No MSK for MD Students?

[mtm34]

Hey I just wanted to see what everyone thinks on this one... the Medical school (and PT school) at my university are ranked in the top tier within their respective fields in the country. A professor in my PT dept. was discussing the fact that within the 4 year med school cirriculum there are ZERO hours spent on NMSK evaluation... ZERO! He said that he and the chair of the PT dept. approached the med school dean about giving a 2 hour lecture on basic NMSK eval concepts and they said there was no time for it???? My classmates and I were baffled at this...

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[facetguy]

I had posted this in another forum a couple of years ago on this topic:

Since we are on the topic of musculoskeletal knowledge/education among medical students, I thought these might be of interest:

http://www.ncbi.nlm.nih.gov/pubmed/9...ubmed_RVDocSum
Gave a standardized MSK quiz to recent med school grads.
82% failed.
Published in J Bone Joint Surg.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Same authors did follow-up a few years later.
78% failed. (A trend toward improvement, no doubt.)
Published in J Bone Joint Surg.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Gave MSK quiz to med students, residents and staff physicians.
79% failed.
Published in J Bone Joint Surg.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Modified version of MSK quiz given to students at Univ of Washington (not a bad school, if I'm not mistaken).
4th year students did better than 'younger' students.
Still, less than 50% of 4th years "showed competency" (I'm guessing that means failed).
Published in Clin Ortho Relat Res.

(I won't mention the study of what happened when chiro students were given the same test. Oh, heck, why not...)
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Not perfect, but way better.

 

[mtm34]

Wow... that is awful and IMO should be addressed by the higher med school educational boards

 

[hefe]

That's because most of this sort of training will be covered for med students in residency for the respective specialties that msk issues are pertinent (such as PM&R, Orthopedics, Family Med and other msk specialties that are subset through fellowships).

So yes, medical school (especially non-osteopathic) may be limiting in this area the first two years, but there's plenty of exposure to be had if sought out in elective rotations 4th year, and the appropriately chosen residency.

Medical school curriculum is NOT the only part of physician's training. Those who choose to specialize in this area certain can do it.

Sounds like you're talking to the wrong docs or wrong areas of the education spectrum. It works out in the end, and there are plenty of MD's who are msk specialists. Usually their role in the treatment of care is just different than that of PT's (or chiro's since facetguy jumped in). Their role in continuum of care is what's different.

Not all DO's or MD's are incompetent in muskuloskeletal examination, those that need that skill for their practice can be exposed to it. Just their formal MSI and MSII year is so packed it's not included currently. Just a different approach.

 

[mtm34]

Hefe- take a look at the literature posted by faceguy... these were 4th year med students in one studay, another was a followup after graduation. I don't expect a PCP or neurologist to score in the 90's... but to fail? I find that inexcusable

 

[DrBowtie]

Consider it job security.

 

[hefe]

I actually agree the 4 yr education does not cover MSK competency well. The data shows this fact.

What I'm trying to say is that the end result physicians boarded in orthopedic surgery, PM&R, and Sports Med doubtfully are incompetent in MSK when then complete their residency training. The studies actually tend to point this out. A physicians training doesn't stop at 4th year of medical school.

I had posted this in another forum a couple of years ago on this topic:

Since we are on the topic of musculoskeletal knowledge/education among medical students, I thought these might be of interest:

http://www.ncbi.nlm.nih.gov/pubmed/9...ubmed_RVDocSum
Gave a standardized MSK quiz to recent med school grads.
82% failed.
Published in J Bone Joint Surg.

"The mean score for the eight orthopaedic chief residents was 98.5 +/- 1.07 per cent, and that for the eighty-five residents in their first postgraduate year was 59.6 +/- 12 per cent."

"recommended for the assessment of basic competency was 73.1 +/- 6.8 per cent."

This shows that those just out of MD are failed this competency while those who've nearing completion of residency (chief residents) passed with flying colors. Thus by the time they were ready for boards and independent practice they gained competency from residency training. The end product is good.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Same authors did follow-up a few years later.
78% failed. (A trend toward improvement, no doubt.)
Published in J Bone Joint Surg.

