Dr Scher is from the Department of Orthopedic Surgery, William Beaumont Army Medical Center, El Paso, Texas; Dr Boyer is from
the Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri; Dr Hammert is from the
Department of Orthopedic Surgery, University of Rochester Medical Center, Rochester, New York; and Dr Wolf is from the Department
of Orthopedic Surgery, University of Connecticut Health Center, Farmington, Connecticut.
Drs Scher, Boyer, Hammert, and Wolf have no relevant financial relationships to disclose.
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or
as reflecting the views of the Department of the Army or the Department of Defense. One of the authors is an employee of the
United States government, and this work was prepared as part of their official duty.
Correspondence should be addressed to: Jennifer Moriatis Wolf, MD, Department of Orthopedic Surgery, New England Musculoskeletal
Institute, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030-4037 (email@example.com).
Musculoskeletal complaints account for 9.9% of outpatient primary care office visits and 13.9% of emergency department visits
in the United States.
Orthopedic care accounted for 5.6% of emergency department procedures performed with annual direct and indirect costs for
bone and joint health accounting for $849 billion—7.7% of the gross domestic product.
In particular, the upper extremity was the most common injury-related body site in the emergency department, with injuries
of the wrist, hand, and fingers accounting for 10.4% of injuries.
The prevalence of musculoskeletal conditions, in particular those involving the upper extremity, initially being seen by
non-orthopedic physicians is high and a basic level of orthopedic knowledge is critical for optimizing patient care.
The literature has noted the lack of formal musculoskeletal education within medical schools. Only 25 of the 122 United States
medical schools surveyed included a required musculoskeletal clerkship within their clinical years.
Students at Harvard medical school reported insufficient curriculum time devoted to musculoskeletal education.
Forty-two percent of final year undergraduate students in India felt that they had the most difficulty in examining and diagnosing
In our study we evaluated the level of upper-extremity knowledge in a group on internal medicine and emergency department
residents from various medical schools and residences throughout the United States.
Materials and Methods
Forty-six residents from 6 residency training programs completed an online examination covering common upper-extremity conditions.
Twenty-eight residents were from an internal medicine program and 18 were from an emergency department program. A 38-question
upper-extremity examination was created by a group of hand and upper-extremity surgeons from the Resident Education Committee
of the American Society for Surgery of the Hand. The examination was reviewed by 30 hand fellowship directors at an annual
professional meeting, who rated each question on a Likert scale and developed a recommended passing percentage.
Institutional review board approval was obtained. Residents were informed of the purpose and details of the hand knowledge
evaluation and provided with the specific internet address for accessing the examination. Each examinee was identified only
by postgraduate training year and institution. Assessment of the number of questions correct was performed electronically.
The recommended passing grade was 73%. A total of 28 internal and 18 emergency medicine residents completed the examination.
The majority of respondents were in their first (33%) or second (33%) year of training. The average scores were 56% (range,
11% to 78%) and 46% (range, 30% to 81%) for the internal and emergency medicine residents, respectively. The shows the breakdown of scores by year in training.
Figure:. Average raw score for each postgraduate year residency group (PGY) out of total of 100 points.
On review of the individual questions, some topics had a higher rate of correct answers than other topics. Some of this variability
is due to the background of the physician completing the test, as emergency medicine physicians would be expected to have
greater knowledge of acute traumatic injuries while an internal medicine physician would likely have more knowledge regarding
chronic or nontraumatic conditions that often present to their office. For example, a question describing an acute carpal
tunnel syndrome was answered correctly by both 100% of internal and emergency medicine residents. In contrast, questions regarding
posterior interosseous nerve palsy and acute management of a gunshot wound were answered by 50% and 37% of emergency medicine
and internal medicine residents, respectively. The identification of the management of an acute compartment syndrome was answered
correctly by 96% of emergency medicine residents, but only 63% of internal medicine residents. Alternatively, only 33% of
emergency medicine residents identified the correct step in management in diagnosing septic wrist arthritis, whereas 70% of
the internal medicine residents correctly answered this question.
Out of 122 United States medical schools, only 41.8% offer a required preclinical module focused on musculoskeletal education,
with 20% requiring a clinical musculoskeletal clerkship.
