Equip Students for Musculoskeletal Evaluation by including a Hands-on Musculoskeletal Workshop Early in Your Curriculum Toney Welborn MD, MPH, MS; Brian Coleman MD; Mack Green MD – University of Oklahoma College of Medicine, Oklahoma City, OK; Jason Deck MD – University of Oklahoma School of Community Medicine, Tulsa, OK

Disclosures None

Objectives Articulate the extent of musculoskeletal complaints seen in primary care and recognize the need for proper physical exam training. Discuss current musculoskeletal exam curriculum at the University of Oklahoma College of Medicine, Oklahoma City, OK and School of Community Medicine, Tulsa, OK. Strategize methods to introduce or enhance current musculoskeletal physical exam education. Trouble shoot barriers to musculoskeletal physical exam education.

Time Table Introduction - 7 min. Pre-clinical MSK skills Education – 7 min. Oklahoma City Clerkship MSK skills Education – 7 min. Tulsa Clerkship MSK skills Education– 7 min. Questions & Suggestions for Small Group Topics – 10 min. Small Group Instructions – 2 min. Small Group Discussions – 30 min. Summary of Small Group Discussions – 10 min. Wrap up, Questions & Trouble Shooting Barriers – 10 min

Rate of Musculoskeletal Complaints National Ambulatory Care Survey 2010 top five ICD-9 Categories –V codes 19.4% –Respiratory 10.0% –Musculoskeletal 9.3% –Nervous and Sensory systems 8.8% –Circulatory 7.4% Ambulatory and Hospital Care Statistics Branch. National Ambulatory Medical Care Survey: 2010 Summary Tables. Washington DC: Centers for Disease Control and Prevention 2010, 33 pgs.

STFM FM Clerkship Curriculum Topics 3 of 20 in Core Acute Presentations –Joint Pain and Injury –Low Back Pain –Chest Pain (eg, costochondritis) Topics 2 of 14 in Core Chronic Disease Presentations –Arthritis –Chronic Back Pain Fields S, Society of Teachers of Family Medicine Clerkship Curriculum Task Force. The Family Medicine Clerkship Curriculum. Kansas City: STFM Foundation. September, 2009, 15 pgs.

fmCASES 40 Cases 4 Cases MSK focused Exam – 100 item

NBME FM Shelf Exam Core exam 80 questions –5-10% Diseases of MSK system & Connective Tissue Optional 10 question module in Musculoskeletal/Sports Injury

Medical Student MSK Knowledge Many studies focus on knowledge of musculoskeletal disease, few evaluate physical exam skills. Most of these knowledge evaluation studies find that students fall short of expectations. Grunfeld R, Banks S, Fox E, Levy BA, Craig C, Black K. An assessment of musculoskeletal knowledge in graduating medical and physician assistant students and implications for musculoskeletal care providers. J Bone Joint Surg Am 2012;94 (4): Day CS, Yeh AC. Evidence of educational inadequacies in region-specific musculoskeletal medicine. Clin Orthop Relat Res 2008;466 (10):

Medical Student MSK Exam Skills 2011, Harvard Medical School – Assessment of New Integrated Preclinical Musculoskeletal Curriculum –135 second year medical students –No change in clinical confidence at physical exam Day CS, Ahn CS, Yeh AC, Tabrizi S. Early assessment of a new integrated preclinical musculoskeletal curriculum at a medical school. Am J Orthoped 2011;40 (1):14-8.

Medical Student MSK Exam Skills 2012, U of Michigan – Assessment of musculoskeletal exam skills of 4 th year medical students using OSCE –3 stations – shoulder, back, knee –45 fourth year students – recognition but inability to perform Monrad SU, DiPonio L, Zeller J, et al. Assessment of musculoskeletal examination skills of 4th year medical students using a novel OSCE. Poster presented at: Medical Education Day Ann Arbor: University of Michigan Medical School; June 5, 2012.

Pre-Clinical MSK Education Brian Coleman MD 2 main methods during the first 2 years of school. –PBL cases –MSK workshop

Pre-Clinical MSK Education Review of the exams from the lecture I-(I)- Inspection P-(prefer)- Palpation R- (running)- ROM N- (naked)- Neurovascular exam S- (sometimes)- Special Tests Taught throughout the course of all MSK education on campus.

