JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Topics in Training:
Karl Bilderback, Jane Eggerstedt, Kalia K. Sadasivan, Leonard Seelig, Robert Wolf, Shane Barton, Richard McCall, Andrew L. Chesson, Jr., and Andrew A. Marino
Design and Implementation of a System-Based Course in Musculoskeletal Medicine for Medical Students
J Bone Joint Surg Am 2008; 90: 2292-2300 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Dr. Marino and colleagues respond to Dr. Queally and colleagues
Andrew A. Marino, PhD, Karl Bilderback, MD; Jane Eggerstedt, MD; and Richard McCall, MD   (22 December 2008)
[Read Letter to the Editor] Undergraduate and Post Graduate Teaching of Musculoskeletal Medicine
Joseph M Queally, Paul D. Kiely, Brendan J. O'Daly, Prof John M. O'Byrne   (25 November 2008)

Dr. Marino and colleagues respond to Dr. Queally and colleagues 22 December 2008
Previous Letter to the Editor Top
Andrew A. Marino, PhD,
Professor
Department of Orthopaedic Surgery, LSU Health Sciences Center,
Karl Bilderback, MD; Jane Eggerstedt, MD; and Richard McCall, MD

Send letter to journal:
Re: Dr. Marino and colleagues respond to Dr. Queally and colleagues

amarino{at}lsuhsc.edu Andrew A. Marino, PhD, et al.

We did not study the musculoskeletal knowledge-base of primary care practitioners, but rather accepted that deficiencies existed, as documented by others (1-3). Our goal was to develop a comprehensive course in musculoskeletal medicine for medical students to help address the problem. In 2009 we expect to post course materials including Powerpoint presentations and audio files of the lectures, small group cases, criteria documents for evaluating student proficiency in performing the musculoskeletal physical exam, and video files of actual student examinations (http://lsumusculoskeletal.com).

We agree there does not seem to have been much progress regarding the education of primary care physicians in musculoskeletal medicine during the Bone and Joint decade. In our view, a major reason is that too few deans of medical schools are aware of the deficiencies in the musculoskeletal knowledge of their graduates, and consequently have not been motivated to change the traditional undergraduate curriculum. Unfortunately, evidence of the deficiencies (as opposed to the deficiencies themselves) may soon become difficult to produce because an important tool for documenting the problem, the Freedman and Bernstein test (2,3), is likely to become a victim of its popularity. We reported that 55% of students in 2007 passed the examination (4). The passing rate for the 2008 freshmen was 58%. However, we can no longer use the test because, unlike the situation in 2007 and 2008, the existence of the test is now more or less common knowledge among the medical students. We anticipate that the same thing will happen elsewhere, with the result that efforts to demonstrate the need for a course in musculoskeletal medicine in the undergraduate curriculum, or the effectiveness of specific courses, will be seriously hampered, at least until another authoritative, validated test is developed.

Now is the time to do more than simply develop exemplary teaching materials, an effective assessment tool, and a course based on them. The professional academies and societies devoted to the study and treatment of musculoskeletal disease need to make the case directly to the deans of the medical schools that musculoskeletal medicine should be presented as an independent academic subject in the undergraduate curriculum.

References

1. Queally, J.M., Kiely, P.D., Shelly, M.J., O'Daly, B.J., O'Byrne, J.M. and Masterson, E.L. Deficiencies in the education of musculoskeletal medicine in Ireland. Ir. J. Med. Sci. 177:99-105, 2008.

2. Freedman, K.B. and Bernstein, J. The adequacy of medical school education in musculoskeletal medicine. J. Bone Joint Surg. 80-A:1421-1427, 1998.

3. Freedman, K.B. and Bernstein, J. Educational deficiencies in musculoskeletal medicine. J. Bone Joint Surg. 84-A:604-608, 684, 2002.

4. Bilderback, K., Eggerstedt, J., Sadasivan, K.K., Seelig, L., Wolf, R., Barton, S., McCall, R., Chesson Jr., A.L. and Marino, A.A. Design and implementation of a system-based course in musculoskeletal medicine for medical students. J. Bone Joint Surg. 90:2292-2300, 2008.
Undergraduate and Post Graduate Teaching of Musculoskeletal Medicine 25 November 2008
Next Letter to the Editor Top
Joseph M Queally,
Lecturer in Trauma & Orthopaedic Surgery
Royal College of Surgeons in Ireland,
Paul D. Kiely, Brendan J. O'Daly, Prof John M. O'Byrne

Send letter to journal:
Re: Undergraduate and Post Graduate Teaching of Musculoskeletal Medicine

josephqueally{at}gmail.com Joseph M Queally, et al.

To the Editor:

We read with interest the article by Bilderback et al.(1) demonstrating the benefits of a comprehensive system-based course in musculoskeletal medicine for medical students.

At the onset of the Bone and Joint decade, an appeal was made for reform in the education of musculoskeletal medicine (2). Yet, as that decade draws to an end, this is the first study to demonstrate a significant improvement in the passing score for a group of medical students taking a validated test in musculoskeletal examination (55% of students passed in this study compared to 22% in a previous study)(1). We commend the authors on the design of their course, in particular for using a multi-disciplinary approach (rheumatologists, orthopaedic surgeons and anatomists).

Along with reform at the undergraduate level, reform is also required at the postgraduate level. We have demonstrated deficiencies in musculoskeletal education at multiple levels of education (3). Our study focused on primary care where we found that 71% of general practitioners and 71.8% of general practice trainees failed the same validated examination used by Bilderback et al as part of their assessment process. Only 17% of general practitioners were satisfied with their postgraduate education in musculoskeletal medicine. No general practice training scheme included a rotation in either orthopaedic surgery or rheumatology. We would advocate that general practice trainees should participate in a rotation in musculoskeletal medicine that has been designed to meet the needs of general practitioners. It should focus on the common presenting problems seen in general practice, the musculoskeletal examination, and basic practical procedures such as joint injection. Such exposure of trainees should reflect the burden of musculoskeletal disease in general practice where musculoskeletal disorders are the second most common reason for visits, accounting for up to 28% of all visits across Europe and the United States (4).

The course designed by Bilderback et al. represents an encouraging start to solving a continuing problem in undergraduate medical education. However, we advocate that attention should also be focused on postgraduate medical education, particularly in the area of primary care.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References

(1) Bilderback K, Eggerstedt J, Sadasivan KK, Seelig L, Wolf R, Barton S et al. Design and implementation of a system-based course in musculoskeletal medicine for medical students. J Bone Joint Surg Am 2008; 90(10):2292-2300.

(2) Weinstein SL. 2000-2010: the bone and joint decade. J Bone Joint Surg Am 2000; 82(1):1-3.

(3) Queally JM, Kiely PD, Shelly MJ, O'Daly BJ, O'Byrne JM, Masterson EL. Deficiencies in the education of musculoskeletal medicine in Ireland. Ir J Med Sci 2008; 177(2):99-105.

(4) Woolf AD, Akesson K. Understanding the burden of musculoskeletal conditions. The burden is huge and not reflected in national health priorities. BMJ 2001; 322(7294):1079-1080.