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From the Virginia College of Osteopathic Medicine and Virginia Polytechnic Institute and State University, both in Blacksburg, Va (Stockard), and Oklahoma State University College of Osteopathic Medicine in Tulsa (Allen). Dr Stockard served as president of the American Osteopathic Academy of Sports Medicine from 2002 to 2003. Dr Allen served as the American Osteopathic Association's editor in chief from 1987 to 1998.

Address correspondence to Alan R. Stockard, DO, Virginia College of Osteopathic Medicine, 2265 Kraft Dr, Blacksburg, VA 24060-6360. E-mail: astockard{at}vcom.vt.edu

Background: Consistent with osteopathic principles and practice, the nation's colleges of osteopathic medicine (COMs) have emphasized the significance of the musculoskeletal system to the practice of medicine. The authors hypothesized that graduating COM students would, therefore, demonstrate superior knowledge and competence in musculoskeletal medicine when compared with graduates of allopathic medical schools.

Methods: The authors asked graduating COM students to complete a standardized and previously validated 25-question basic competency examination on musculoskeletal medicine in short-answer format. Originally developed and validated in the late 1990s, the examination was distributed to allopathic medical residents at the beginning of their residencies. The authors compare their results with those reported by Freedman and Bernstein for allopathic residents.

Results: When the minimum passing level as determined by orthopedic program directors was applied to the results of these examinations, 70.4% of graduating COM students (n=54) and 82% of allopathic graduates (n=85) failed to demonstrate basic competency in musculoskeletal medicine. Similarly, the majority of both groups failed to attain the minimum passing level established by the directors of internal medicine programs (graduating COM students, 67%; allopathic graduates, 78%).

Conclusion: In an examination of competence levels for musculoskeletal medicine, students about to graduate from a COM fared only marginally better than did their allopathic counterparts. To ensure that all graduating COM students have attained a level of basic competence in musculoskeletal medicine, the authors recommend further study as a prelude to evaluation of the didactic and clinical curriculum at all 22 COMs and their branch campuses.

Because 56% of primary care physicians report that the only formal instruction they have received on the musculoskeletal system was during medical school,³ the importance of undergraduate medical education training in musculoskeletal medicine is clear. However, nearly half of all allopathic training institutions in the United States had no required student instruction in musculoskeletal medicine.⁴ Indeed, other researchers⁵ have found that many medical students and residents in the United States are inadequately trained and poorly prepared to manage their patients' musculoskeletal complaints.

Knowledge of the anatomy, physiology, and pathology of the musculoskeletal system is the cornerstone of osteopathic medical practice. The ability to treat patients' musculoskeletal conditions using osteopathic manipulative treatment (OMT) requires that the osteopathic physician have a basic understanding of the biomechanics of the musculoskeletal system. It is estimated that, when compared with their allopathic counterparts, osteopathic medical students receive an additional 200 hours of training in musculoskeletal medicine.⁶ For example, the anonymous institution involved in the present investigation, has a required 4-week clinical rotation in osteopathic manipulative medicine (OMM) (data on file; written communication, 2002). Because the colleges of osteopathic medicine (COMs) emphasize excellence in musculoskeletal medicine—in keeping with osteopathic principles and practice—it is reasonable to hypothesize that graduating COM students would perform much better than their allopathic counterparts when tested for basic competence in musculoskeletal medicine.

In 1998, Freedman and Bernstein⁷ reported on student knowledge of concepts in musculoskeletal medicine during medical training at allopathic institutions. They used a basic competency examination in musculoskeletal medicine that was validated by orthopedic surgery residency program directors who set a minimum passing grade of 73.1%.⁷ Several years later, they reported on the review and validation of this examination by internal medicine residency program directors who set a slightly lower passing grade of 70% for the same examination.⁸ In Freedman and Bernstein's investigation,^7,8 the 25-question, self-administered examination was voluntary for first-year allopathic medical and surgical residents in various specialties who were beginning the first year of their residencies. The examination was not a requirement for the residency program. The training of these new allopathic residents was equivalent to what COM students would also have in the first month of an osteopathic internship, approximately 4 to 8 weeks after graduation. In the results reported by Freedman and Bernstein,^7,8 82% of first-year allopathic residents failed to demonstrate basic competency in musculoskeletal medicine when measured by the standards set by the orthopedic chairmen, and 78% failed when measured by the standards set by the internal medicine directors.

	Materials and Methods

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This study received prior approval from the institutional review board at the anonymous COM involved in the present study. As noted, the 25-question examination was previously validated^7,8 and was in fill-in-the-blank, short-answer format, which minimizes the possibility that respondents could guess correct answers as in multiple-choice examinations. The examination tests basic clinical knowledge in musculoskeletal medicine (Table 1). As noted in Table 1, test developers provided answers that allow for some subjectivity, but only within strict guidelines. No time limit was provided for completion of the examination, but we found that most graduating COM students took less than 1 hour to complete it.

