Scientific Articles   |    
An Assessment of Musculoskeletal Knowledge in Graduating Medical and Physician Assistant Students and Implications for Musculoskeletal Care Providers
Robert Grunfeld, MD1; Sharon Banks, DO1; Edward Fox, MD1; Bruce A. Levy, MD2; Clifford Craig, MD3; Kevin Black, MD1
1 Departments of Orthopaedics and Rehabilitation (R.G., E.F., and K.B.) and Medicine, Division of Rheumatology (S.B.), Penn State College of Medicine, Milton S. Hershey Medical Center, 30 Hope Drive, Hershey, PA 17033. E-mail address for R. Grunfeld: rgrunfeld@hmc.psu.edu
2 Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
3 Department of Orthopaedic Surgery, University of Michigan Health System PED ORS, 1500 East Medical Center Drive, Ann Arbor, MI 48109
View Disclosures and Other Information
  • Disclosure statement for author(s): PDF

Investigation performed at Penn State College of Medicine, Hershey, Pennsylvania

A commentary by Peter V. Scoles, MD, is linked to the online version of this article at jbjs.org.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Feb 15;94(4):343-348. doi: 10.2106/JBJS.J.00417
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case



The purpose of the present study was to evaluate musculoskeletal knowledge among graduating medical students and physician assistant students with use of a National Board of Medical Examiners (NBME) examination. We hypothesized that there would be no difference in scores between the two groups. In addition, we looked for relationships between examination scores and both the student-reported musculoskeletal experiences and the school-reported musculoskeletal curriculum.


One hundred and forty-four students from three medical schools and ninety-one students from four physician assistant schools were included in the present study; both groups were graduating students in the final semester of education. The National Board of Medical Examiners Musculoskeletal Subject Examination (NBME MSK) was utilized to assess musculoskeletal knowledge.


The mean examination score (and standard deviation) was 73.8% ± 9.7% for medical students and 62.3% ± 11% for physician assistant students (95% confidence interval [CI], −13.8 to 0.00; p < 0.05). Medical students with an interest in orthopaedics as a career scored significantly higher than those without an expressed orthopaedic interest, and medical students without an expressed career interest in orthopaedics scored significantly higher than physician assistant students (p < 0.05). Among medical students, a longer duration of a clinical rotation in orthopaedics was associated with a higher examination score (p < 0.05). The average number of hours of preclinical musculoskeletal education in the first two years of school was significantly higher for medical schools (122.1 ± 25.1 hours) than for physician assistant schools (89.8 ± 74.8 hours) (p < 0.05).


Graduating medical students scored significantly higher than graduating physician assistant students on the NBME MSK. This may be related to multiple factors, and further studies are necessary to evaluate the overall musculoskeletal clinical competence of both groups of students.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org


    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.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe

    Susan Robarts, Advanced Practice Physiotherapist, Team Leader; Dr. Helen Razmjou, Advanced Practice Physiotherapist; Deborah Kennedy, Manager, Program Development; Anne Marie MacLeod, Chief Operating Officer; Dr. Richard Holtby, Orthopaedic Surgeon; Dr. Jeffrey Gollish, Medical Director, Orthopaedic Surgeon.
    Posted on March 07, 2012
    Who is appropriate to provide nonoperative musculoskeletal services in order to alleviate system pressures?
    Sunnybrook Holland Orthopaedic & Arthritic Centre, Toronto, Canada.