Fifty-seven of these schools reported no dedicated musculoskeletal block, although orthopedic topics may be interspersed
throughout the curriculum. The lack of dedicated time may not allow students adequate exposure to gain a mastery of musculoskeletal
In 2007, Day et al
surveyed Harvard medical students to determine their confidence in performing musculoskeletal physical examinations and their
level of musculoskeletal competency. Not only did students report a statistically significant difference between their level
of confidence in the physical examination and differential diagnosis between the musculoskeletal system and the pulmonary
system (acting as the control), but also only 26% of the fourth year students passed a validated musculoskeletal examination
(7% of third year students and 2% of second year students). Students who had attended a musculoskeletal clerkship performed
significantly better than those who had only received the required musculoskeletal curriculum.
A validated examination
with a passing score determined by United States orthopedic residency chairman, showed 82% of interns in non-orthopedic programs
failed to reach a level of basic competency on musculoskeletal topics. Again, the mean scores for residents who had elected
to take a clerkship in orthopedics was significantly higher than those who had only participated in the basic medical school
curriculum. When the passing rate was adjusted by internal medicine program directors, 78% of the students failed to have
a passing score.
The lack of musculoskeletal education in medical school curriculums has also been identified in India
Residents have self-reported a lack of preparation and training for musculoskeletal examinations, with 26% of allopathic physicians
in 1 study reporting poor preparation for the lower back examination and 60% for examination of foot pain.
Interestingly, 41% of these physicians reported a very good/excellent preparation for the evaluation of hand problems. In
response to these concerns, several initiatives have attempted to address the lack of musculoskeletal education in medical
schools. A new curriculum in a Great Britain medical school improved the performance on musculoskeletal multiple-choice examinations.
Harvard’s new addition of mandatory musculoskeletal anatomy, pathophysiology, and physical examination hours, including 14
additional hours of upper-extremity study in the preclinical years has shown a statistically significant increase in students’
perceived confidence in performing a clinical examination of the hand and wrist.
It has been shown that internal medicine program directors and orthopedic program directors emphasize different levels of
importance on various musculoskeletal problems.
This highlights the need for multispecialty physicians to collaborate in the designing of medical school curriculums. In
addition, as shown in the present study, there is a lack of knowledge of various orthopedic upper-extremity issues among internal
medicine and emergency medicine residents. In addition, Finestone et al
showed that family practitioners had deficiencies in their knowledge of current orthopedic pharmacologic treatment and imaging
guidelines for lower back pain. This stresses the need to disseminate musculoskeletal education on examination, diagnosis
and current treatment regimens to both medical schools and non-orthopedic residency training programs.
The authors thank the Resident Education Committee of the American Society for Surgery of the Hand for their assistance in
performing this study.
- 1. Cherry DK, Woodwell DA, Rechtsteiner EA. National ambulatory medical care survey: 2005 summary.
Adv Data. 2007; (387):1–40.
- 2. Nawar EW, Niska RW, Xu J. National hospital ambulatory medical care survey: 2005 emergency department summary.
Adv Data. 2007; (386):1–32.
- 3. The burden of musculoskeletal diseases in the United States: Prevalence, societal and economic cost. Available at:
http://www.bo-neandjointburden.org. Accessed November 19, 2009.
- 4. DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools.
J Bone J Surg Am. 2003; 85(3);565–567.
- 5. Day CS, Yeh AC, Franko O, Ramirez M, Krupat E. Musculoskeletal medicine: An assessment of the attitudes and knowledge of medical students at Harvard Medical School.
Acad Med. 2007; 82(5):452–457. doi: 10.1097/ACM.0b013e31803ea860
- 6. Menon J, Patro DK. Undergraduate orthopedic education: Is it adequate?
Ind J Orthop. 2009; 43(1):82–86. doi: 10.4103/0019-5413.45328
- 7. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine.
J Bone J Surg Am. 1998; 80(10):1421–1427.
- 8. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine.
J Bone J Surg Am. 2002; 84(4):604–608.
- 9. Broadhurst N. Measuring cognitive and clinical competency in orthopaedics.
J Bone J Surg Am. 2002; 84(4):683–684.
- 10. Day CS, Ahn CS, Yu Y. The addition of an upper-extremity curriculum in medical school education and its assessment [published online ahead of print
September 28, 2009].
J Hand Surg Eur. 2009; 34(6):797–799.
- 11. Finestone AS, Raveh A, Mirovsky Y, Lahad A. Orthopaedists’ and family practitioners’ knowledge of simple low back pain management.
Spine (Phila Pa 1976). 2009; 34(15):1600–1603. doi: 10.1097/BRS.0b013e3181a96622