The examination was administered in May 2003 to the COM site's 108 fourth-year students 1 week prior to graduation. As in the original study,⁷ informed consent was obtained verbally from the students prior to test distribution. No personal identifiers were placed on the examinations by researchers or by the students. The examination was scored anonymously by the principal investigator (A.R.S.) according to the answer key, and partial credit was given when appropriate (Table 1). The raw score was then multiplied by four to obtain a percentage score. Although demographic data were gathered for the allopathic medical students in the original study, we chose not to collect it in the present study of graduating COM students because of the tendency of the COMS to emphasize primary care practice throughout the 4-year curriculum.^6,9

	Results

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Fifty-four (50%) of the 108 eligible graduating COM students voluntarily completed the examination. The mean examination score for these students was 65.65%, with a range of 35% to 86%. It is interesting to note that this range is identical to the range reported by Freedman and Bernstein⁷ for allopathic medical graduates. Thirty-eight (70.4%) graduating COM students failed to meet the minimum passing score of 73.1% set as the standard by orthopedic directors. Thirty-six (67%) graduating COM students failed to meet the minimum passing score of 70% set as the standard by internists.

	Comment

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Given the assumption that COM graduates should have more knowledge of musculoskeletal medicine than their allopathic counterparts because of the osteopathic medical profession's emphasis on the musculoskeletal system,⁶ the anticipated result of such an examination would be that the majority of students about to graduate from a COM would receive a passing score on any standardized and validated measure. Instead, however, the majority of graduating COM students failed this standardized and validated examination designed to demonstrate basic competence in musculoskeletal medicine.

Although graduating COM students fared better than their allopathic counterparts, it is the responsibility of researchers and osteopathic medical educators to ask: Is a 70% (or 67%) failure rate acceptable? The findings of the present study suggest that the curriculum of this COM should be further examined to determine the factors responsible for the observed inadequacies. Whether these findings can be extrapolated to other COMs is yet to be demonstrated. Further study is encouraged.

In the earlier Freedman and Bernstein study,⁷ students who had taken a required orthopedic clinical rotation in medical school did not score as well as those who took an elective orthopedic rotation, suggesting that the required rotation was either of little interest to students or that the course was "too brief for the essential information to be conveyed." The authors also stated that, based on their experiences, "many elective orthopedic rotations stress inpatient experiences in highly specialized areas of orthopedic surgery rather than common outpatient problems."⁷ Although demographic data and training history were not gathered for these graduating COM students, as noted, one might assume that osteopathic medical students who took an elective rotation in orthopedic surgery would have performed equally well.

	Dividing the Work: Redressing Competence in Musculoskeletal Medicine at the COMs

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In analyzing the questions that the graduating COM students most often answered correctly, as well as the ones on which students performed most poorly, some deductions can be made. On the assumption that a thorough didactic or clinical course in orthopedics would allow the examinee to score 100%, one could also look at other medical disciplines and make observations about which other medical specialties (given similar didactic or clinical time) could impart the knowledge necessary to allow COM students to demonstrate an adequate mastery of musculoskeletal medicine on this standardized examination.

After further review of Freedman and Bernstein's examination, we decided to group the 25 questions by the medical specialty or academic department that would be the most likely to impart the knowledge necessary for students to appropriately address the clinical question(s) presented. The 11 medical specialties used in this analysis are as follows: anatomy, emergency medicine, family medicine, internal medicine, neurology, OMM, orthopedic surgery, pediatrics, radiology, rheumatology, and sports medicine (Table 1).

As might be expected, there were many areas of overlap. Question 1 could be addressed in any of three departments, while question 10 might be addressed in any (or all) of eight. On average, nearly six departments were potentially able to convey the particular information sought for any single question appearing in the competency examination by Freedman and Bernstein.

By our determination, of the 25 questions, all were related to the practice of orthopedic surgery and/or family medicine, with 24 questions related to primary care sports medicine, and 18 to the practice of emergency medicine. Fifteen of the questions could conceivably be covered in coursework from OMM departments. All other disciplines noted were represented in the single digits (Table 2).

Because the five disciplines of family medicine, orthopedic surgery, sports medicine, emergency medicine, and OMM make up the bulk of the disciplines that could impart the most clinically applicable knowledge of musculoskeletal medicine to COM students, one could infer that an emphasis on musculoskeletal clinical topics in these five disciplines would produce better proficiency in this discipline as measured in Freedman and Bernstein's validated examination.⁷ Ideally, clinical knowledge of musculoskeletal medicine and physical examination skills should be an integral part of the required OMM and physical diagnosis courses students take during their first 2 years at the COMs.⁶ These skills are then honed in subsequent clinical rotations.

