Teaching the Musculoskeletal Exam: A Pathophysiology-Focused Approach

Renee Modica, MD, Emily von Scheven, MD
Fall 2003

BACKGROUND INFORMATION:
Traditionally, the musculoskeletal exam is taught and practiced on normal adult subjects early in one's medical training without a structured link to abnormal physical findings, disease pathology or differential diagnosis. The introduction of these concepts occurs after a significant time lag in one's medical training. Learning the musculoskeletal physical exam in the context of disease pathology and relevant clinical scenarios will allow students to utilize physical findings to assist in the development of differential diagnosis. Rheumatic and Orthopedic disciplines include a variety of disorders that provide an excellent framework to teach the basic principles of the musculoskeletal exam, as well as disease pathology and differential diagnosis.

There are many arguments to support the importance of developing competence in musculoskeletal exams skills and knowledge of musculoskeletal conditions within the core medical curriculum. Musculoskeletal complaints are common in the primary care setting. Often, primary providers are under skilled in the intricacies of the musculoskeletal exam as well as knowledge of musculoskeletal diseases. Despite current efforts to provide appropriate training, many of these diseases continue to go unrecognized in the primary care setting for many years; resulting in inefficient and substandard care for these patients. The prevalence of long term, chronic, debilitating musculoskeletal diseases continues to rise with escalating economic and social consequences within the societal and medical communities.

It is imperative to improve the manner in which the musculoskeletal exam is taught. This curricular need can be improved through the use of a novel approach to teaching the musculoskeletal exam. The use of pathophysiology-focused clinical vignettes as an addition to the Musculoskeletal FPC curriculum will help first year medical students not only learn the appropriate exam, but arrive at differential diagnosis of musculoskeletal conditions.

GOALS:
There will be two primary goals of our project:

1. We propose to teach musculoskeletal physical diagnosis to medical students in a novel manner that will facilitate the integration of physical exam findings with the underlying pathogenesis and differential diagnosis. Our approach will utilize case-based vignettes that focus on potential underlying disease pathology as a tool for reviewing abnormal physical findings and generating differential diagnoses.
2. To evaluate the efficacy of our intervention through the use of a randomized crossover design that compares pre- and post-intervention questionnaire performances. Additionally, course evaluations for student feedback and perception of competence will be administered.

PROCEDURES:
The following methods will be used to achieve the educational goals outlined above:

AIM I: Musculoskeletal skills teaching
A large group didactic lecture will provide an overview of the musculoskeletal system by reviewing the relevant anatomy, physiology and gait cycle. The instructor will then demonstrate the physical exam on a student volunteer and explain the components of the exam as it is performed.
Students will then divide into small groups of 5-7 students and a facilitator. A series of pathophysiology focused clinical vignettes will be discussed. The vignettes will concentrate on one of the following three areas of the musculoskeletal systems: "upper extremities," "lower extremities," and "spine." Each case will be problem-oriented and will consist of a chief compliant, brief history, and picture(s) and/or video clip of the physical exam abnormality within one of these regions of the musculoskeletal system. The students will discuss 2-3 cases per each region of the musculoskeletal system.
Discussions of the cases will proceed in a step-wise fashion in order to link the history and physical exam findings to the disease pathology and ultimately a differential diagnosis. First, the morbid finding will be identified and described. Second, the underlying pathophysiology of the physical abnormality will be discussed. Third, a differential diagnosis will then be generated based on the presumed pathophysiology. Finally, that region of the physical exam will be practiced on the individual members of the small group. By discussing the clinical scenarios in the context of disease pathology, we believe the students will conduct their exam in a more purposeful manner.

