Discussion
Our students’ mean examination score was significantly lower than the passing (competency) score of 73.1%. Although Project 100 acknowledged many medical schools for implementing a required musculoskeletal course, our study results showed that adequate competency as indicated by a passing score on the Freedman and Bernstein examination was not achieved in medical school despite devoted musculoskeletal lecture time. Our postmodule group had lower scores than our premodule group despite being exposed to more lecture and laboratory material that systematically addressed every examination question. Similarly, Day and colleagues6 found that medical students scored a mean of 45% on the Freedman and Bernstein examination despite increased lecture and laboratory time.6 Lecture and laboratory exposure does not result in long-term information retention. Medical school competency is not significantly higher than what Freedman and Bernstein4 found for musculoskeletal education almost a decade earlier.
Musculoskeletal medicine typically is not revisited during medical school unless a student opts for an elective with a musculoskeletal basis. This specialty differs from others, such as neurology, which requires a 1-month clinical rotation before graduation. As increasing lecture and laboratory time did little to increase competency, adding a required clinical rotation in a musculoskeletal field or integrated musculoskeletal modules for anatomy and clinical training may be the best option for educational reform.
Our study found significantly higher Freedman and Bernstein examination scores for students with orthopedic surgery or rheumatology experience than for students without this experience. First- and second-year medical students are allowed to do a “selective” rotation—1 afternoon a week in an elective rotation of their choice. Students with orthopedics or rheumatology experience in this setting tended to score higher on the examination, possibly a result of both exposure to and interest in musculoskeletal issues. Many other studies have found that clinical exposure within a musculoskeletal field resulted in significantly higher musculoskeletal knowledge.8,12-16 Skelley and colleagues12 found that musculoskeletal clinical exposure of as short as 15 days significantly increased understanding among medical students. Grunfeld and colleagues15 found that students interested in orthopedics also had significantly more musculoskeletal knowledge. Musculoskeletal clinical exposure should be considered in medical school reform. As coordinating a curriculum with orthopedic resident and faculty involvement can set up educational barriers at some medical schools, dedicated musculoskeletal modules with a mock clinical skills component may be a useful consideration, and these have been shown to improve musculoskeletal knowledge.10,11
There are limitations to our study. The musculoskeletal examination was not given to an equal number of medical students in each group. The study also did not control for attendance, and therefore some students who took the musculoskeletal examination may not have attended all musculoskeletal module lectures. The validated examination used for basic competency is another possible limitation. The Freedman and Bernstein examination is the only validated examination used for basic competency, but it may not accurately assess meaningful development of clinical skills applicable to a patient musculoskeletal setting. No studies have assessed the correlation between musculoskeletal competency based on the Freedman and Bernstein examination and patient outcomes.
We conclude that increasing dedicated musculoskeletal lecture hours does not improve musculoskeletal knowledge. Future considerations should include incorporating further hands-on training through clinical skills workshops or rotations in orthopedic surgery or rheumatology.