The rationale for a preclinical musculoskeletal course lies in the prevalence of musculoskeletal diseases, injuries, and disorders. More than 30% of Americans have a musculoskeletal condition requiring medical attention, and workers in the United States miss nearly 440 million days of work annually because of musculoskeletal injuries1. Musculoskeletal disorders cost the United States nearly 850 billion dollars yearly and are the leading cause of disability in the United States1.
The economic impact of musculoskeletal disorders is also considerable. Yelin et al. estimated that the economic impact was nearly $200 billion per year, or approximately 2.5% of the annual U.S. gross domestic product2. Moreover, many studies have demonstrated a substantial deficit in musculoskeletal knowledge among recent medical school graduates and other practitioners3-5. There have been calls to reform the preclinical musculoskeletal medical school curriculum6, as well as proposals for a core set of standards for musculoskeletal content7.
Two recent studies have described the development of a self-contained preclinical musculoskeletal course for either first or second-year students8,9. Another recent study described the process of curricular reform in the first and second years of medical school without a self-contained musculoskeletal course10. Both were designed with input from educators in several different medical and basic-science specialties, as was ours. The University of Minnesota course included seventeen hours of lecture content, similar to the amount in our course (twenty hours). The authors cited their small-group experience as essential to the success of the course8. The Louisiana State University course spanned six weeks and included forty-four hours of lecture and seventeen hours of small-group teaching9. Both studies emphasized anatomy and physical diagnosis and found substantial improvement in musculoskeletal knowledge and physical examination skills.
Despite the development of these courses, musculoskeletal disorders remain underrepresented in the curricula of many medical schools. In 2003, only fifty-one of 122 medical schools in the continental United States and Hawaii reported having a preclinical musculoskeletal course11. The increasing prevalence of musculoskeletal disease and the documented dearth and deficiencies of providers are important justifications for increased curricular attention.
To provide more elective time and to better integrate the basic-science and clinical years, a curriculum revision was adopted at our School of Medicine in 1970-1971. Although other aspects of the curriculum have since been modified, an organ-system approach to the entire second year has been retained. General pathology is part of block one, and specialty-specific pathology and pharmacology are integrated into each organ-system block. An introduction to clinical medicine and seminars in the humanities and social sciences run intermittently throughout the year.
Coursework in gross and microscopic anatomy and other basic medical sciences, including embryology, biochemistry, physiology, immunology, and bacteriology, takes place in year one, and specialty-specific material on each subject is added during the organ-system blocks in year two.
Clinical clerkships make up the third year. The fourth year is elective, for which successful completion of at least seven one-month electives is required. About 40% of all students have a rotation on orthopaedics during their third (two weeks) or fourth (four weeks) year.
The committee that developed the musculoskeletal course originally was set up by the chief of orthopaedics who served as chair. It was composed of five orthopaedists, a physiologist, a biochemist, an anatomist, and a pathologist who met monthly during 1968 through 1970. Over approximately eighteen months, the committee planned the course, outlined educational objectives, wrote the syllabus, and prepared lectures and laboratory material. The preparation (thirty hours) and presentation (120 hours) of the course in subsequent years has taken about 150 faculty hours and begins about four months prior to the course. The preparation is managed by a small committee of orthopaedists and a staff person, although lectures are also given by a biochemist, rheumatologists, an anatomist, and other orthopaedists. Basic scientists are asked to demonstrate clinical relevance in their lectures, and clinicians are expected to point out the basic science underlying the recognition and management of clinical disorders. Six faculty members have participated in the course for twenty years or more.
The two-week course begins with normal development of the musculoskeletal system and proceeds to how this development may go awry to produce congenital malformations. The gross anatomy of the limbs and back is then reviewed and related to common clinical disorders encountered in these areas. Next, the tissues of the musculoskeletal system, i.e., bone, muscle, cartilage, and synovium, are considered separately with respect to histologic structure, physiology, biochemistry, and pathology. Two days are devoted to cartilage and the arthritides and one day is devoted to trauma, which includes the systemic and local response to musculoskeletal injury and principles of diagnosis and management.
The course is given at the end of the second year and has forty contact hours. The four-hour period each day (8 a.m. to 12 noon) is divided equally between lectures and small-group sessions (see Appendix). The lectures focus on the objectives and amplify and illustrate the material contained in the syllabus. The syllabus is 235 pages in length, consisting of 188 pages of textual material that addresses the educational objectives and forty-seven pages of material for small-group sessions, which includes a list of radiographs with normal and abnormal findings to be shown each day, photomicrographs of slides for study by streaming video and virtual microscopy (which has replaced microscopes), points to be covered in physical diagnosis of the limbs and back, and case mysteries, for which students must integrate clinical, radiographic, and pathologic information.
The objectives and text for each topic in the syllabus are reviewed by the committee and topic lecturers annually and are modified as needed to accommodate new developments and areas deserving more or less emphasis or clarification as determined by student performance and comment.
