Extract
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 twenty-five-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 concern 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%,
nine of twenty-five 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—covers 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 patients with 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 on
those dealing with orthopaedic emergencies. For instance, 89% of the
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 in one study osteoporosis was found to be the third most common
musculoskeletal problem addressed by primary care
physicians2. 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 it was originally weighted by the test's
creators3.
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 twenty-five-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 concern 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%,
nine of twenty-five 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—covers 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 patients with 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 on
those dealing with orthopaedic emergencies. For instance, 89% of the
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 in one study osteoporosis was found to be the third most common
musculoskeletal problem addressed by primary care
physicians2. 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 it was originally weighted by the test's
creators3.
Of course, Dr. Gardner is right that no examination 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 to 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 perhaps
examine other populations to see whether the findings that 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 also to graduate medical
education and continuing medical education that our work suggests are
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.
Freedman KB, Bernstein J. The adequacy of medical school education
in musculoskeletal medicine. J Bone Joint Surg Am.
1998;80:
1421-7.801421
1998
[PubMed]
Lynch Jr, Gardner GC, Parsons RR. Musculoskeletal workload versus
musculoskeletal clinical confidence among primary care physicians in rural
practice. Am J Orthop.
2005;34:
487-92.34487
2005
[PubMed]
Freedman KB, Bernstein J. Educational deficiencies in
musculoskeletal medicine. J Bone Joint Surg Am,
2002;84:
604-8.84604
2002
[PubMed]