The US Bone & Joint Decade (USBJD) campaign has improved public awareness, increased research efforts, and enhanced clinical care for musculoskeletal (MSK) disorders. One major goal of the USBJD has been to improve the MSK knowledge base of physicians who practice primary care medicine, because these physicians actually manage most patient visits related to MSK conditions.
MSK-related complaints are the most common reason patients visit primary care physicians and emergency departments in the United States, accounting for 10 percent to 28 percent of all primary care visits. Despite this high frequency of MSK disorders, significant evidence indicates that most primary care physicians do not feel adequately prepared to address such patient complaints.
A survey of family practice physicians found 51 percent of respondents felt that they had insufficient training in orthopaedics. Furthermore, 56 percent of those surveyed claimed that medical school was their only source for formal MSK training. Similarly, in another study, pediatric residents said they had the least adequate training in orthopaedics. Graduating family practice residents felt significantly more confident in performing physical exams, evaluating radiographs, and diagnosing and treating non-MSK disorders than they did for MSK conditions.
Although these studies demonstrate subjective deficiencies in the quality of MSK training, a landmark 1998 study published in The Journal of Bone and Joint Surgery demonstrated objective and quantitative deficits. The study involved a 25-question MSK competency survey validated by the chairs of orthopaedic residency programs from across the country and administered to 85 incoming residents (of all specialties) at the University of Pennsylvania. The survey included the following questions:
- What orthopaedic problem must all newborns be examined for?
- What is the normal function of the ACL?
- What is the difference between osteoporosis and osteomalacia?
The failure rate was 82 percent! Obviously, there is a significant disparity between the number of patients with MSK conditions who are seen by primary care physicians and the amount of MSK training these physicians have received. As a result, patients with MSK disorders receive less-than-optimal care. Delayed diagnoses, inappropriate referrals to MSK specialists, and unnecessary use of therapeutic and diagnostic modalities increase the costs of care for these patients. In addition, there are the indirect costs, such as lost work days for employees who receive suboptimal treatment of MSK conditions, that are difficult to measure.
What can we do?
How can we augment medical student education to improve proficiency in diagnosing and treating MSK conditions?
With the prevalence of MSK disorders and the large number of practitioners from all specialty groups who provide care for patients with MSK disorders, it would seem apparent that physicians-in-training should receive more MSK training during medical school. Studies have shown that medical students who are exposed to MSK conditions in their preclinical years have higher scores on the MSK portions of standardized tests, and those who participate in an MSK clinical rotation have improved treatment skills.
Despite this clear link between training and performance, only 51 of 122 US medical schools have a dedicated preclinical MSK course, and only 25 schools require a clinical course in MSK medicine (rheumatology, orthopaedics, or physical medicine and rehabilitation); 57 schools require neither a preclinical nor a clinical MSK course. This is why the USBJD launched “Project 100,” which is designed to incorporate dedicated musculoskeletal education into the core curriculum of each of the 122 U.S. medical schools.
Many nonorthopaedic specialty groups have endorsed the USBJD’s medical school educational initiative. Representatives from eight different physician specialty groups have acknowledged that “medical students entering their residencies are ill prepared to deal with the more common musculoskeletal conditions,” and recommended educational reform. In 2005, the Association of American Medical Colleges published a report that was intended to provide the impetus and a set of guidelines by which medical schools could accomplish MSK curricular reform.
Changing medical school curricula to incorporate more effective MSK teaching requires that medical schools accept the inadequacy of the current level of MSK education. Physician educators and medical school professors from disciplines such as rheumatology, orthopaedics, anatomy, primary care, pediatrics, and geriatrics must become intimately involved in this reform process at each school. This change will require a fundamental shift in the attitudes toward MSK medicine and should result in required preclinical and clinical exposure to MSK conditions to best serve the needs of patients with MSK disorders. Help support the USBJD and Project 100 to improve medical education for the next generation of physicians.
The Washington Health Policy Fellows include Aaron Covey, MD; Ryan Nunley, MD; Samir Mehta, MD; Sharat K. Kusuma, MD; Alok D. Sharan, MD; Jamie Genuario, MD; Anil Ranawat, MD; John Flint, MD; and Alex Jahangir, MD. Please send your comments to firstname.lastname@example.org
For more information on the USBJD Project 100, click here.
- Geyman JP, Gordon MJ. Orthopedic problems in family practice: incidence, distribution, and curricular implications. J Fam Pract 1979 Apr;8(4):759-65.
- Marsland DW, Wood M, Mayo F. Content of family practice. Part I. Rank order of diagnoses by frequency. Part II. Diagnoses by disease category and age/sex distribution. J Fam Pract 1976 Feb;3(1):37-68.
- Rekola KE, Keinanen-Kiukaanniemi S, Takala J. Use of primary health services in sparsely populated country districts by patients with musculoskeletal symptoms: consultations with a physician. Journal of Epidemiology & Community Health 1993 Apr;47(2):153-7.
- Sneiderman C. Orthopedic practice and training of family physicians:A survey of 302 North Carolina practitioners. J Fam Pract 1977 Feb;4(2):267-50.
- Camp BW, Gitterman B, Headley R, Ball V. Pediatric residency as preparation for primary care practice.see comment. Arch Pediatr Adolesc Med 1997 Jan;151(1):78-83.
- Matheny JM, Brinker MR, Elliott MN, Blake R, Rowane MP. Confidence of graduating family practice residents in their management of musculoskeletal conditions. American Journal of Orthopedics (Chatham, NJ) 2000 Dec;29(12):945-52.