Harvard Medical School study finds musculoskeletal training lacking

Third- and fourth-year students surveyed reported the current musculoskeletal curriculum was poor.

Harvard Medical School students believe their careers will require a solid background in musculoskeletal medicine, yet they feel the current musculoskeletal curriculum might not fully prepare them for what is needed on-the-job.

Charles S. Day, MD, assistant professor of orthopedic surgery at Harvard Medical School (HMS), Boston, and colleagues surveyed students to assess the HMS musculoskeletal health curriculum. The survey is part of an educational research project, which included objective evaluation of the students’ musculoskeletal knowledge, that they developed and started in September and that runs through to the end of the 2005-2006 academic year.

Day presented the group’s preliminary findings at the recent 2006 Northeast Group on Educational Affairs (NEGEA) Annual Education Retreat. NEGEA is one of four regional groups of the Association of American Medical Colleges Group in Educational Affairs (GEA).

“My interest is in getting all medical students to graduate with more of a fundamental understanding of musculoskeletal medicine,” Day told Orthopedics Today.

Exam and survey

All students at HMS across all four years are eligible to participate in this study, which consists of administering the survey and a validated basic musculoskeletal medicine competency examination, which was developed at the University of Pennsylvania, Philadelphia. The program’s goal: at least 50% participation from all four classes. Scores for the first-year students will serve as baseline measurements.

To date, the exam has been administered to 98 first-year students (60%), 84 third-year students (52%) and 66 fourth-year students (40%) at HMS.

“The part we added, that has never been done before, was on the medical students’ attitudes about musculoskeletal education,” Day said. The attitude survey, intended for all students except those in their first year, has already been given to the thirdand fourth-year students. Researchers expect to survey the second-year students as a group soon.

Education assessment

The survey asks questions about the overall importance of musculoskeletal medicine as well as its importance compared to pulmonary medicine and other subjects. Students are also asked self assessment competency questions, such as how comfortable they feel developing a musculoskeletal differential diagnosis based on their skill and knowledge level. For some questions, students rank their answers by importance.

The survey is unique because no one else has captured the students’ perceptions of musculoskeletal medicine, and the data were surprising, said Day, chief of orthopedic hand and upper extremity surgery at Harvard’s Beth Israel Deaconess Medical Center.

For example, about 20% of all primary care physician (PCP) visits nationally are due to musculoskeletal conditions, Day said. But, third- and fourth-year students thought the frequency of such problems in the PCP setting was about 40%.

“They think it is actually more than the national numbers and the national numbers are already pretty high at 20%, and certainly it’s not 20% of the curriculum at any medical school ...,” he said. “I don’t think [Harvard Medical School students] are seeing more musculoskeletal problems in their clinical exposures here, but the fact that, if they are not comfortable performing a musculoskeletal examination or do not have the knowledge base to provide a diagnosis, then those cases are going to stand out in their minds.”

Other survey results included:

Musculoskeletal medicine knowledge was considered to be of major importance to medical careers, almost as important as pulmonary medicine.
Asked to rank the value of eight courses, students ranked cardiovascular, respiratory and musculoskeletal medicine studies, in sequential order, as the three most important courses to their future medical careers. The other five topics — renal, neuro-medicine, epidemiology, genetics and cell biology — actually had more time devoted to them than musculoskeletal medicine.
Third- and fourth-year students rated the quality/quantity of curriculum time spent on musculoskeletal medicine as poor (average of 2 on a scale of 1 to 5).

“This result of this survey is the most surprising aspect of this project. The students recognize the importance of musculoskeletal medicine and they recognize that they’re not getting enough of it during their medical [education],” Day said.

Exam scores, based on a validated passing score of 70%, reflected the survey results. Fourth-year students had a 27% passing rate, while third-year students had a 9.4% passing rate. Only the students who took a musculoskeletal elective had an average score higher than the passing rate at 75%.

“There are courses at Harvard Medical School that will help them, an they are already in the curriculum. I think it’s a matter of making [the courses] mandatory rather than electives,” Day said.

The 2005 Medical Student Objective Project (MSOP) report by the American Association of Medical Colleges confirmed what Day and his colleagues originally thought: The musculoskeletal curriculum at most U.S. medical schools needs help, he said. “The [MSOP] report put out last September regarding the need for a musculoskeletal component for all four years is starting to focus at least some attention toward this aspect of the medical school curriculum,” Day said.

“Harvard Medical School is undergoing a radical educational curriculum reform right now,” Day noted. “I am a member of an Harvard Medical School-appointed task force looking specifically into improving the musculoskeletal curriculum, and this study can serve as a measuring stick for the effectiveness of any of those upcoming changes.”

Project 100 of the U.S. Bone and Joint Decade 2002-2011 is also dedicated to improving medical schools’ required musculoskeletal medicine courses.

For more information:
Day CS, Yeh A, Ernster E, et al. Preliminary results on the effectiveness of Harvard Medical School’s musculoskeletal curriculum. C4:1. Presented at the Northeast Group on Educational Affairs 2006 Annual Education Retreat. March 3-4, 2006. Philadelphia.