Editorial:

End Medical Mis-Management
of Musculoskeletal Complaints

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary.   If you want information about a specific disease, you can access the Merck Manual.   You can also search Pub Med for more abstracts on this, or any other health topic.

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Editorial Commentary:

Question:   Are medical doctors well trained to diagnose
or treat musculoskeletal complaints?

Answer:   Discover the unsettling truth in this series of peer-reviewed articles.

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Chiropractors pride themselves in their ability to diagnose and manage neuro-musculo-skeletal (NMS) complains. According to all the surveys, this is our bread and butter, and no one on the planet is better trained to diagnose (locate) and treat (correct) neck, low back, or peripheral joint (knee, elbow etc) complaints. But, don't just take my word for it. Read on.

Orthopedic surgeons are supposed to be the *gods* of medicine, the pinnacle of medical knowledge. First they become MDs, then rotate through a variety of specialties, and finally take residence in a highly competitive orthopedic program. You may want to review this interesting description of the requirements for the UCLA Orthopedic Surgery's Residency Program.

The following is a long and sad tale about the weakness of modern medical education. This series of articles were all mostly published in the prestigious Journal of Bone and Joint Surgery, the Number One journal for orthopedic surgeons.

In 1998, two medical doctors at the University of Pennsylvania School of Medicine in Philadelphia, contacted all 157 chairpersons of orthopedic residency programs in the United States. Together they developed and validated a basic-competency examination in musculoskeletal medicine to give to the first year orthopedic residents. The results were astounding, because 82% of these medical school graduates failed this BASIC competency exam!

Four years later they redesigned the exam and LOWERED the passing score from 74% to 70%. Even so, 78% of them STILL failed the exam, with a mean test score average of 59.9 percent. Isn't that frightening?

To add insult to injury, this exact same test was given to a group of 51 chiropractic students during their last semester of schooling.   The results? 70% of the chiropractic students passed the test. This is in contrast to an 80% failure rate for the MDs.

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For clarity sake, you need appreciate the actual difference between the chiropractic and the medical participants in these studies.

• The chiropractic group were still JUST STUDENTS in their last undergraduate year
  
  
• The medical group had already graduated medical school, been awarded their MD degrees, completed all their hospital rotations, and finally been accepted into a highly competitive orthopedic residency program.

One would expect that, during their 5 years of medical training, followed by endless hours of hospital rotations and residency programs, that all these doctors *might have* picked up a little more musculoskeletal knowledge along the way.   Evidently this is NOT the case.

These medical authors concluded that residents in orthopedic surgery programs are not provided with sufficient training in NMS analysis. The truth is, they are incompetent in musculoskeletal assessment or treatment. This situation was not corrected during the 4-year interim between the publication of the 1st and 2nd article, and this has yet to be corrected 16 years later!

This is a HUGE problem because: “conditions affecting the musculoskeletal system are the primary reason patients seek medical care from physicians, accounting for nearly 100 million office visits per year. [1] Furthermore, musculoskeletal conditions are the most common cause of long-term pain and physical disability.” [2, 3] What's the best solution? If you have spinal pain, seek care from someone who is properly trained to assess and manage your care. That person is a chiropractor. REFERENCES: Musculoskeletal Cconditions in the United States. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999 Burden of Major Musculoskeletal Conditions Bull World Health Organ 2003 (Nov 14); 81: 646–656 Musculoskeletal Curricula in Medical Education Physician and Sportsmedicine 2004 (Nov);   32 (11)

The following articles are listed from the oldest to the newest, so that you can fully appreciate the lack of progress at medical schools in correcting this issue.

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The Adequacy of Medical School Education in Musculoskeletal Medicine
Journal of Bone and Joint Surgery 1998 (Oct);   80-A (10):   1421–1427
This is the original article, which found that 82 per cent of medical school graduates failed a valid musculoskeletal competency examination. They concluded that "we therefore believe that medical school preparation in musculoskeletal medicine is inadequate" and that medical students were inadequately trained to diagnose and treat musculoskeletal complaints.

Educating Medical Students About Musculoskeletal Problems:
Are Community Needs Reflected in the Curricula of Canadian Medical Schools?
Journal of Bone and Joint Surgery 2001 (Sept);   83-A (9):   1317–1320
Musculoskeletal problems are a common reason why patients present for medical treatment. The purpose of the present study was to review the curricula of Canadian medical schools to determine whether they prepare their students for the demands of practice with respect to musculoskeletal problems. The curriculum analysis revealed that, on the average, medical schools in Canada devoted 2.26% (range, 0.61% to 4.81%) of their curriculum time to musculoskeletal education. Our literature review and survey of local family physicians revealed that between 13.7% and 27.8% of North American patients presenting to a primary care physician have a chief symptom that is directly related to the musculoskeletal system. (So they conclude:) There is a marked discrepancy between the musculoskeletal knowledge and skill requirements of a primary care physician and the time devoted to musculoskeletal education in Canadian medical schools.

