieved during the medical school years, by students with an interest in orthopaedics, and that residency in orthopaedics reinforces important musculoskeletal concepts. The discrepancy between the Internet-based survey scores for the third-year and fourth-year students and their mean Step 1 and Step 2 USMLE scores merits concern. One might expect that above-average mean scores on the musculoskeletal subtest of the USMLE Step 2 exam would suggest a high proportion of students with competency in musculoskeletal medicine. The instructors in our musculoskeletal preclinical course would certainly expect it, as ⅓ of the class routinely receives an honors grade. Perhaps the routine use of standardized multiple-choice exams as a measure of competency, such as in our preclinical course, several musculoskeletal clerkships at the University of Washington, and the USMLE, disguises a higher level of misunderstanding than test results suggest. Freedman and Bernstein elected an open-ended response format for their original test “to eliminate the possibility of the examinee scoring points by random guessing.”12 This format may have ferreted out students who incompletely understood the concept or facts but who may have been able to recognize the best answer if given enough options on a multiple choice exam.
Limitations of this study include using a test setting that was different from that used in the University of Pennsylvania study, where incoming interns were given the paper exam during their residency orientation.12 The exam for this study was administered as an Internet-based survey and allowed for optimal consenting of study participants without the pressure or coercion that might have existed had the study been given during regular class time. It insured anonymity of responses and allowed students unlimited time to complete each survey. Splitting the exam into two forms of comparable difficulty reduced the time necessary to complete the task and reduced any practice effect. Drawbacks to this method of survey administration included the inability for the examiners to proctor the exams; students were on their honor to complete the surveys without assistance. Because the survey was administered as an Internet-based questionnaire through an E-mail invitation for participation, it likely contributed to low response rates, particularly for third-year and fourth-year students who frequently take clinical rotations away from Seattle. Using a school-wide list-serve to address the E-mail invitations also may have discouraged many students from opening the messages and reading the invitation for participation, as these list-serves often are used for a wide variety of noncritical communication purposes in the School of Medicine. Also, students without access to high-speed Internet connections off-campus may have been discouraged from completing an Internet-based questionnaire because of slow system response. The low response rates also may call these results into question. How representative is a survey of a group of students when the response rate is less than 50%? Assuming that the particularly dutiful students were more likely to complete the surveys, and that dutiful students more often are better students, these results may have exaggerated the level of understanding of the average medical student at the University of Washington.
The design of this study differed in many ways from that of Freedman and Bernstein,12 making comparison of results problematic. Nonetheless, our results for all fourth-year students (mean weighted score, 67% ± 17%) were similar to those of Freedman and Bernstein in their survey of 85 incoming interns (mean weighted score, 60% ± 12%).12 Does more clinical experience in related areas such as rehabilitation medicine improve competency rates? The results of our study and those of Freedman and Bernstein12 show that students who took elective clinical rotations in orthopaedic surgery scored higher on the competency exams. Students most interested and already skilled in musculoskeletal medicine might have been more likely to take additional elective clinical training in this area, meaning a required orthopaedic clerkship may not necessarily achieve the same results for the average fourth-year student. There was no indication that one, 4-week required rotation in rehabilitation medicine provided enough additional clinical exposure to lead to uniform competency, nor did it make a difference in the study of interns by Freedman and Bernstein.12 In our study, however, as the majority of students take the rehabilitation rotation during their fourth year, the rehabilitation clerkship likely contributed to the improvement in exam scores and competency rates for the fourth-year students when compared with third-year students’ scores.
