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Impact of Clinical Electives and Residency Interest on Medical Students' Education in Musculoskeletal Medicine
Albert C. Yeh, BA1; Orrin Franko, BA1; Charles S. Day, MD, MBA1
1 Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Orthopedic Surgery, 330 Brookline Avenue, Boston, MA 02215. E-mail address for C.S. Day: cday1@bidmc.harvard.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at Harvard Medical School, Boston, Massachusetts

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Feb 01;90(2):307-315. doi: 10.2106/JBJS.G.00472
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Abstract

Background: Despite the frequency of musculoskeletal conditions seen in a broad spectrum of medical practice, there is compelling evidence that medical schools are inadequately preparing students in this field. We compared medical students across all residency interests with respect to their clinical confidence, cognitive mastery, and perception of education in musculoskeletal medicine.

Methods: A cross-sectional survey study of third and fourth-year students at Harvard Medical School was conducted during the 2005-2006 academic year. Two hundred and forty-nine of 337 students completed the survey, yielding an overall response rate of 74%. All participants were asked to complete a nationally validated objective examination in musculoskeletal medicine and a thirty-question survey soliciting their top residency choice, all of the musculoskeletal electives that they had taken, their clinical confidence, and their attitudes toward musculoskeletal education.

Results: Residency interest significantly affected the third-year students' performance on the cognitive mastery examination (p = 0.018) and also significantly affected both the third and the fourth-year students' clinical confidence in their ability to perform an examination of the musculoskeletal system (p = 0.023 and p = 0.015, respectively). The students' perception of the importance of musculoskeletal medicine, regardless of their residency interest, correlated with their decision to take musculoskeletal clinical electives (p = 0.009 and p < 0.001 for third and fourth-year students, respectively). Perceived importance was also correlated with higher clinical confidence for third-year students (p = 0.043) and increased examination scores for fourth-year students (p < 0.001). However, only students who listed orthopaedic surgery as their top residency choice demonstrated cognitive mastery in musculoskeletal medicine and reported above-average clinical confidence in their ability to conduct an examination of the musculoskeletal system.

Conclusions: Students' residency interest and their perception of the importance of musculoskeletal medicine to their future career influence the education that they receive in this field. In particular, students interested in non-orthopaedic residencies failed to demonstrate cognitive mastery and lacked clinical confidence. Possible approaches for medical schools to tackle this important issue that merit further exploration include requiring additional time for education in musculoskeletal medicine and providing a more structured musculoskeletal curriculum.

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    References

    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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    Jaimo Ahn, M.D., Ph.D.
    Posted on March 20, 2008
    Educating and Recruiting Future Orthopaedists
    University of Pennsylvania, Philadelphia, PA

    To The Editor:

    As orthopaedic caregivers, we must regard proper medical education as the foundation of informed and caring musculoskeletal health in our communities. As orthopaedic surgeons treating a progressively larger cohort of patients, it is also critical to continue to recruit an increasing number of the best and the brightest into our field.

    Yeh and colleagues, in their article entitled “Impact of Clinical Electives and Residency Interest on Education in Musculoskeletal Medicine”(1), have made significant strides in tackling the former of the two issues by elucidating factors that contribute to cognitive mastery of and clinical confidence in musculoskeletal medicine. In their conclusion, they echo the challenge put forth in 2005 by the Association of American Medical Colleges to enhance exposure to musculoskeletal content over the course of a four-year medical education(2).

    Yeh et al. “suggest that the current medical school curricula may not be adequately preparing all medical students to deal with common musculoskeletal conditions.”(1). They also note that “possible approaches to addressing this issue include increasing the exposure that students receive in this field.”(1). This increased exposure to musculoskeletal medicine may not only enhance cognitive mastery of and clinical confidence in the subject matter, as the authors suggest, but it my also help tackle the second issue: enhance interest and potentially increase residency application rates in orthopaedic surgery among medical students.

    Why should this concern us? After all, orthopaedics has always had plenty of applicants and attracted the best. Recent trends from the NRMP, however, suggest that the popularity and competitiveness of orthopaedics in the Match is decreasing. So much so that the combined AOA and COA meeting in 2008 has convened a special symposium to address this issue. In addition, orthopaedic surgery has the second lowest relative rate of female applicants (after cardiothoracic surgery(3)-- effectively losing out on more than half of graduating medical student pool-- which will further hamper our ability to meet the demands of a growing orthopaedic patient population.

    What can we do to fix this downward trend? Required medical school instruction in musculoskeletal medicine has previously been associated with higher rates of application to orthopaedic surgery residency programs, with up to a 75% higher in rates of application among females(4). Yet clinical courses in musculoskeletal medicine are required by only 20% of American medical schools(5). Therefore, we have set out to prospectively evaluate the effects of exposure to easily available supplemental educational resources (Web-based or available materials, elective lectures of musculoskeletal content) on interest in orthopaedics among the largest but most neglected applicant pool: female medical students.

    Preliminary data at two years reveals that interim enhanced exposure to orthopaedic resources is significantly associated with increased interest, intent to enroll in an elective, and intent to apply for residency in orthopaedic surgery. As this cohort progresses in their medical education, we will determine if increased exposure to elective resources does, in fact, impact application and match rates among females in our field.

    Yeh et al.(1) comment that participants in their study rated “the amount of time spent on musculoskeletal education throughout their four years [as] ‘poor’”. Our preliminary data suggests that early exposure to educational resources of musculoskeletal content may prove a critical tool in recruiting more students, especially women, into enrolling in orthopaedic electives. With time, our prospective study will elucidate if this, in turn, translates into increased residency application and match rates among females, which will be necessary to meet the anticipated demands of the growing orthopaedic patient population.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Yeh AC, Franko O, Day CS. Impact of clinical electives and residency interest on medical students' education in musculoskeletal medicine. J Bone Joint Surg Am. 2008;90:307-315.

    2. Association of American Medical Colleges. Report VII. Contemporary issues in medicine: musculoskeletal medicine education. Medical School Objectives Project. Washington, DC: Association of American Medical Colleges; September 2005. https://services.aamc.org/Publications/index.cfm?fuseaction=Product.displayForm&prd_id=204&prv_id=245. Accessed 2008 Mar 10.

    3. Jolly P, Hudley DM, editors. AAMC data book: statistical information related to medical education. Washington, D.C.: Association of American Medical Colleges; 1999, Table F9.

    4. Bernstein J, DiCaprio MR, Mehta S. The relationship between required medical school instruction in musculoskeletal medicine and application rates to orthopaedic surgery residency programs. J Bone Joint Surg Am. 2004;86:2335-2338.

    5. DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am. 2003;85:565-7.

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