ChiroACCESS Article

Medical Training Related to Musculoskeletal Conditions is Inadequate

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ChiroACCESS Editorial Staff



Published on

January 6, 2010

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Low Back Pain
From Harvard Medical School in the U.S. to medical schools in Europe, medical education related to musculoskeletal conditions is inadequate. A 2009 survey tested physician’s knowledge related to simple low back pain management.  The average survey score of family practitioners was 69.7 and the average score of orthopedists was far less at 44.3.  Orthopedists were less likely to make the proper radiological referral and appropriate pharmacological prescription based upon the literature.

Another 2009 study from the U.K. found that only 13% of the junior doctors felt they had adequate musculoskeletal medical training.  Research from the University of Washington found that less than 50% for the fourth-year student interns were competent in the area of musculoskeletal medicine.  A 2007 study of Harvard medical students found that they were not confident in management of musculoskeletal cases and failed to demonstrate cognitive mastery.  The study concluded that “These findings, which are consistent with those from other schools, suggest that medical students do not feel adequately prepared in musculoskeletal medicine and lack both clinical confidence and cognitive mastery in the field.”

The current failure of modern medicine worldwide to adequately train physicians and the continually growing problems like low back pain creates a window of opportunity for the chiropractic profession. 

Orthopaedists' and family practitioners' knowledge of simple low back pain management.

Spine (Phila Pa 1976). 2009 Jul 1;34(15):1600-3.

Finestone AS, Raveh A, Mirovsky Y, Lahad A, Milgrom C.
Department of Orthopaedics, Assaf HaRofeh Medical Center, Zeriffin, Israel.

STUDY DESIGN: Comparative knowledge survey.

OBJECTIVE: This study compared the knowledge of orthopaedic surgeons and family practitioners in managing simple low back pain (LBP) with reference to currently published guidelines.

SUMMARY OF BACKGROUND DATA: LBP is the most prevalent of musculoskeletal conditions. It affects nearly everyone at some point in time and about 4% to 33% of the population at any given point. Treatment guidelines for LBP should be based on evidence-based medicine and updated to improve patient management and outcome. Studies in various fields have assessed the impact of publishing guidelines on patient management, but little is known about the physicians' knowledge of the guidelines.

METHODS: Orthopedic surgeons and family practitioners participating in their annual professional meetings were requested to answer a questionnaire regarding the management of simple low back pain. Answers were scored based on the national guidelines for management of low back pain.

RESULTS: One hundred forty family practitioners and 253 orthopaedists responded to the questionnaire. The mean family practitioners' score (69.7) was significantly higher than the orthopaedists' score (44.3) (P < 0.0001). No relation was found between the results and physician demographic factors, including seniority. Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclo-oxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs. Significantly less importance was attributed to patient encouragement and reassurance by the orthopaedists as compared with family physicians.

CONCLUSION: Both orthopaedic surgeons' and family physicians' knowledge of treating LBP is deficient. Orthopedic surgeons are less aware of current treatment than family practitioners. Although the importance of publishing guidelines and keeping them up-to-date and relevant for different disciplines in different countries cannot be overstressed, disseminating the knowledge to clinicians is also very important to ensure good practice.

The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom.

J Bone Joint Surg Br. 2009 Nov;91(11):1413-8.

Al-Nammari SS, James BK, Ramachandran M.
Department of Trauma & Orthopaedics, 2nd Floor, John Harrison House, The Royal London Hospital, Whitechapel Road, London E1 1BB, UK.

The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment. Those with exposure to orthopaedics, with a career interest in orthopaedics, and who felt that they had gained adequate exposure to musculoskeletal medicine obtained significantly higher scores. Those interested in general practice as a career obtained significantly lower scores. Only 15% had any exposure to orthopaedics during the foundation programme and only 13% felt they had adequate exposure to musculoskeletal medicine. The foundation programme currently provides inadequate training in musculoskeletal medicine. The quality and quantity of exposure to musculoskeletal medicine during the foundation programme must be improved.

Competence in evidence-based medicine of senior medical students following a clinically integrated training programme.

Hong Kong Med J. 2009 Oct;15(5):332-8.