Approximate time course:
1. Each session will take approximately four hour's time to complete for each group of students (5-7students/group/instructor).
a. One hour didactic session
b. Thirty minutes for instructor to demonstrate the exam and answer questions
c. Two and a half hours to review the cases and practice the exams

AIM II: Evaluation
Evaluation of the efficacy of this methodology will be important for the purpose of scholarly publication. Pre and Post intervention questionnaires will be created for this purpose. (SEE: PLAN FOR MEASUREMENT AND DOCUMENTATION OF PROJECT EFFICACY AND OUTCOME for details). Direct questioning during the case based vignettes will allow assessment of the learner's knowledge. Students will provide and receive feedback on each other as they practice their physical exam techniques. Direct observation by the educators will provide another means of assessing skills performance and competence. A checklist in the facilitator manual will be created for this purpose. After completion of the physical exam exercise, the students will then complete a course evaluation. Student evaluation forms will obtain feedback regarding the teaching methods used, the quality of the educators and the educational materials, and their own self-perception of competence in the musculoskeletal exam.

Implementation:
In order to accomplish these educational goals we will need to create the case-vignettes, modules for the facilitators, evaluation forms, checklists, as well as "pre- and post-intervention questionnaires" over the next six months. Videotaping and photographing patients in the pediatric rheumatology and orthopedic clinics will create cases with a wide representation of various gait and musculoskeletal abnormalities. This session will be incorporated into the current core curriculum in the "FPC-Musculoskeletal Skills I & II" targeting 1st year medical students.

PLAN FOR MEASUREMENT AND DOCUMENTATION OF PROJECT EFFICACY AND OUTCOME
We will evaluate the efficacy of our intervention through the following modalities:

See accompanying appendix IV for a schematic of the study design described below:

Administration of a "knowledge skills based" pre/post-intervention student questionnaire in a randomized cross over design will allow for us to study the effectiveness of this intervention. The class will be randomly divided into two equal sized groups: "I" and "II." The same intervention will be given on both Tuesday and Thursday within the same week by the same facilitators and all pre and post testing will occur within the same week as follows: All students will take the same baseline pretest on Monday, prior to this intervention. The intervention will be given to group I on Tuesday. All students from both groups will take an equivalent test on Wednesday. This test will function as the first posttest for the "group I" and the second pretest for the "group II." Students from the group II will receive the same intervention on Thursday. On Friday, all students will take another equivalent test. This test will be the second posttest for the "group I" and the first posttest for the "group II."

The following analyses will be preformed:
1. The pretest given on Monday will serve as an individual knowledge baseline for both groups.
2. The first posttest scores from the "group I" can be compared to the second pretest scores for "group II." This comparison will assess the effectiveness of this intervention by comparing the difference in scores between the two groups; group I with the intervention and group II without the intervention.
3. Pre and post test scores of individual subjects within each group can be compared to assess individual subject improvement.
4. The first and second posttest scores for group I can be compared to evaluate their retention of knowledge by looking for a diffusion effect.

Course evaluation:
A course evaluation form will be given at the completion of the course; directly after the intervention in their small groups. Students will be asked questions regarding feedback, course evaluation and their perception of competence in performing the musculoskeletal exam.
Facilitators will be given checklists to document the student's individual competence in performing the musculoskeletal exam. Also, we will consider looking at performance scores on a musculoskeletal OSCE later in the year; which can be compared to prior years' performances.

PLAN FOR CONTINUATION OF PROJECT AT THE END OF FUNDING CYCLE:
Once the cases, didactic materials, facilitator manuals, questionnaires, checklists, and evaluation forms are constructed, this project will be very portable, expandable and self-sustainable from a financial standpoint. There is willing faculty available in the departments of pediatric orthopedics and rheumatology to continue to expand upon and sustain this project. Additionally, there are many other potential areas for this curriculum to be integrated, for example: "I-3" block course, "Physical Exam Elective," pediatric rheumatology and orthopedic elective rotations. The sophistication of the cases can be easily adjusted to the level of the learner. Future cases will be created for the purpose of the pediatric rheumatology elective rotation prior to the completion of my fellowship.

For more information, please contact:
Renee Modica, MD
Emily von Scheven, MD