All lectures are now presented in a PowerPoint format (Microsoft Office; Microsoft, Redmond, Washington) and are posted on the School of Medicine's second-year curriculum web site ten to fourteen days before the lecture. Audio from the lectures is also recorded through the School of Medicine's lecture capture system. These audio files are available for students to review in conjunction with the slides. The audio and PowerPoint files are available to students for approximately one year from the date of the lecture, facilitating review of material for the course examination as well as Part I of the U.S. Medical Licensing Examination (USMLE-I). Attendance at musculoskeletal course lectures has not decreased in the year since the institution of lecture recording.
Content issues and questions are addressed in real time by lecturers and small-group faculty during their respective sessions. The School of Medicine also maintains an online course forum where students can post questions or raise administrative issues. The course director posts responses to these issues as expeditiously as possible.
There are five small-group sections, each containing thirty to thirty-five students and taught by a faculty member and a resident. On most days, the groups will be split into two, with the faculty member and resident each teaching groups of fifteen to eighteen students. These sessions allow opportunities for interactive discussion and clinical applications of the day's topics. Physical diagnosis is covered on anatomy days, along with normal and abnormal findings on radiographs. Pathology is studied in groups of three or four students with streaming video and virtual microscopy. Pathologic material is correlated with radiographs, laboratory values, clinical findings, and, when feasible, with patient presentations. The final day of the course is a review in the small-group sections, emphasizing the objectives for each topic and allowing time for student questions.
The emphasis of the course is the basic science of musculoskeletal disease. Instructors are specifically discouraged from using the word "orthopaedic(s)" in their discussion groups and lectures. While surgical treatment may be discussed in general terms, the course is not intended to be an introductory course in orthopaedics, although it does generate interest in the clinical aspects of musculoskeletal diseases and disorders.
Course Objectives
General educational objectives (course goals) were developed, along with specific objectives for each of the twenty-three topics covered. All objectives are stated in behavioral terms. The general objectives, which have not changed, are that the students, on completion of the course material, and using the syllabus as a standard reference, will be able to describe, list, or recognize the following:
- Normal development, structure (gross and microscopic), and function of the musculoskeletal system
- Normal physiology and biochemistry of bone, cartilage, synovium, and muscle
- Pathologic changes produced in bone, cartilage, synovium, and muscle by injury or disease
- Correlations among the pathologic, radiographic, laboratory, and clinical aspects in patients with musculoskeletal disorders.
Because of the limited experience of students with the musculoskeletal system, the objectives are confined to knowledge, comprehension, and application of the course material. Approximately 70% of the questions entail application of basic information in a clinical setting.
The objectives for each topic are currently under study to determine whether they can be aligned with the core competencies used to guide graduate medical education.
The order in which the lecture topics are listed in the musculoskeletal course schedule reflects the order of their coverage in the syllabus (see Appendix).
The topical objectives, course content, and format have changed remarkably little during the forty-year history of the course, although advances in technology, e.g., PowerPoint, streaming video, and virtual microscopy, have led to improved methods of presenting the course material.
Evaluation of Students
Two-thirds of the student grade comes from a final examination consisting of eighty multiple-choice questions, with the number of questions on each topic determined by the time dedicated to the teaching of that subject. Approximately 75% of the questions each year come from previous tests that are at least three years old, and the remaining questions are new. All written examination questions are based on one or more of the educational objectives.
The other third of the grade comes from performance in the small groups, half of which is determined by a "practical" test consisting of twenty multiple-choice questions that involve correlation of basic and clinical information; the other half is derived from day-to-day performance in Socratic teaching exchanges.
Normative scoring is used, with honors awarded to approximately the top 15% of the class. A failing grade is given if the raw score is <70% and more than two standard deviations below the mean. Typically, one to three students fail the course, which requires remediation and passing another "final" examination before the student can progress to the next year. Temporary grades of "incomplete" (usually due to illness) and "conditional" (borderline failure) are also available, although we have rarely used the conditional grade. Missed examinations must be made up within eight weeks and are converted to an honors, pass, or fail grade.
Test scores are returned to the course director within a few hours after the examination, along with test item psychometrics that include the difficulty and discrimination indices. The difficulty index represents the proportion of students who answer a question correctly; indices range from 0 to 1.00, with larger numbers representing an easier item and smaller numbers, a harder one. The preferred range for the difficulty index is 0.20 to 0.80. The discrimination index reports the difference in performance on a given item between students whose overall test scores were high and those who had overall low scores. Discrimination indices range from 0.00 to 1.00; higher is better. A negative index means that more low scorers on the entire test answered the question correctly than high scorers. Questions with a difficulty index and a discrimination index below 0.20 are reviewed for construction, appropriate distractors, and correlation with course objectives. If question(s) are thrown out (usually one or two each year), the examination is regraded for all students without those questions.
Pretest
A recent innovation has been the use of a pretest before the delivery of any course material. Our aim was to determine the students’ level of musculoskeletal knowledge from previous courses to assess the appropriate emphasis for each topic. The pretest was the same length (eighty multiple-choice questions), with approximately the same average difficulty and discrimination indices as the final examination (a difficulty index of 0.72 compared with 0.77, and a discrimination index of 0.22 compared with 0.21).