Pre-Clinical MSK Education Principles of clinical medicine course –Cases related to MSK problems. Knee pain Hip pain –Simulated patients used for interviews and exam skills. –Worked up by the first year students for possible diagnoses and treatments. –Reviewed with faculty and group assignments written out.

Pre-Clinical MSK Education Workshop Done during second semester of first year as part of the Principles of Clinical Medicine Coursework. Entire class (~150) has lecture about exams and methods. 2-5 days later workshop held to demonstrate and have hands on learning of exams. Groups of 6-10.

Pre-Clinical MSK Education Workshop faculty are sports medicine faculty, orthopedic faculty and residents, sports medicine fellow and SM track family medicine residents. 1.5 hours spent with each small group of students to learn the skills.

Pre-Clinical MSK Education KNEE –Varus/valgus stress test –Test for effusion –Lachman/anterior drawer –Posterior drawer –McMurray –Ober –Patellar tests: apprehension, grind ANKLE –Anterior drawer –Talar tilt –Compression

Pre-Clinical MSK Education SHOULDER –Rotator cuff strength –Drop arm test –Instability tests(apprehension, drawer signs) –Impingement signs(Neer’s, Hawkins’s) –Crossover LOW BACK –Straight leg raise –Patrick (FABER)—SI joint –Schober (ankylosing spondy) (10-15 cm) –Hoover (test for effort given)

OKC FM 3 rd year Clerkship Mack Green, MD Musculoskeletal workshop taught at the beginning of the rotation –4 week rotation –Small groups ~12 students –3 hour session –3 Faculty, 1 fellow 15-20% FM visits –Knee –Shoulder –Neck/Back –Wrist

PowerPoint Slide Handout Read prior to lecture Basic physical exam information –Concise –Relevant –To the point –Examples key history points and exam findings

Setting for MSK Workshop Student Feedback –More practice –Less lecture Hands on experience Tutorial vs lecture

Session Elements of good history –Mechanism, swelling, mechanical symptoms, alleviating/exacerbating factors, previous injury, etc. Inspection, palpation, ROM, Examination ANATOMY –Quiz throughout the session

Joint Exams Checklist Demonstration –One exam or specialty test at a time –Incorporate pathology and mechanism –Provide variation Allow practice –Observe each group Next test Entire exam

Checklist Example - Knee Inspection Palpation  Joint line  Patella  Quad tendon  Patellar tendon  IT band  LCL  MCL  Effusion  Tibial tuberosity  Femoral condyles  Fibular head ROM  Flexion  Extension Neurovascular Specialty exams  Lachman  Anterior drawer  Posterior drawer  Godfrey test (sag sign)  Valgus stressing  Varus stressing  McMurray’s  Apley’s compression test  Patellar compression test  Patellar grind test  Ober’s test

Visual-Positive Lachman

Additional Info Know Normal! Pathology? Mnemonics Clinical Pearls Cases –Buzz words

Tulsa 3rd Year MSK Skills Education Jason Deck MD Clinical site for MS3 and MS4 –Approximately 25 per class Full 30 month PA program –25 students in current class Primary Care Sports Medicine Fellowship –1 fellow, 2 full time faculty on site

Bedlam Clinic Free clinic run by medical students 1 afternoon per week (mandatory) and 2 evenings per week (voluntary) Students have a panel of patients for 2 years Longitudinal primary care experience

Family Medicine Clerkship 4 week rotation 2-6 medical students 2-4 PA students All students at one clinical site Most students in at least one sports clinic 1 hour musculoskeletal lecture during the rotation Musculoskeletal OSCE at the end of the rotation

MS3 Academy Once a month for entire 3 rd year class All day on a single topic One day on musculoskeletal exam/procedures Taught by sports medicine faculty and fellow - Physical exam - Injections

Small Group Instructions Introduce yourself, institution and current musculoskeletal physical exam curriculum Discuss the topic for your group –How can we do this without a Sports Medicine Fellowship? –How can hands on practice be maximized? –How do we provide experience with abnormal findings? –What are options for placement in my school’s curriculum? Identify action steps related to your topic Identify barriers preventing moving forward Teams share action steps and barriers with the large group

Action Steps & Barriers –How can we do this without a Sports Medicine Fellowship? –How can hands on practice be maximized? –How do we provide experience with abnormal findings? –What are options for placement in our curriculum?