August 2004 Bulletin

Musculoskeletal education lacking in medical schools

AAOS publishes first-ever musculoskeletal textbook designed for medical students

By Carolyn Rogers

Each year, musculoskeletal conditions and injuries account for more than 100 million visits to physicians’ offices, a number that’s sure to rise as the U.S. population ages. Because musculoskeletal care is provided by a variety of practitioners—including internists, family practitioners, rheumatologists, emergency physicians, pediatricians and orthopaedists—a solid knowledge base in musculoskeletal medicine is essential for most, if not all, medical students.

A recent series of studies, however, found that four out of five first-year medical residents failed to demonstrate a basic competency in musculoskeletal medicine, according to criterion established by directors of internal medicine residency programs and orthopaedic residency programs.

The findings aren’t all that surprising, given that the residents reported spending an average of just 2.1 weeks in courses or rotations dedicated to orthopaedics while in medical school. Thirty-three percent of the examinees had graduated from medical school with no exposure to musculoskeletal medicine at all.

At this time, however, fewer than half of the country’s medical schools require any course in musculoskeletal medicine, says Joseph Bernstein, MD, MS, who conducted the studies with Kevin B. Freedman, MD, MSCE.

The ideal musculoskeletal medicine course should concentrate on common outpatient orthopaedic problems, orthopaedic emergencies and the musculoskeletal physical examination,” he says. Topics seen as important by internal medicine program directors include fractures, back pain, arthritis and infections.

“Because of the aging population, the prevalence of musculoskeletal disease in the United States—already the primary reason people seek medical care—is sure to rise,” Dr. Bernstein says. “Medical school curricula must place greater emphasis on this discipline.”

New text: Musculoskeletal Medicine

Part of the difficulty in integrating musculoskeletal education into medical schools’ curricula has been the lack of accepted texts and teaching materials on musculoskeletal medicine, Drs. Bernstein and Freedman determined.

To fill that need, AAOS recently published Musculoskeletal Medicine—the first-ever musculoskeletal textbook designed specifically for teaching and learning in medical schools and residency programs. The text’s effective student-directed learning format makes it an excellent resource for classroom use as well as self-directed study. The book covers the structure and functions of the musculoskeletal system, normal and abnormal conditions, how to properly identify maladies and injuries, and why problems arise.

Musculoskeletal Medicine’s five sections—biology, anatomy, disorders, clinical evaluation and management—provide a comprehensive foundation in musculoskeletal medicine that more complex studies can be built upon. Features such as key term definitions, detailed illustrations and images, key point summaries, anatomy plates and an entire chapter on the physical exam set this book apart by speaking to the medical student audience on their level.

Highlights include:

Dr. Bernstein served as editor of Musculoskeletal Medicine, which was reviewed and approved by the AAOS, the American Academy of Family Physicians and the American Academy of Pediatrics.

The cost of the text is $70 for AAOS members and residents; the list price is $85. The book may be purchased online at ( The Academy is also offering a volume discount program for classroom adoption. For more about this program, contact AAOS Customer Service at 800-626-6726.

Ohio State adopts text, unites orthopaedic community

Thanks to the efforts of Ohio State’s Gary D. Bos, MD, and Columbus-area orthopaedists, Ohio State University College of Medicine and Public Health was one of the first U.S. medical schools to adopt Musculoskeletal Medicine into its educational program.

When Dr. Bos accepted the orthopaedic chairmanship at Ohio State two years ago, “one of my goals was to develop a musculoskeletal course for second-year medical students,” he recalls. He was aware that Musculoskeletal Medicine was in the pipeline, and he was able to get some advance copies.

“The text is very readable, and the format is great in that it takes the student up to Step 3 of the USMLE,” he says. “The book really provides the best coverage of orthopaedic medicine at the student level that’s ever been out there.”

When he noticed that AAOS planned to offer a substantial discount for classroom adoption, “I sent a letter to all the orthopaedists in Columbus, saying, ‘I think it would be a great service to our medical students if we as orthopaedists in the community subsidize this book and make it available to students for $10,’” he says.

The response was overwhelming.

“More than $12,000 came in,” Dr. Bos says. “We were able to buy books for 220 students, and we still have some funds left for next year’s subsidy.”

The three-week course, which ran in March 2004, was constructed around the format of the book.

“The course was a great success,” he says. “Students had a lot of good things to say about the book as well as the orthopaedic community.”

The Columbus-area orthopaedists received high marks not only for their financial contributions, but also for volunteering their time. At one point during the course, Dr. Bos broke the students into small groups and 20 local orthopaedists came to the school to teach the groups for six afternoons.

“This whole idea really took off here in Columbus, and it’s helped our orthopaedic community,” Dr. Bos says. “I see this as a way to bridge all the orthopaedists together, united behind one purpose. I think I’ll have even broader representation next year.”

Next, Dr. Bos plans to go to the curriculum committee with the recommendation that every medical student has at least one clinical rotation in a musculoskeletal-related area, such as rheumatology, orthopaedics or physical medicine and rehabilitation.

“That way, every student will have at least three weeks of didactics in the musculoskeletal system as a second-year medical student, and at least one clinical rotation emphasizing the musculoskeletal system in either the third or fourth year.”

AMA resolution 310

Interest is improving medical school education in musculoskeletal medicine is not restricted to orthopaedists. In June 2003, the American Medical Association (AMA) House of Delegates passed Resolution 310, “Musculoskeletal Care In Graduate Medical Education.” In this resolution, the AMA strongly urges U.S. medical schools to formally reevaluate the musculoskeletal curriculum and make changes to ensure that medical students have the appropriate education and training in musculoskeletal care. The AMA also strongly encourages medical schools to make competence in basic musculoskeletal principles a requirement for graduation.

Project 100

In addition, the U.S. Bone and Joint Decade (BJD) is sponsoring “Project 100”—an initiative to promote musculoskeletal education in all U.S. medical schools and develop a mandate for a required curriculum. The project is a collaborative effort among organizations participating in the U.S. Bone and Joint Decade. Project 100 is currently working with the Association of American Medical Colleges on recommendations regarding improved musculoskeletal education. The group’s goal is to have 100 percent of American medical schools offer a required course in musculoskeletal medicine by 2010.

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