Each topic was given a similar number of questions in both examinations, and the time to complete the pretest was identical to that for the final examination. Students were asked to bring the same motivation to the pretest as to the final examination and were assured that no individual grades would be produced for the pretest.
The advantage of a pretest for the students is the opportunity to take a practice test (actually, an old final examination) under standardized conditions. We also posted the test with the answers on the second day of the course so that students might learn from their mistakes. The advantage to the faculty was the opportunity for more precise planning of the content emphasis given to each topic.
In 2009, the pretest was well received by the students and was associated with the highest class mean on the final examination in the past five years. The mean score on the pretest, which was taken by 153 of the 159 students, was 32.23 (range, 10 to 48.75). For the final examination, which was taken by all 159 students, the class mean was 76.74 (range, 50 to 100), with a broad Gaussian distribution of scores for both tests.
The overall quality of the courses was numerically rated (from 1 indicating excellent to 5, poor) by the students. According to the data that were available for eight years prior to 1998, the mean rating was 1.84 (range, 1.7 to 2.0) for the musculoskeletal course and 2.43 (range, 1.7 to 3.79) for all courses.
Since 1998, each student has been required to complete a more detailed questionnaire (four to twenty pages, depending on the number of narrative comments), providing similar (1 through 5) numerical ratings on the pedagogical aspects of the course: grading and assessment, course materials, instructional methods, and the treatment of students, along with narrative comments in each area. Since 1987, there has also been a separate vote by the students for the best course of the second year. In the twenty-three years since the best course award was established, the musculoskeletal course has won it ten times, another course has won it three times, three others have won it twice, and four have won it once.
In the narrative feedback from students in their end-of-course evaluations, the most highly praised aspects of the course have consistently been (1) the small-group teaching sessions, (2) course organization and content, and (3) the course materials provided.
The positive aspects of the small-group sessions cited most often by the students each year are as follows:
- Problem-solving by correlation of the clinical, radiographic, laboratory, and pathological findings, with emphasis on fitting all of the pieces together logically
- Faculty members and residents becoming quickly familiar with the names and faces of the students in their small groups
- Use of illustrative patients
- Use of a collegial (versus so-called pimping) approach in the Socratic exchanges, with nonthreatening, interactive dialogues, in which students are encouraged to request consult from one of their peers, if needed.
While students invariably prefer small-group teaching to lectures, the lectures set the stage by covering the content material that will be discussed in the small groups that follow each day. Since these small-group sessions require five faculty members and five residents for two hours each morning, preliminary planning and adjustment of clinic and operating room schedules are necessary.
In addition to generating very favorable ratings among second-year students, the course prepares students well for national examinations, although we have made no specific effort to prepare students for such testing. The USMLE has been given only since 1992, and the National Board of Medical Examiners (NBME) does not provide specific numerical data for individual courses because their test items are frequently integrated across disciplines, thereby contributing to more than one subscore area. The NBME now releases discipline/organ system-specific performance information each year in the form of a "score plot," which provides the mean course scores and one standard deviation from the national mean for first-time U.S. and Canadian test takers. We were able to recover plots from 1999 through 2007. Over this nine-year period, our students performed above the national mean in the musculoskeletal course each year, which was equaled by only one other course. In four of those years, the mean score on Part I of the USMLE for the musculoskeletal system was the highest among the nineteen second-year courses at our institution. In the other five years, it was second to the score for biostatistics and epidemiology, an area of emphasis at our institution that offers a semester-long clinical epidemiology course. This degree of exposure perhaps makes our course somewhat unique among medical schools. It may also be noteworthy that most schools that offer biostatistics and epidemiology do so during the first year of medical school12.
During the forty-year history of this course, it has become clear that its continued effectiveness is related primarily to the use of small-group teaching. Other critical elements include the following:
- Detailed precourse planning, including development of the objectives and syllabus
- Annual postcourse analysis of student performances, comments, and suggestions, followed by review of the course objectives, text (syllabus), and pedagogy, with modifications as needed for currency, emphasis, or clarification
- Faculty commitment and continuity.
Increasing clinical demands on faculty members have made it more difficult to sustain the quality of the course. While the School of Medicine provides financial support, this remuneration is not commensurate with the clinical revenues "lost" because of faculty time spent in lecture and small-group sessions. It is therefore critically important that departments and institutions prioritize teaching at the level of support necessary to ensure quality education. The orthopaedic department at our university has fostered such a culture to the extent that even the more clinically oriented faculty members support and contribute to the course each year.
Given the prevalence of musculoskeletal disease and injuries, we believe that medical education should include a thorough introduction to the anatomy and pathophysiology underlying these conditions.
This course has been highly effective in teaching residents as well as medical students, and many features of our course, such as the substantial amount of time devoted to small-group teaching and multidisciplinary involvement, have been emulated by other courses in our school. Rotating the teaching responsibilities each year for small-group activities has enabled us to spread the time commitment more equitably among the faculty.
We hope that our experience will be instructive to educators creating or modifying similar courses in other institutions.