Lai NM, Teng CL.
Department of Paediatrics, School of Medicine and Health Sciences, Monash University Malaysia, JKR 1235, Bukit Azah, 80100, Johor Bahru, Johor Darul Takzim, Malaysia.

OBJECTIVE: To assess the impact of a structured, clinically integrated evidence-based undergraduate medicine training programme using a validated tool.

DESIGN: Before and after study with no control group.

SETTING: A medical school in Malaysia with an affiliated district clinical training hospital.

PARTICIPANTS: Seventy-two medical students in their final 6 months of training (senior clerkship) encountered between March and August 2006.

INTERVENTION: Our educational intervention included two plenary lectures at the beginning of the clerkship, small-group bedside question-generating sessions, and a journal club in the paediatric posting.

MAIN OUTCOME MEASURES: Our primary outcome was evidence-based medicine knowledge, measured using the adapted Fresno test (score range, 0-212) administered before and after the intervention. We evaluated the performance of the whole cohort, as well as the scores of different subgroups that received separate small-group interventions in their paediatric posting. We also measured the correlation between the students' evidence-based medicine test scores and overall academic performances in the senior clerkship.

RESULTS: Fifty-five paired scripts were analysed. Evidence-based medicine knowledge improved significantly post-intervention (means: pre-test, 84 [standard deviation, 24]; post-test, 122 [22]; P<0.001). Post-test scores were significantly correlated with overall senior clerkship performance (r=0.329, P=0.014). Lower post-test scores were observed in subgroups that received their small-group training earlier as opposed to later in the clerkship.

CONCLUSIONS: Clinically integrated undergraduate evidence-based medicine training produced an educationally important improvement in evidence-based medicine knowledge. Student performance in the adapted Fresno test to some extent reflected their overall academic performance in the senior clerkship. Loss of evidence-based medicine knowledge, which might have occurred soon after small-group training, is a concern that warrants future assessment.

More evidence of educational inadequacies in musculoskeletal medicine.

Clin Orthop Relat Res. 2005 Aug;(437):251-9.

Schmale GA.
Children's Hospital and Regional Medical Center, University of Washington, Seattle, 98105, USA.

In their study, Freedman and Bernstein suggested that 80% of a group of graduates from many of the best medical schools in the United States were deficient in their knowledge of basic facts and concepts in musculoskeletal medicine. How do these results compare with results from students attending a medical school with a long-standing dedicated program to musculoskeletal education? Does additional clinical experience in musculoskeletal medicine improve understanding of the basic facts and concepts introduced in a second-year course? A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.

Musculoskeletal medicine: an assessment of the attitudes and knowledge of medical students at Harvard Medical School.

Acad Med. 2007 May;82(5):452-7.

Day CS, Yeh AC, Franko O, Ramirez M, Krupat E.
Musculoskeletal Curriculum, Harvard Medical School, Orthopedic Hand Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.

PURPOSE: To assess medical students' knowledge and clinical confidence in musculoskeletal medicine as well as their attitudes toward the education they receive in this specialty.

METHOD: A cross-sectional survey of students in all four years of Harvard Medical School was conducted during the 2005-2006 academic year. Participants were asked to fill out a 30-question survey and a nationally validated basic competency exam in musculoskeletal medicine.

RESULTS: The response rate was 74% (449/608). Medical students rated musculoskeletal education to be of major importance (3.8/5) but rated the amount of curriculum time spent on musculoskeletal medicine as poor (2.1/5). Third-year students felt a low to adequate level of confidence in performing a musculoskeletal physical examination (2.7/5) and failed to demonstrate cognitive mastery in musculoskeletal medicine (passing rate on competency exam: 7%), whereas fourth-year students reported a similar level of confidence (2.7/5) and exhibited a higher passing rate (26%). Increasing exposure to the subject by taking clinical electives resulted in greater clinical confidence and enhanced performance on the exam (P < .001). Students' feedback suggested that musculoskeletal education can be better integrated into the preclinical curriculum, more time should be spent in the field, and more focus should be placed on common clinical conditions.

CONCLUSIONS: These findings, which are consistent with those from other schools, suggest that medical students do not feel adequately prepared in musculoskeletal medicine and lack both clinical confidence and cognitive mastery in the field. Implementing a four-year integrated musculoskeletal curriculum is one way that medical schools can address this concern.
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