A Comparison of Chiropractic Student Knowledge Versus Medical Residents
Proceedings of the World Federation of Chiropractic Congress 2001 Pgs. 255
A previously published knowledge questionnaire designed by chief orthopedic residents was given to a Chiropractic student group for comparison to the results of the medical resident group. Based on the marking scale determined by the chief residents, the Chiropractic group (n = 51) showed statistically significant higher average grade than the orthopedic residents. Expressed in other terms, 70% of chiropractic students passed the knowledge questionnaire, compared to an 80% failure rate for the orthopedic residents.

Educational Deficiencies in Musculoskeletal Medicine
Journal of Bone and Joint Surgery 2002 (Apr);   84–A (4):   604–608
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. NOTE: This is a follow-up article to the Freedman study cited above, which demonstrated that medical students were inadequately trained to diagnose and treat musculoskeletal complaints. What would the headlines scream if, after 4 years, chiropractors had failed to improve their skills in musculoskeletal assessment and management? Ask your self why medicine is shown more slack?

Musculoskeletal Knowledge: How Do You Stack Up?
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.

Musculoskeletal Curricula in Medical Education
Physician and Sportsmedicine 2004 (Nov);   32 (11)
It's 8:00 pm on a Monday night. Just as you're getting ready to put your 5-year-old son to bed, he falls from a chair, landing on his wrist. It quickly swells, requiring a visit to a nearby urgent care clinic. At the clinic, a pleasant young resident takes a history, performs a physical exam, and orders an x-ray to evaluate the injury. You are told that nothing is broken, and a wrist splint is placed. The following day, however, you receive a phone call from the clinic informing you that upon further review of the radiographs, a fracture was detected, and your son will need a cast for definitive treatment. This scenario, while fictitious, is not unusual. According to some studies, up to 10% of wrist fractures are missed at the initial evaluation.¹ While pediatric fractures are often difficult to detect, this example highlights a problem that continues to plague medical education: inadequate instruction in musculoskeletal medicine in both medical school and residency training.

Adequacy of Education in Musculoskeletal Medicine
Journal of Bone and Joint Surgery Am 2005 (Feb);   87 (2):   310–314
In this study, 334 medical students, residents and staff physicians, specializing in various fields of medicine, were asked to take a basic cognitive examination consisting of 25 short-answer questions - the same type of test administered in the original JBJS 1998 study. The average score among medical doctors, students and residents who took the exam in 2005 was 2.7 points lower than those who took the exam in 1998. Just over half of the staff physicians (52%) scored a passing grade or higher on the 2005 exam. Only 21% of the residents registered a passing grade, and only 5% of the medical students passed the exam. Overall, Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination.

More Evidence of Educational Inadequacies in Musculoskeletal Medicine
Clin Orthop Relat Res 2005 (Aug);   (437):   251–259
A modified version of an exam used to assess the competency of incoming interns at the University of Pennsylvania was used to assess the competency of medical students during various stages of their training at the University of Washington. Despite generally improved levels of competency with each year at medical school, less than 50% of fourth-year students showed competency. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient and that competency increased when learning was reinforced during the clinical years.

Why is the Bone and Joint Decade Important?
Welcome to the United States Bone and Joint Decade
The Bone and Joint Decade initiative is a global campaign to improve quality of life for people with musculoskeletal conditions and to advance understanding and treatment of these conditions through research, prevention, and education. [1]   The Decade aims to raise the awareness of the increasing societal impact of musculoskeletal injuries and disorders; empower patients to participate in decisions about their care; increase funding for prevention activities and research; and promote cost-effective prevention and treatment of musculoskeletal injuries and disorders.

Doctors Likely to Encounter Children With Musculoskeletal Complaints
Have Low Confidence in Their Clinical Skills
The Journal of Pediatrics 2009 (Feb);   154 (2):   267–271
Questionnaires, filled out by a broad spectrum of medical providers in England [Primary Care (n = 75), Pediatrics (n = 39), Emergency (n = 39), Orthopedics (n = 40), and experienced doctors in Primary Care (n = 93), and Pediatrics (n = 60).], revealed that 74% of them scored their personal confidence in pediatric musculoskeletal clinical assessment as "no" to "low".

Orthopaedists' and Family Practitioners' Knowledge of
Simple Low Back Pain Management
Spine 2009 (Jul 1);   34 (15):   1600–1603
One hundred forty family practitioners and 253 orthopaedists responded to the questionnaire. The mean family practitioners' score (69.7) was significantly higher than the orthopaedists' score (44.3) (P < 0.0001). No relation was found between the results and physician demographic factors, including seniority. Most orthopaedists incorrectly responded that they would send their patients for radiologic evaluations. They would also preferentially prescribe cyclo-oxygenase-2-specific nonsteroidal anti-inflammatory drugs, despite the guidelines recommendations to use paracetamol or nonspecific nonsteroidal anti-inflammatory drugs.

The Inadequacy of Musculoskeletal Knowledge After Foundation Training
in the United Kingdom
Journal of Bone and Joint Surgery Br 2009 (Nov);   91 (11):   1413–1418
The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment.

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Updated 9-02-2014