Journal of Bone and Joint Surgery 2002 (Apr); 84–A (4): 604–608
Kevin B. Freedman, MD, MSCE and Joseph Bernstein, MD, MS
Investigation performed at the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Kevin B. Freedman, MD, MSCE
1725 West Harrison Street, Suite 1063, Chicago, IL 60612
Joseph Bernstein, MD, MS
Department of Orthopaedic Surgery and Leonard Davis Institute of Health Economics, 424 Stemmler Hall, University of Pennsylvania, Philadelphia, PA 19104-6081. E-mail address: firstname.lastname@example.org
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Office of the Dean for Health Services Research, University of Pennsylvania. None of the authors 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, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Background: We previously reported the results of a study in which a basic competency examination in musculoskeletal medicine was administered to a group of recent medical school graduates. This examination was validated by 124 orthopaedic program directors, and a passing grade of 73.1% was established. According to that criterion, 82% of the examinees failed to demonstrate basic competency in musculoskeletal medicine. It was suggested that perhaps a different passing grade would have been set by program directors of internal medicine departments. To test that hypothesis, and to determine whether the importance of the individual questions would be rated similarly, the validation process was repeated with program directors of internal medicine residency departments as subjects.
Methods: Our basic competency examination was sent to all 417 program directors of internal medicine departments in the United States. Each recipient was mailed a letter of introduction explaining the purpose of the study, a copy of the examination, and our answer key and scoring guide. There was no mention of the results of the first study. The subjects were requested to rate the importance of each question on the same visual analog scale, ranging from "not important" to "very important," as had been used by the orthopaedic program directors. These ratings were converted into numerical scores. The program directors were also asked to suggest a passing score for the examination, and this score was used to assess the examinees' performance on the examination. The results on the basis of the internal medicine program directors' responses and those according to the orthopaedic program directors' reponses were compared.
Results: Two hundred and forty (58%) of the 417 program directors of internal medicine residency departments responded. 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. The internal medicine program directors assigned a mean importance score of 7.4 (of 10) to the questions on the examination compared with a mean score of 7.0 assigned by the orthopaedic program directors. The internal medicine program directors gave twenty-four of the twenty-five questions an importance score of at least 5 and seventeen of the twenty-five questions an importance score of at least 6.6.
Conclusions: According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.
From the Full-Text Article:
Musculoskeletal care is provided by a variety of practitioners, including internists, family practitioners, rheumatologists, emergency physicians, pediatricians, and orthopaedic surgeons. Mastery of the basics of musculoskeletal medicine is therefore essential for many, if not all, medical students. Ideally, a solid knowledge base would be acquired in medical school and refined during postgraduate training.
We previously evaluated the quality of musculoskeletal knowledge among a cohort of recent medical school graduates.  In that study, we administered a basic competency examination in musculoskeletal medicine to eighty-five residents on their first day of residency at our institution. We validated this examination by surveying orthopaedic program directors. These experts were asked to review the examination, rate the importance of each question, and establish a minimum passing score. According to their criterion, 82% of our test group of recent medical school graduates failed to demonstrate basic competency in musculoskeletal medicine.
On the basis of these data, we suggested that medical school training in musculoskeletal medicine is inadequate. Still, we recognize that some may believe that orthopaedic surgeons are not the best group to validate the examination. It could be argued that orthopaedists provide only a minority portion of musculoskeletal medical care and thus may not appreciate what points are important to the average practitioner.
Also, it is possible that surgeons overvalue topics with surgical relevance.
To respond to these critics, we surveyed a cohort of program directors who were not surgeons. We wished to first determine
whether standards are similar and then to use this second, nonsurgical standard to ratify (or negate) our conclusion
that many examinees failed the basic competency examination. Our second purpose, no less important, was to identify topics that both surgeons and nonsurgeons rate as important. Our hope was that the set of topics with broadly acknowledged importance could then be used to generate a consensus curriculum for medical students.
ccording to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine. It is reasonable, therefore, to conclude that medical school preparation in musculoskeletal medicine is inadequate. The use of a second criterion to evaluate the musculoskeletal competency examination further validates the use of the examination and confirms the conclusions from our previous study. 
As we noted previously1, the average amount of time spent in courses or rotations dedicated to orthopaedics was only 2.1 weeks for all examinees, and 33% of them graduated from medical school with no such exposure. One or two weeks, representing
<2% of the entire typical curriculum, is probably insufficient, and even if all students were to receive two weeks of
instruction, it would be important that the emphasis of that exposure be on topics of acknowledged importance. (The standard
rotation in orthopaedic surgery probably emphasizes too many particulars of surgical practice.) The ideal course in usculoskeletal medicine should concentrate on common outpatient orthopaedic problems, orthopaedic emergencies, and the
musculoskeletal physical examination. As seen from the responses of program directors of internal medicine departments,
topics such as fractures, back pain, arthritis, and infections are recognized as important. Indeed, for sixteen of twenty-five questions, the importance score given by the internal medicine program directors was higher than that given by the orthopaedic program directors.
It should be noted that the mean absolute difference in importance scores was <1 for fifteen of the twenty-five questions and <2 for twenty-two. Still, some of the areas of disagreement are instructive. One of the three questions for
which the difference in the importance scores was >2 (question 1) asked about perinatal hip dislocation; this question addresses a topic that is no doubt important but perhaps not to a group of program directors of internal medicine departments. It is fair to say that the patients seen in their departments do not present with this condition. Likewise, the other two questions (18 and 21), which asked about differences between rheumatoid arthritis and osteoarthrosis and between osteoporosis and osteomalacia, can be thought of as more typical issues for internists. Accordingly, the internal medicine
group ranked the importance of these questions higher than the orthopaedic group did. Thus, if only one group of doctors
contributes to curricular design, it is likely that some important topics will be omitted. These data suggest that a concerted effort will be most productive.
Medical school curricula must place a greater emphasis on musculoskeletal medicine. Because of the aging of the population, the prevalence of bone and joint diseases in the United States -- already the primary reason that people seek medical care -- is sure to rise. Thus, the demands will soon be even greater. Students must master the topic of musculoskeletal medicine.