To The Editor:
As chairman of the Publications Committee of the American Academy of
Orthopaedic Surgeons (AAOS), I was pleased to see a review of our book
Musculoskeletal Medicine
(2004;86:
1350). I was further pleased to see
that the reviewer had noted the book's "pleasing breadth and depth of
information" and had cited its clear writing, excellent illustrations,
and very useful section on physical examination.
It was disappointing, however, to read the reviewer's complaint that the
book may frustrate primary care physicians or specialists. In Dr. Bernstein's
preface, it was clearly stated that Musculoskeletal Medicine is a
book for students written because "nearly half of American medical
schools did not require a course in musculoskeletal medicine." Students
often acquire information on musculoskeletal conditions in a piecemeal fashion
on a variety of rotations. As the preface clearly states, this book was
conceived as an overview providing an organizational structure "to help
place concurrent observations, readings, and clinical experiences in
perspective. It aims to serve as a springboard to further study and
application. There are gaps in this book, no doubt, but they are unavoidable.
To make things manageable, some detail had to be sacrificed."
The AAOS has published a book for primary care physicians—the
well-received Essentials of Musculoskeletal Care, now in its second
edition—and, of course, many, many books for specialists. I am pleased
that the reviewer ended by stating that "this book can be recommended to
medical students and residents as an excellent introduction to musculoskeletal
medicine." But such a disproportionate amount of the reviewer's critique
was dedicated to listing the book's failings as a "best reference text
for primary-care practitioners" that I am afraid that the overall
positive recommendation for students might be drowned out.
R.A. Deyo replies:
In response to Dr. Levine's concerns, I am happy to reiterate and amplify
my statement that Musculoskeletal Medicine can be recommended to
medical students and residents. I certainly understand the constraints of
space, format, and readability. However, most of the readers of JBJS
are not medical students or residents, so it seemed important in the review to
offer caveats for the general reader. I also had the impression that
Musculoskeletal Medicine was intended in part for primary care
physicians; hence my comments in that direction.
Intended audience aside, I think it is time for all of us in medical
education to bring more emphasis to the principles of evidence-based medicine.
Once we move beyond the realm of anatomy and physiology into diagnosis and
therapy, these principles become paramount. Just how accurate is a diagnostic
test in comparison to some "gold standard"? What is the clinical
evidence that a treatment is more effective than a placebo (or alternate
treatments), beyond a physiologic rationale?
It seems important to expose to our trainees the quality of clinical
evidence and ambiguities in our knowledge, lest they believe that medical
knowledge is more monolithic than it is. Even for a trainee audience, I might
have hoped for more emphasis on these principles.