At the University of Washington, a preclinical course in musculoskeletal medicine and a physical medicine and rehabilitation clerkship are required for graduation. Yet, less than ½ of 122 US medical schools surveyed in one study require a preclinical block in musculoskeletal medicine, and only six require a clinical rotation in physical medicine and rehabilitation; none required a clinical rotation in orthopaedics.10 Reviews of residency programs in primary care fields suggested that musculoskeletal medicine was an area of low confidence for program graduates.5,17,26 Of 202 family practitioners surveyed, more than ½ stated that they had not spent enough time in orthopaedics during medical school and residency training, which was a higher percentage than identified for any other surgical subspecialty area.21 Another survey of more than 1900 second-year residents in the United States revealed that 26% of residents in allopathic residencies considered themselves ill-prepared to evaluate a patient with low back pain and 60% considered themselves ill-prepared to evaluate a patient with foot pain.6
What can we do as physicians and educators to better prepare our students in musculoskeletal medicine? Certainly a curriculum requiring a preclinical course in musculoskeletal medicine, a clerkship in rehabilitation and physical medicine, and offering clerkship electives in musculoskeletal medicine would be a good place to start. But, as shown here, that may not be enough. As the scores of the fourth-year students show, repeated exposure to the subject improves understanding and competency. More experiences in musculoskeletal medicine during the third year of medical school might measurably increase competency rates of third-year students, boosting that of fourth-year students as well. How additional musculoskeletal medicine might be integrated into the clinical years remains a challenge. The most useful experiences might be found in a community ambulatory clinic with an unscreened general orthopaedic population. Rotations at specialized, prescreened clinics at a tertiary referral center where most patients have patients with diagnoses requiring surgery may do little to introduce the future primary care physician to the most common nonoperative musculoskeletal problems. Because a large proportion of the patients seen by orthopaedic surgeons are referred from primary care providers, who make up the largest proportion of medical school graduates, it behooves us to optimize the training of these future referrers so that they are competent in basic musculoskeletal anatomy and principles. Such training would better prepare students for residencies where they refine their understanding of appropriate diagnostic and treatment strategies for common musculoskeletal complaints, most of which can and should be treated by the primary care physician.
Acknowledgments
I thank Craig Scott, PhD, Carol Teitz, MD, Jan Carline, PhD, Carol MacLaren, PhD, and Dan Graney, PhD for help in the planning and completion of this study.
APPENDIX 1
Form A*
(Precourse exam A-L, Postcourse exam M-Z, Year 3 exam A-L, Year 4 exam M-Z)
The survey below will be used for research purposes only. Thank you for your honest and unassisted participation.
- 1. For the purposes of linking your responses on this survey to any future surveys that you may take as a part of this study, without revealing your identity, please prepare a name which is a combination of: a two or three letter abbreviation for the name of your institution (eg, UW for University of Washington), followed by the first four letters of your mother’s maiden name, followed by the first four letters of the city or town of your birth, with no intervening spaces.
2. What common problem must all newborns be examined for?
A: CDH, DDH, dislocation, subluxation, hip instability all accepted, 1 pt
(Importance score 9.1; question type PEDIATRICS)
3. Acute septic arthritis of the knee may be differentiated from inflammatory arthritis by which laboratory test?
A: Any analysis of fluid from aspiration (cell count, Gram stain, culture), 1 pt
(Importance score 8.5; question type GENERAL)
4. A patient punches his companion in the face and sustains a fracture of the 5th metacarpal and a 3-mm break in the skin over the fracture. What is the correct treatment, and why?
A: Irrigation and debridement; risk of infection, ½ pt each
(Importance score 8.4; question type TRAUMA)
5. How is compartment syndrome treated?
A: Fasciotomy (surgery also accepted), 1 pt
(Importance score 7.9; question type GENERAL)
6. A 25-year-old male is involved in a motor-vehicle accident. His left hip is in a position of flexion at the knee and hip, with internal rotation and adduction of the hip. What is the most likely diagnosis?
A: Hip dislocation, 1 pt
(Importance score 7.6; question type TRAUMA)
7. A patient has a disc herniation pressing on the fifth lumbar nerve root. How is motor function of the 5th lumbar nerve root tested?
A: Dorsiflexion of the great toe or toe extensors, 1 pt (Importance score 7.2; question type SPINE)
8. A 12-year-old girl severely twists her ankle. Radiographs show only soft tissue swelling. She is tender at the distal aspect of the fibula. What are two possible diagnoses?
A: Ligament sprain and physeal fracture, ½ pt each
(Importance score 7.0; question type PEDIATRICS)
9. A patient has a displaced fracture near the fibular neck. What structure is at risk for injury?
A: Common peroneal nerve (peroneal nerve also accepted), 1 pt
(Importance score 6.8; question type GENERAL)
10. What are the five most common sources of cancer metastatic to bone?
A: Breast, prostate, lung, kidney, thyroid, ¼ pt each
(Importance score 6.7; question type ONCOLOGY)
11. Which malignancy may be present in bone yet typically is not detected with a bone scan?
A: Myeloma (leukemia and lymphoma also accepted), 1 pt
(Importance score 6.4; question type ONCOLOGY)
12. What is the difference between osteoporosis and osteomalacia?
A: Osteoporosis - decreased bone density, osteomalacia - decreased bone mineral (also accepted any true statement regarding epidemiology or pathophysiology), ½ point each.
