Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
James H. Herndon, MD*,
Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
Posted February 2008
Since the demonstration by Freedman and Bernstein that most
graduating medical students could not pass a basic examination on the
musculoskeletal system1, other papers are beginning to be published
about this deficiency in medical school graduates. It is known that medical
students' exposure to the musculoskeletal system is fragmented, varying widely in
different medical schools and from one extreme to another in the same medical
school. For example, at Harvard Medical School there have been times when no
musculoskeletal lectures were given in the first two years of medical school, and
other periods in which a course on the musculoskeletal system was required. The
same can be said for a two-week required clerkship in the third year of medical
school. Reasons for these variations seem to be dependent on the interests of
the faculty in orthopaedic surgery and other musculoskeletal-associated fields,
the curriculum committee, the surgical clerkship committee, the dean, and the
students themselves.
This debate on the importance of musculoskeletal education
has been ongoing for years from medical school to medical school and at the
highest levels of organized medical school education—the Association of American
Medical Colleges (AAMC). There has been no resolution to these debates,
although in 2005 the AAMC did officially support the importance of
musculoskeletal education for all medical students2.
Now, from the leading medical education professional
organization, comes the directive to include musculoskeletal education for all
medical students. But I suspect that implementation of this directive is going
to take time and that the debates and discussions will continue.
The paper by Yeh et al. describes another aspect of this
issue: "to examine the effect of medical students' residency interest on the
musculoskeletal education that they receive during medical school." The authors
essentially show that medical students who desire a residency in orthopaedics
or who feel that knowledge of the musculoskeletal system is important in their
chosen specialty (internal medicine, pediatrics, emergency medicine, and
others) will take courses on the musculoskeletal system, if offered, and take
orthopaedic surgery electives on their own. Students who have other interests
may graduate from medical school with a relative lack of knowledge of the
musculoskeletal system. It is unfortunate that this choice is left up to the
medical students rather than being directed and/or advised by senior faculty
and curriculum committees for the purpose of broadening all students' education
in all areas relevant to their future chosen field of practice.
It seems intuitive that students—especially students who are
planning a career in orthopaedics—would select courses befitting their career
needs. But the finding reported by Yeh and coauthors was surprising. The fourth-year
students' scores on the cognitive mastery examination were all below the
passing grade of 70% (except for an average score of 74% by the eight students who
were planning a career in orthopaedic surgery and a score of 91% by the one
student who had chosen neurology as a career specialty). In fact, most of the
scores were quite low, as also reported by Freedman and Bernstein1. Most
of the students, however, (except for those listing orthopaedic surgery as
their top residency choice and a few others) also reported average or
below-average clinical confidence in their ability to perform a musculoskeletal
physical examination.
As the authors suggest, exposure to operative orthopaedics
alone is insufficient to improve the students' confidence in performing a
musculoskeletal physical examination and achieving a passing score on the
cognitive mastery examination. The orthopaedic clerkship must teach basic
physical examination techniques and basic core knowledge of clinical
musculoskeletal disease and/or injuries, and it must effectively integrate
these fundamental concepts and skills as suggested by the AAMC. It appears from
the report by Yeh et al. that these objectives have not been achieved to date
for medical students at Harvard Medical School.
This paper as well as the other recent articles on the
subject of musculoskeletal education in medical school will continue to
emphasize the importance of musculoskeletal education for all medical students.
Those who oppose such clinical curriculum reform will cite the article by
Bernstein et al. that such required education was associated with a 12%
increase in applications to orthopaedic surgery residency programs3. Those who favor such clinical
curriculum reform will also cite the same article3 because the
authors found that this increase in applications to orthopaedic training
programs was highest amongst women (75% difference in application rate) and
minorities (35% difference in application rate). I remain optimistic that, when
all factors are considered, medical schools will follow the suggestions of the AAMC
and incorporate comprehensive musculoskeletal education in their curriculum for
all medical students.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Zimmer, DePuy) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
References
1. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002;84:604-8.
2. Report VII. Contemporary Issues in Medicine: Musculoskeletal Medicine Education. Medical School Objectives Project. Washington, DC: Association of American Medical Colleges; September 2005. https://services.aamc.org/Publications/showfile.cfm?file=version93.pdf&prd_id=204&prv_id=245&pdf_id=93.
Accessed 2008 Jan 11.
3. Bernstein J, Dicaprio MR, Mehta S. The relationship between required medical school instruction in musculoskeletal medicine and application rates to orthopaedic surgery residency programs. J Bone Joint Surg Am. 2004;86:2335-8.
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