This follow up was on a different group of subjects for re-evaluation of scoring standards from an internal medicine perspective. This was not a "follow up" in the manner you suggest for the same group of orthopedic residents.

"They suggested a mean passing score (and standard deviation) of 70.0% +/- 9.9%. As reported previously, the mean test score of the eighty-five examinees was 59.6%.Sixty-six (78%) of them failed to demonstrate basic competency on the examination according to the criterion set by the internal medicine program directors."

MSK care and evaluation has never been much of a specialty of Internal Medicine (other than perhaps rheumatology via fellowship), that's why they'll likely refer for consults when appropriate in this area.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Gave MSK quiz to med students, residents and staff physicians.
79% failed.
Published in J Bone Joint Surg.

"Sixty-nine participants (21%) obtained a score of >/=73.1%, the recommended mean passing score. Of the sixty-nine with a passing score, forty (58%) were orthopaedic residents and staff physicians with an overall average score of 94%."

"The average score was 69% for the 124 participants who stated that they had taken a required or an elective course in orthopaedics during their training compared with an average score of 50% for the 210 who had not taken an orthopaedic course (p < 0.001)"

Again shows that orthopods and their residents know their stuff in msk evaluation. This data shows it's taken care of in residency for the area it's clinically relevant. I doubt PM&R was included much in this study.

"'The average score was 69% for the 124 participants who stated that they had taken a required or an elective course in orthopaedics during their training compared with an average score of 50% for the 210 who had not taken an orthopaedic course (p < 0.001)"

This shows that a majority who took the elective in orthopedics had a mean very close to passing. Those who didn't take the elective did noticeably worse.

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Modified version of MSK quiz given to students at Univ of Washington (not a bad school, if I'm not mistaken).
4th year students did better than 'younger' students.
Still, less than 50% of 4th years "showed competency" (I'm guessing that means failed).
Published in Clin Ortho Relat Res.

"Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective."

Again, those who sought education in this area leaned towards competency. This time, those who took the elective passed the set score of 70-73% with an average of 78%.

This is also again before residency where appropriate specialties get more exposure.

(I won't mention the study of what happened when chiro students were given the same test. Oh, heck, why not...)
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Not perfect, but way better.

Lol, way to throw a cheap shot in there.

This is for the CANADIAN educational system not the United States. So, for the 98% of the SDN board who are training through and talking about through U.S.A. MD, DO, PT, and DC programs this study is inherently non-representative for what we're discussing (U.S. programs).

Come up with another study of graduated DC's against boarded orthopedic surgeons, PM&R, Sports Med, and DPT's all taking the same MSK evaluation competency test in the U.S. then we'll make comparisons.

What's also interesting is that DO's are not really mentioned in these studies. I'd imagine their competency would be higher.

 

[hefe]

Hefe- take a look at the literature posted by faceguy... these were 4th year med students in one studay, another was a followup after graduation. I don't expect a PCP or neurologist to score in the 90's... but to fail? I find that inexcusable

See above about literature.

Many PCP's (talking about FM) have so many other pressing things on their plate that unless they choose to specialize via fellowship they may not have that much in the way MSK training.

This may be part of why outpatient PT has a lot of freedom over range of care within their scope after the patient is prescribed PT.

 

[facetguy]

I have no doubt that orthos and physiatrists would do well on tests like these.

In another thread in the PT forum earlier today, it was suggested that DCs might miss some red flags when evaluating a patient, in this case because they got a C in organic chemistry in college. But somehow when an internal medicine MD doesn't know his a** from his elbow in a MSK context, it's still perfectly fine for that MD to see MSK patients everyday? Does he get a pass because he got an A in chemistry 10 years prior?

 

[DeadCactus]

The question is, does it really matter or is this like worrying about the percentage of DPTs that can successfully work up a myocardial infarction?

Obviously the NMSK specialists are doing fine on their knowledge base. Many non-NMSK physicians are failing, but what knowledge is needed to pass?