(Importance score 5.7; question type GENERAL)
13. What muscle(s) is/are involved in lateral epicondylitis (tennis elbow)?
A: Wrist extensors (any single wrist extensor accepted), 1 pt
(Importance score 5.1; question type SPORTS)
Form B*
(Precourse exam M-Z, Postcourse exam A-L, Year 3 exam M-Z, Year 4 exam A-L)
- For the purposes of linking your responses on this survey to any future surveys that you may take as a part of this study, without revealing your identity, please prepare a name which is a combination of: a two or three letter abbreviation for the name of your institution (eg, UW for University of Washington), followed by the first four letters of your mother’s maiden name, followed by the first four letters of the city or town of your birth, with no intervening spaces.
What is a compartment syndrome?
A: Increased pressure in a closed fascial space, 1pt
(Importance score 9.0; question type GENERAL)
3. A patient dislocates his or her knee in a car accident. What structure(s) is/are at risk for injury and therefore must be evaluated?
A: Answer must include popliteal artery, 1 pt
(Importance score 8.4; question type TRAUMA)
4. A patient comes to the office complaining of low-back pain that wakes him from sleep. What two diagnoses are you concerned about?
A: Tumor and infection, ½ pt each
(Importance score 8.0; question type SPINE)
5. A patient lands on his hand and is tender to palpation in the “snuff box” (the space between the thumb extensor and abductor tendons). Initial radiographs do not show a fracture. What diagnosis must be considered?
A: Scaphoid fracture, 1 pt
(Importance score 7.8; question type TRAUMA)
6. What nerve is compressed in carpal tunnel syndrome?
A: Median nerve, 1pt
(Importance score 7.4; question type GENERAL)
7. How is motor function of the median nerve tested in the hand?
A: Any median nerve function in the hand (MCP flexion; thumb opposition, palmar abduction)
(Importance score 7.0; question type GENERAL)
8. A patient presents with new-onset low-back pain. Under what conditions are radiographs indicated? Please name five. (Example-history of trauma)
A: Age > 50 or postmenopausal, neurologic deficit, bowel or bladder changes; history of cancer, drug use, or steroid use, systemic symptoms such as night pain or fever, skeletally immature, ¼ pt each, 1 pt max total
(Importance score 7.0; question type SPINE)
9. A 20-year-old injured her knee while playing soccer. You see her on the same day, and she has a knee effusion. An aspiration shows frank blood. What are the three most common diagnoses?
A: Ligament tear, fracture, meniscal tear (patellar dislocation also accepted), ½ point each, 1 pt max total
(Importance score 6.8; question type SPORTS)
10. Name two differences between rheumatoid arthritis and osteoarthritis.
A: Any two correct statements (i.e. inflammatory vs. degenerative, PIP vs. DIP involvement) ½ pt each, 1 pt max
(Importance score 6.6; question type GENERAL)
11. What is the function of the normal anterior cruciate ligament in the knee?
A: Resists anterior translation of the tibia on the femur, 1 pt
(Importance score 6.2; question type SPORTS)
12. In elderly patients, displaced fractures of the femoral neck are typically treated with joint replacement, whereas fractures near the trochanter are treated with plates and screws. Why?
A: Tenuous blood supply to the femoral head (avascular necrosis and nonunion also accepted) 1 pt
(Importance score 5.2; question type TRAUMA)
13. Rupture of the biceps at the elbow results in weakness of both elbow flexion and ______?
A: Supination, 1 pt
(Importance score 5.1; question type GENERAL)
References
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19. Praemer A, Farmer S, Rice D: Musculoskeletal Conditions in the United States. Rosemont, American Academy of Orthopaedic Surgeons 1999.
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21. Reznick RK, Brewer ML, Wesley RM, Stauffer ES: Orthopaedic teaching: The practicing family doctor’s perspective. Orthop Rev 16:529-535, 1987.
22. Rosenblatt RA, Cherkin DC, Schneeweiss R, et al: The structure and content of family practice: Current status and future trends. J Fam Pract 15:681-722, 1982.
23. Sirotnik K, Wellington R: Incidence sampling: An integrated theory for “matrix sampling.”. J Educ Measur 14:343-399, 1977.
24. News US: and World Report: America’s Best Graduate Schools. Washington, DC, US News and World Report 2004.
25. Williams JR: The teaching of trauma and orthopaedic surgery to the undergraduate in the United Kingdom. J Bone Joint Surg 82B:627-628, 2000.
26. Wright V, Helliwell PS: Undergraduate education in musculoskeletal diseases. Br J Rheumatol 31:279-280, 1992.
*Questions, answers, and importance score from Freedman and Bernstein.12
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