Academic Medicine 2007 (May); 82 (5): 452–457
Charles S. Day, MD; Albert C. Yeh; Orrin Franko; Miguel Ramirez; Edward Krupat, PhD
Harvard Medical School,
Orthopedic Hand Surgery,
Beth Israel Deaconess Medical Center,
Boston, Massachusetts 02215, USA
Purpose: To assess medical students' knowledge and clinical confidence in musculoskeletal medicine as well as their attitudes toward the education they receive in this specialty.
Method: A cross-sectional survey of students in all four years of Harvard Medical School was conducted during the 2005-2006 academic year. Participants were asked to fill out a 30-question survey and a nationally validated basic competency exam in musculoskeletal medicine.
Results: The response rate was 74% (449/608). Medical students rated musculoskeletal education to be of major importance (3.8/5) but rated the amount of curriculum time spent on musculoskeletal medicine as poor (2.1/5). Third-year students felt a low to adequate level of confidence in performing a musculoskeletal physical examination (2.7/5) and failed to demonstrate cognitive mastery in musculoskeletal medicine (passing rate on competency exam: 7%), whereas fourth-year students reported a similar level of confidence (2.7/5) and exhibited a higher passing rate (26%). Increasing exposure to the subject by taking clinical electives resulted in greater clinical confidence and enhanced performance on the exam (P < .001). Students' feedback suggested that musculoskeletal education can be better integrated into the preclinical curriculum, more time should be spent in the field, and more focus should be placed on common clinical conditions.
Conclusions: These findings, which are consistent with those from other schools, suggest that medical students do not feel adequately prepared in musculoskeletal medicine and lack both clinical confidence and cognitive mastery in the field. Implementing a four-year integrated musculoskeletal curriculum is one way that medical schools can address this concern.
From the FULL TEXT Article:
The discrepancy between the widespread impact of musculoskeletal diseases on society and the relative inattention devoted to this subject in the undergraduate medical curriculum has been a subject of increasing concern during the past five years. [1–8] In data reported over the past 15 years, musculoskeletal complaints and injuries have comprised approximately 15% to 30% of primary care visits in the United States and Canada,  20% of emergency room visits in the United States,  and 20% of nonroutine pediatric visits in Europe.  In 2004, the National Ambulatory Medical Care Survey indicated that musculoskeletal conditions were the number-one reason across the United States for visits to physicians’ offices, with approximately 92.1 million cases reported annually.  As part of the global initiative aimed at increasing awareness and reducing societal burden arising from these conditions, the World Health Organization designated the years 2000 to 2010 as The Bone and Joint Decade.  The United States later reemphasized this effort by adopting the National Bone and Joint Decade in 2002. 
In light of these initiatives, there has been much focus recently on the responsibilities of undergraduate medical institutions in providing adequate musculoskeletal education. In 2005, the Association of American Medical Colleges (AAMC) brought to attention that despite the increasing prevalence of musculoskeletal conditions spread across a broad spectrum of clinical practice, it is not clear that medical schools are effectively educating future physicians in this field.  Furthermore, recent studies suggest that the discrepancy between the magnitude of musculoskeletal problems and physician competency in musculoskeletal medicine likely stems from educational deficiencies at the medical school level. [2–8]
Various metrics have been employed to evaluate the adequacy of musculoskeletal training. In 2001, a comprehensive study reviewing the curricula of all Canadian medical schools indicated that directors of undergraduate musculoskeletal programs felt dissatisfied with the curricular time devoted to musculoskeletal education.  In the same year, survey responses by over 1,900 second-year residents in United States residency programs revealed that residents felt poorly or very poorly prepared in their training when conducting a musculoskeletal examination on various parts of the body.  In 2003, Freedman and Bernstein2 reported first-year residents’ performance on a validated basic competency exam in musculoskeletal medicine. According to a passing standard set by 240 internal medicine residency program directors in the United States, 78% of these first-year residents failed to meet the passing criterion expected from medical school graduates.
In an effort to gain a more comprehensive assessment of students’ overall attitudes toward and knowledge of musculoskeletal medicine, we combined the various approaches from the literature by evaluating medical students’ clinical confidence, cognitive mastery, and perception of education in musculoskeletal medicine.