If the PCP knows when to refer to a specialist, they've probably got most of the knowledge base they need to know...

 

[zippa]

If the PCP knows when to refer to a specialist, they've probably got most of the knowledge base they need to know...

Ditto on the above. An IM doc does not need to be a MSK specialist, that's why MD/DO will consult to other doctors that do specialize in MSK. I wouldn't expect a radiologist to physically evaluate a ACL tear or anesthesiologist to exam hip ROM.

 

[mtm34]

Good discussion thus far, my biggest worry is with PCP's- I have been referred too many patients who have suffered from LBP for 3-4 months who were originally put on bed rest and a dose pack. In all honesty, with literature support, they needed referred to PT (either directly or after ortho consult) and would most definitely be feeling much better if their intial workup was appropriate.
Bottom line- I understand PCP's have a VERY VERY difficult job and have more red flag type issues to be concerned with- but when MSK patients are not reffered and are poorly handled by their PCP, this is where I have my gripe. If someone comes in your office hunched over they don't have a strain of their lumbar spine extensors, they would put them on slack and stand stiff as a board...

 

[facetguy]

Good discussion thus far, my biggest worry is with PCP's- I have been referred too many patients who have suffered from LBP for 3-4 months who were originally put on bed rest and a dose pack. In all honesty, with literature support, they needed referred to PT (either directly or after ortho consult) and would most definitely be feeling much better if their intial workup was appropriate.
Bottom line- I understand PCP's have a VERY VERY difficult job and have more red flag type issues to be concerned with- but when MSK patients are not reffered and are poorly handled by their PCP, this is where I have my gripe. If someone comes in your office hunched over they don't have a strain of their lumbar spine extensors, they would put them on slack and stand stiff as a board...

This study (http://www.jmptonline.org/article/S0161-4754(10)00216-2/abstract) was just published a few months ago and sort of speaks to this issue. This particular study looked at Blue Cross/Shield records of back pain patients who had either initiated care with a DC or their MD/DO PCP. In short, the conclusions were that initiating care with a DC was more cost-effective. I think this may be because these patients were managed more appropriately right from the start. Although we can't say from this particular study, perhaps the same would hold true had these patients seen a PT early on.

 

[jesspt]

Good discussion thus far, my biggest worry is with PCP's- I have been referred too many patients who have suffered from LBP for 3-4 months who were originally put on bed rest and a dose pack. In all honesty, with literature support, they needed referred to PT (either directly or after ortho consult) and would most definitely be feeling much better if their intial workup was appropriate.
Bottom line- I understand PCP's have a VERY VERY difficult job and have more red flag type issues to be concerned with- but when MSK patients are not reffered and are poorly handled by their PCP, this is where I have my gripe. If someone comes in your office hunched over they don't have a strain of their lumbar spine extensors, they would put them on slack and stand stiff as a board...

I agree that the results of the studies that are being duscussed here are not all that relevant clinically, until a PCP/FM/IM doc decides that they need to manage a patient's care from a musculoskeletal perspective. I too have had far too many patients who have been given poor education regarding staying as active as possible, and little education regarding the generally positive prognosis of LBP. Then, they walk into my clinic with a prescription requesting a bunch of modalities, hamstring stretching and massage.

So, if they want to hange their hat on recognizing red flags (which I think they do a great job with) then just refer patients with a request for evaluation and treatment, not a long laudnry list of stuff that is likely not going to make them better, and may potentially lead to a worse outcome.

 

[jesspt]

This study (http://www.jmptonline.org/article/S0161-4754(10)00216-2/abstract) was just published a few months ago and sort of speaks to this issue. This particular study looked at Blue Cross/Shield records of back pain patients who had either initiated care with a DC or their MD/DO PCP. In short, the conclusions were that initiating care with a DC was more cost-effective. I think this may be because these patients were managed more appropriately right from the start. Although we can't say from this particular study, perhaps the same would hold true had these patients seen a PT early on.

I would tend to agree with the overall conclusions of this study, but it has some really large methodilogical flaws....