Physician and Sportsmedicine 2002 (Aug); 30 (8)
One of every 4 or 5 primary care visits is for a musculoskeletal problem. Yet undergraduate and graduate training for this burden of illness continues to constitute typically less than 5% of the medical curriculum. This is an area of clear concern, but also one in which sports medicine practitioners can assume leadership.
In a 1998 study by Freedman and Bernstein,  82% of recent medical school graduates failed a basic competency exam in musculoskeletal medicine. One of the criticisms of the study was that the pass rate (73.1%), set by 124 orthopedic surgeons, was too high. In a new study by Freedman and Bernstein,  though, the same exam was validated by 240 (58%) of the 417 program directors of internal medicine departments in the United States. The pass score, set by the program directors themselves, was 70% (not much different than the pass score set by orthopedic surgeons). Using this new criterion, 78% of the previously tested examinees would still have failed the exam. The authors' conclusion is that medical school preparation in musculoskeletal medicine is inadequate.
In a follow-up letter to the most recent study, Broadhurst et al  reported results of the same musculoskeletal examination administered to an Australian cohort. Among 66 Australian interns, 60.6% failed the exam. However, 68% of 47 general practitioners who were also tested passed the exam.
Why did the GPs do better? Probably because they learned on the job. Using that as our "scientific theory," we recently administered the examination to attendees of The Physician and Sportsmedicine annual editorial board meeting. Our "hypothesis" was that sports medicine clinicians should perform pretty well on the exam, even though questions related to bone cancer or newborn physical examination are outside of their required knowledge domain. We controlled for confounding variables by administering the exam at the beginning of the dinner meeting, before wine was served.
Twenty-seven clinicians took the exam; 4 were orthopedic surgeons, and 23 were nonsurgical sports medicine practitioners. The average score was 89.1%. Twenty-six scored higher than 19 of 25, and 1 scored 17.5. Using the criterion of a 70% pass rate, 100% of the editorial board members passed the exam.
If the examination is a reflection of clinical competency, it is worth noting that sports medicine physicians seem to be particularly well suited to diagnose and treat the musculoskeletal burden of illness. Certainly, more study is needed to understand the outcome of such cognitive exams. It would be interesting to see what the pass rate would be for fellowship- and non-fellowship-trained physicians. Or for a large group of sports medicine clinicians.
For perspective, consider the results of a study  that looked at musculoskeletal injuries over a 20- to 30-year period and found one fourth of all participants sustained musculoskeletal injuries. Of these, one-third permanently stopped their exercise program. One wonders if the outcome of this study would have been different had these participants had access to good sports medicine physicians. Or, better yet, if there were more PSM editorial board members available!
Gordon O. Matheson, MD, PhD