    We read this article with interest, and we applaud the authors for their effort in investigating a matter related to healthcare human resources and alternate musculoskeletal service providers. The appropriateness of physician assistants in assuming roles in musculoskeletal care has not been extensively investigated in the literature. The authors’ goals were to assess and compare musculoskeletal (MSK) knowledge of students graduating from both medical schools and physician assistant programs through a standardized assessment of MSK knowledge. The authors’ interest in performing this comparison was based on the premise that physician assistants may be expected to contribute to the nonoperative management of patients with MSK conditions in that there is a shortage of orthopaedic surgeons on the horizon in the United States. The article by Dr. Grunfeld and colleagues addresses a critical question: who is appropriate to provide nonoperative MSK care in order to alleviate system pressures? In order to answer that question one must look beyond student-level knowledge and consider professional competency. The alternate care provider has to be at least as good as the medical counterpart they are replacing. We faced the same question 6 years ago. In Canada, a surgeon shortage was documented in 2003 (1). At our facility, Canada’s largest hip and knee arthroplasty program, wait times for consultations and surgery grew beyond what was acceptable in a publicly funded system. In 2005 we redesigned our system. From our experience with alternate care providers there are additional important factors to consider such as patient acceptance, maximization of existing human resources, value-add of various professionals and working examples of interprofessional MSK models of care around the world. The study’s population was that of graduating students with little specific MSK training. None of the participating medical schools required an MSK rotation while only one of the physician assistant programs required a clinical MSK rotation. Less than half of the participating physician assistants had taken an MSK clinical rotation and the amount of their preclinical MSK education was 55% that of the medical students. The comparison of 2 student groups with little MSK training cannot answer the question as to whether physician assistants are in a position to contribute to the management of orthopaedic patients, let alone perform as an alternate. Furthermore, test scores do not equal clinical competence. Competence in this scenario relates to the physician assistant’s ability to make similar and accurate diagnoses and care decisions relative to that of the orthopaedic surgeon. If the alternate care provider cannot do that, they have not added value. Where musculoskeletal competence (specifically, clinical diagnostic accuracy) has been studied, physician assistants have performed significantly below their physician counterparts (2). In contrast, the clinical diagnostic accuracy of experienced physiotherapists has not only been found to be higher than other physician groups but consistently comparable to that of orthopaedic surgeons (2-11). This should not be surprising; physiotherapists graduate with extensive experience in MSK evaluation. The authors state that patients deserve a “basic fund of musculoskeletal knowledge from their providers”. We would argue that patients deserve expert-level competence from their providers. Why should patients expect less? When developing interprofessional models of care, patient input on alternate care providers should be sought and acceptability evaluated (12). Several studies have demonstrated that patients are highly satisfied with advanced practice physiotherapists (alternate role title ‘extended scope physiotherapist’) providing the nonoperative management of musculoskeletal conditions previously provided by physician specialists in outpatient clinics and emergency departments (2-11). Similar results with physician assistants as alternates have yet to be reported. The growing body of literature surrounding advanced practice physiotherapists is promising. Our own 5-year experience in utilizing advanced practice physiotherapists in triaging patients for surgical consultation as well as performing hip and knee arthroplasty surveillance has been successful. Wait times to consultation have dropped and high patient satisfaction has been maintained, supporting earlier findings from the United Kingdom (14,15). The program has now been expanded to shoulder and spine specialty outpatient clinics and studies have commenced to evaluate agreement on recommendations for care as well as patient satisfaction between the surgeon and advanced practice physiotherapist. The added value that advanced practice physiotherapists bring is unique to their education and training and complements our surgical team. The advanced practice physiotherapist in orthopaedics brings expertise in nonoperative management, optimizing function, community resources, research and program evaluation, standards of care and quality assurance. The introduction of our interprofessional model of care has led to system-wide improvements in efficiency including: reducing wait times to assessment, redirecting 30% of referrals that are non-operative to appropriate conservative care (50%, in the shoulder program) and improving response times to patients with problems. Patients now see the healthcare provider that matches their needs, enabling the surgeon to see patients requiring their unique skillset. The study’s authors conclude with a quote from an official statement from the American Association of Physician Assistants that states that, because they train in a similar fashion, physician assistants “think like doctors”. When it comes to providing quality musculoskeletal care, we have found it beneficial to utilize regulated health care professionals that perform comparably to orthopaedic surgeons while adding-value with a complementary skillset. The shortage of orthopaedic surgeons looming in the United States was felt in the United Kingdom’s National Health Service well over a decade ago, spawning innovative interprofessional models of care. In Canada, we have benefitted from such experience and will continue to advocate for alternate care providers that demonstrate expert-level competence in order to face surgeon shortages and financial restraints with effective strategies. Only when the skill of alternate providers compares favourably, can we replace orthopaedic surgeons in the nonoperative management of patients with musculoskeletal care. REFERENCES: (1) Shipton D, Badley EM, Mohamed N. Critical shortage of orthopaedic services in Ontario, Canada. J Bone Joint Surg Am 2003;85-A(9):1710-1715. (2) Moore JH, Goss DL, Baxter, RE, DeBerardino TM, Mansfield LT, Fellows DW, Taylor DC. Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons and nonorthopaedic providers. J Orthop Sports Phys Ther 2005;35(2):67-71. (3) Hockin J, Bannister G. The extended role of a physiotherapist in an out-patient orthopaedic clinic. Physiotherapy 1994;80:281–4. (4) Weale AE, Bannister G. Who should see orthopaedic outpatients—physiotherapists physiotherapists or surgeons? Ann R Coll Surg Engl 1995;77 (suppl):71–3. (5) Daker-White G, Carr AJ, Harvey I, Woolhead G, Bannister G, Nelson I, Kammerling M. A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health. 1999;53:643-50. (6) Dickens V, Ali F, Gent H, Rees A. Assessment and diagnosis of knee injuries: the value of an experienced physiotherapist. Physiotherapy 2003; 89: 417-422. (7) Jibuike OO, Paul-Taylor G, Maulvi S, Richmond P, Fairclough J. Management of soft tissue knee injuries in an accident and emergency department: the effect of the introduction of a physiotherapy practitioner. Emerg Med J 2003;20:37-39. (8) Hattam P. The effectiveness of orthopaedic triage by extended scope physiotherapists. Clin Governance 2004; 9: 244-252. (9) Oldmeadow LB, Bedi HS, Burch HT, Smith JS, Leahy ES, Goldwasser M. Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care. Med J Aust. 2007;186:625-8. (10) Lebec MT, Jogodka CE. The physical therapist as a musculoskeletal specialist in the emergency department. J Orthop Sports Phys Ther. 2009; 39:221-229. (11) MacKay C, Davis AM, Mahomed N, Badley EM. Expanding roles in orthopaedic care: a comparison of physiotherapist and orthopaedic surgeon recommendations for triage. J Eval Clin Pract. 2009;15:178-83. (12) Robarts S, Kennedy D, MacLeod AM, Findlay H, Gollish J. A framework for the development and implementation of an advanced practice role for physiotherapists that improves access and quality of care for patients. Healthc Q. 2008;11:67-75. (13) Kennedy D, Robarts S, Woodhouse L, Gollish J. Patients are satisfied with advanced practice physiotherapists in a role traditionally performed by orthopaedic surgeons. Physiother Can. 2010;62:298-305. (14) Hourigan PG, Weatherley CR. Initial assessment and follow-up by a physiotherapist of patients with back pain referred to a spinal clinic. J R Soc Med 1994;87:213–14. (15) Rymaszewski LA, Sharma S, McGill PE, Murdoch A, Freeman S, Loh T. A team approach to musculo-skeletal disorders. Ann R Coll Surg Engl 2005;87:174-80.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    Connecticut - Orthopaedic Foundation
    CA - Mercy Medical Group
    CT - Orthopaedic Foundation