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Important Demographic Variables Impact the Musculoskeletal Knowledge and Confidence of Academic Primary Care Physicians
Joseph R. Lynch, MD1; Gregory A. Schmale, MD1; Douglas C. Schaad, PhD1; Seth S. Leopold, MD1
1 Departments of Orthopaedics and Sports Medicine (J.R.L., G.A.S., and S.S.L.) and Medical Education and Biomedical Informatics (D.C.S.), University of Washington Medical Center, 1959 N.E. Pacific Street, Box 356500, Seattle, WA 98195. E-mail address for J.R. Lynch: joelynch@u.washington.edu
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Investigation performed at the Department of Orthopaedics and Sports Medicine and the Department of Medical Education and Biomedical Informatics, University of Washington, Seattle, WashingtonThe authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Jul 01;88(7):1589-1595. doi: 10.2106/JBJS.E.01365
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Background: Although most musculoskeletal illness is managed by primary care providers, and not by surgeons, evidence suggests that primary care physicians may receive inadequate training in musculoskeletal medicine. We evaluated the musculoskeletal knowledge and self-perceived confidence of fully trained, practicing academic primary care physicians and tested the following hypotheses: (1) a relationship exists between a provider's musculoskeletal knowledge and self-perceived confidence, (2) demographic variables are associated with differences in the knowledge-confidence relationship, and (3) specific education or training affects a provider's musculoskeletal knowledge and clinical confidence.

Methods: An examination of basic musculoskeletal knowledge and a 10-point Likert scale assessing self-perceived confidence were administered to family practice, internal medicine, and pediatric faculty at a large, regional, academic primary care institution serving both rural and urban populations across a five-state region. Subspecialty physicians were excluded. Individual examination scores and self-reported confidence scores were correlated and compared with demographic variables.

Results: One hundred and five physicians participated. Ninety-two physicians adequately completed the musculo-skeletal knowledge examination. Fifty-nine (64%) of the ninety-two physicians scored <70%. Higher examination scores were associated with male gender (p = 0.01) and participation in a musculoskeletal course (p = 0.009). Practitioners who took elective courses demonstrated higher scores compared with those who took required courses (p = 0.014). Greater musculoskeletal confidence was associated with the number of years in clinical practice (p = 0.045), male gender (p = 0.01), residency training in family practice (p < 0.00001), and prior participation in a musculoskeletal course (p = 0.0004). Physicians demonstrated greater confidence with medical issues than with musculoskeletal issues (mean confidence scores, 8.3 and 5.1, respectively; p < 0.00001). Higher scores for musculoskeletal knowledge correlated significantly with increasing levels of musculoskeletal confidence (r = 0.416, p < 0.0001).

Conclusions: Although a large proportion of primary care visits are for musculoskeletal symptoms, the majority of primary care providers tested at a large, regional, academic primary care institution failed to demonstrate adequate musculoskeletal knowledge and confidence. Further characterization of the relationship between knowledge and confidence and its association with demographic variables might benefit the education of musculoskeletal providers in the future.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Joseph R. Lynch, MD
    Posted on August 12, 2006
    Dr. Lynch and colleagues respond to Dr. Gardner
    Dept. Orthopaedics & Sports Medicine, University of Washington School of Medicine, Seattle, WA

    We thank Dr. Gardner for his thoughtful comments concerning our paper and we agree that this issue warrants further study.