There has long been a debate at the COMs about the necessity of requiring predoctoral clinical rotations in family medicine, emergency medicine, and orthopedic surgery. Not all COMs require an OMM clinical rotation.¹⁰ Very few, if any, COMs require clinical rotations for primary care sports medicine.¹⁰

Freedman and Bernstein⁸ recommended that the "standard" orthopedic rotation should exclude the particulars of operative techniques and instead emphasize office orthopedic skills. Because the current methods of teaching musculoskeletal knowledge appear to not be effective, as measured in the Freedman and Bernstein competency examination, we recommend that the COMs consider requiring a 2- to 4-week clinical rotation in musculoskeletal medicine that emphasizes common outpatient orthopedic problems, orthopedic emergencies, and physical examination of the musculoskeletal system. This kind of clinical experience should give each COM student the base of knowledge necessary to adequately evaluate clinical musculoskeletal problems. A primary care sports medicine rotation would also adequately address all of these areas of clinical knowledge. One possibility would be to require a primary care sports medicine rotation, either in lieu of an orthopedic rotation or as 2 to 4 weeks of the 3-month family medicine rotation.

	Conclusion

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Clearly, graduates of any COM should be able to perform basic musculoskeletal and orthopedic clinical examinations. As stated earlier, a great deal of primary care practice involves musculoskeletal problems.^1–3 Because most osteopathic graduates enter primary care residencies,⁹ it is important that COM graduates be well prepared as they continue to hone their clinical skills in diagnosing and treating patients' musculoskeletal complaints. Until the COMs can improve the musculoskeletal knowledge base of their graduates, perhaps a 4-week primary care sports medicine rotation, at the very least, should be mandatory in every family medicine residency program. Based on the current inadequacies of medical education in musculoskeletal medicine, we recommend that pediatric and internal medicine residency programs include primary care sports medicine rotations as well. Improving the knowledge of clinical musculoskeletal medicine in these primary care specialties should be a priority for osteopathic medical educators.

We have made some generalizations about all COMs in this study based on our experiences in the field of osteopathic medical education. It is our belief, however, that the present study serves the osteopathic medical profession well when interpreted as a snapshot in time of a single COM. Further study is required to make more concrete statements and recommendations. Future researchers on this topic may consider adding a survey to obtain demographic and related information about students, enhancing researchers' abilities to further scrutinize possible relationships between students' academic and clinical experiences and the results of validated examinations of competence on various clinical topics.

	Acknowledgment

 
The authors thank administrative assistant Donna K. Spencer for her assistance in preparing this manuscript.

	References

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1. Craton N, Matheson GO. Training and clinical competency in musculoskeletal medicine [review]. Identifying the problem. Sports Med.1993;15:328 –337.[Medline]

2. De Lorenzo RA, Mayer D, Geehr EC. Analyzing clinical case distributions to improve an emergency medicine clerkship. Ann Emerg Med. 1990;19:746 –751.[Medline]

3. Rekola KE, Keinanen-Kiukaanniemi S,Takala J. Use of primary health services in sparsely populated country districts by patients with musculoskeletal symptoms: consultations with a physician. J Epidemiol Community Health.1993; 47:153 –157.[Abstract]

4. DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am. 2003;85:565 –567.[Free Full Text]

5. Clawson DK, Jackson DW, Ostergaard DJ. It's past time to reform the musculoskeletal curriculum. Acad Med.2001; 76:709 –710.[Medline]

6. Association of Colleges of Osteopathic Medicine. Osteopathic Medical College Information Book: 2006 Entering Class. Chevy Chase, Md: Association of Colleges of Osteopathic Medicine; 2005. Available at: http://www.aacom.org/data/cib/CIB2006.pdf. Accessed May 25, 2006.

7. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am.1998; 80:1421 –1427.[Abstract/Free Full Text]

8. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am.2002; 84:604 –608.[Abstract/Free Full Text]

9. Obradovic JL, Beaudry SW, Winslow-Falbo P. Osteopathic graduate medical education. J Am Osteopath Assoc. 2006;106:59–68. Available at: http://www.jaoa.org/cgi/content/full/106/2/59. Accessed May 12, 2006.

10. Singer AM. 2004 Annual Report on Osteopathic Medical Education. Chevy Chase, Md: Association of Colleges of Osteopathic Medicine; 2005. Available at: http://www.aacom.org/data/annualreport/index.html. Accessed May 25, 2006.

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Stockard, A. R. Articles by Allen, T. W. Search for Related Content PubMed PubMed Citation Articles by Stockard, A. R. Articles by Allen, T. W.