    Dr. Gardner’s first concern is that the 25-item test originally created by Drs. Freedman and Bernstein does not accurately reflect the musculoskeletal knowledge required of practicing primary care physicians. The specific issue is that some questions concerned topics in orthopaedic trauma, which may be beyond the scope of practice of some primary care providers. Indeed, a minority of the questions do refer to musculoskeletal trauma (36%, 9 of 25 questions). However, these particular questions do not ask the primary care physician for management decisions; rather, they test the ability of the physician to recognize orthopaedic emergencies and identify the anatomic structures that might be in jeopardy when these emergencies occur. While this might not be relevant to the practice of every provider, certainly these issues are likely to come up in the practices of primary care physicians whose scope of practice includes covering high school sports teams, urgent care facilities, and walk-in clinics. Perhaps more importantly, it is worth recognizing that the remainder of the examination – approximately two-thirds of the overall test – covered what would be considered “general practice” by any definition, including diagnoses such as arthritis, compressive neuropathies, back pain, health maintenance screening as it relates to the musculoskeletal system, and common infectious and oncological concerns. The initial evaluation, treatment, and appropriate referral of these conditions are routinely performed by primary care physicians. In fact, the physicians tested in this study performed worse on questions dealing with office-based musculoskeletal care than they did with orthopaedic emergencies. For instance, 89% of participating physicians were able to recognize compartment syndrome as a surgical emergency needing appropriate referral; however, only 58% of the providers understood the difference between osteoporosis and osteomalacia. This must be considered within the purview of a primary care physician, given that osteoporosis in one study was the third most common musculoskeletal problem addressed by primary care physicians(1). Lastly, to our knowledge, the test instrument created by Drs. Freedman and Bernstein is the only previously published, field-tested examination of musculoskeletal knowledge that has been endorsed by program directors of internal medicine programs from across the country, who, incidentally weighted the importance of this test more heavily than originally weighted by the test’s creators(2).

    Of course, Dr. Gardner is right that no exam can cover all topics, and none can be completely relevant to all providers. We also agree that there might be other examinations that could be developed to test particular groups of primary care providers, or examinations that emphasize different kinds of musculoskeletal content. We encourage Dr. Gardner and others interested in these topics to write – and importantly, to validate – other test instruments; and to examine perhaps other populations to see whether the findings we observed at a top academic primary care program generalize well to other physician populations. If such validation can be made, perhaps it will prompt the changes not only to medical school education, but to graduate medical education and continuing medical education that our work suggests is also necessary.

    Again, we thank Dr. Gardner for his interest, and encourage his work toward the creation of evidence-based assessment tools that will help improve the musculoskeletal knowledge and confidence of primary care providers.


    1. Lynch, J. R.; Gardner, G. C.; and Parsons, R. R.: Musculoskeletal workload versus musculoskeletal clinical confidence among primary care physicians in rural practice. Am J Orthop, 34(10): 487-91, discussion 491- 2, 2005.

    2. Freedman, K. B., and Bernstein, J.: Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am, 84-A(4): 604-8, 2002.

    Gregory C. Gardner, M.D., FACP
    Posted on July 19, 2006
    Knowing what our primary care providers need to know
    University of Washington, Seattle, WA 98195

    To The Editor:

    I applaud the efforts of Lynch and colleagues for further enlightening us on the crisis in musculoskeletal education in the US. Their article indicates the lack of a consistent basic fund of musculoskeletal knowledge for our medical providers that our medical schools should be providing to every graduate. I do have several comments.

    As a rheumatologist who has spent his entire career educating internal medicine residents in the area of musculoskeletal medicine, I do not think the Freedman and Bernstein 25 item assesment test (1) accurately reflects the issues most primary care internist face in practice. It is a one size fits all test and is really an orthopaedic assessment that is heavily weighted toward orthopaedic trauma (9/25 items). While this may be more relevant to certain primary care providers (family practice physicians or rural internists) it does not reflect the musculoskeletal problems seen on a daily or weekly basis by most primary care internists. I know chairs of mecical departments endorsed the test but I am not sure in most cases they would be the best group to evaluate orthopaedic issues. I understand a more directed assessment is under study currently.

    My second comment is more general. In Lynch's previous paper on this topic (2), he deliniated what a rural internist was actually seeing in clinic with regard to musculoskeletal problems. I think this type of information should be our starting point for teaching future generations of primary care providers. Teaching should address their future needs rather than be based on a hypothetical curriculum generated by expert opinion and panels. While a good place to start, this cannot substitute for evidence based curriculum development. Knowing what they need to know will help us know what to teach and allow us to develop more useful assessment tools.

    The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.


    1. Freedman, KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80:1421-7.

    2. Lynch Jr, Gardner GC, Parsons RR. Musculoskeletal workload versus musculoskeletal clinical confidence among primary care physicians in rural practice. Am J Orthop. 2005;34:487-92.

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