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Abstract
Objective: To develop core recommendations for the learning outcomes of an undergraduate curriculum in musculoskeletal conditions for any parts of the globe.
Methods: Recommendations were developed by wide consultation with experts in orthopaedics, rheumatology, osteoporosis, and rehabilitation from all parts of the world who had interest and experience in these specialties, with the support of international and national societies. All possible knowledge, skills, and attitudes that might be of relevance to musculoskeletal conditions were initially considered and then reduced to those considered essential for all doctors.
Results: The recommendations focus on (a) basic skills to assess and diagnose musculoskeletal problems; (b) the competency to assess specific common or urgent musculoskeletal problems; (c) the theoretical background of the conditions and their management; and (d) the core knowledge necessary to support diagnosis and management, including basic sciences. At the end of the course, all students should be able to differentiate normal from abnormal locomotor symptoms in a patient, determine the relevant investigations and interpret the results, formulate a limited differential diagnosis, recognise the impact of the problem on the individual patient, and make an appropriate management plan.
Conclusions: The recommendations set global standards for the minimum level of competence in managing patients with musculoskeletal problems. They define what all doctors should know when graduating from medical school, regardless of further specialisation. They are intended to form the basis of a curriculum for a musculoskeletal course and can be adapted for any medical school in any country throughout the world.
- undergraduate education
- musculoskeletal conditions
- curriculum
- standards
- teaching
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Musculoskeletal conditions are common in society and consume enormous healthcare and social resources. They are the most common cause of severe long term pain and physical disability. With the exclusion of trauma, they represent almost 25% of the total cost of illness in westernised countries.1 They are the second most common reason for consulting a doctor, and in most countries constitute up to 10–20% of the primary care practice.2 They are the commonest cause of health problems limiting work in developed countries, and up to 60% of people on early retirement or long term sick leave claim a musculoskeletal problem as the reason.3 For simplicity, musculoskeletal problems may be grouped under the major headings: (a) joint conditions—for example, rheumatoid arthritis, osteoarthritis; (b) osteoporosis—for example, fragility fractures; (c) spinal disorders—for example, low back pain; (d) musculoskeletal injuries—for example, high energy limb fractures, strains and sprains often related to occupation or sports; and (e) childhood disorders. They include a spectrum of conditions, from those of acute onset and short duration to lifelong disorders. The impact of musculoskeletal conditions is predicted to increase dramatically in developing as well as developed countries with the aging of the population, changes in lifestyle resulting in obesity and lack of physical fitness, and the increase in road traffic accidents with the urbanisation and motorisation of the developing world.4 This great and increasing impact of musculoskeletal conditions is now recognised by the United Nations, the World Health Organisation, the World Bank, and governments throughout the world by their support of the Bone and Joint Decade 2000–2010 initiative.5,6
However, patients with musculoskeletal complaints are often ignored, their problems underestimated by doctors7 and, consequently, they do not have timely access to effective treatments. This reflects the common belief that we have to learn to live with musculoskeletal pain and disability as nothing can be done. It also reflects the inadequate education and training of doctors that begins at medical school.
Undergraduate education in musculoskeletal health is at present insufficient in most medical schools world wide in both basic science and clinical training.8,9 Teaching is often mostly in orthopaedic and trauma clinics, giving the student little experience of the common problems that will be encountered in the community. Many students do not receive clinical rheumatology training in medical schools.10 In the examinations students are seldom assessed for their competency to take an appropriate history and to examine the musculoskeletal system. When they have been examined for basic competency, most have failed.11 The locomotor system is not examined as part of the general examination of a patient,12,13 and residents in primary care programmes lack confidence in musculoskeletal problems.14 The lack of education in these conditions is similar in developing countries. Reducing disability is a WHO “Health for All” target,15 yet few interns are competent at assessing disability and handicap.16
There is therefore a clear need to improve the competencies of all doctors in the assessment and management of musculoskeletal conditions, and the education of medical students in these conditions in many medical schools needs to be reconsidered.
The aim of the initiative that is reported here is to produce graduates with the knowledge and skills to manage common or important musculoskeletal conditions from all medical schools, in all continents and cultures, irrespective of future specialty. To achieve this, the minimum level of competence in musculoskeletal conditions for all medical students, that is all future doctors, has been defined. Recommendations are made for the learning outcomes that should be obtained by all students. This provides medical school faculties with the priorities and educational areas that need to be considered when developing an undergraduate curriculum for a medical school in order to achieve these competencies. The recommendations give minimum standards for core knowledge and skills for musculoskeletal conditions that can be used as the basis for developing, implementing, and evaluating a curriculum.
The intention is to improve the quality of life for those with musculoskeletal conditions throughout the world by raising the quality of health care through education, thus meeting one of the goals of the Bone and Joint Decade.6 The recommendations are developed for global application by local adaptation. The recommendations represent the first global standards for a specific area of health.
METHODS
A consultative approach was used to develop recommendations for learning outcomes that reflect the educational needs of all doctors.
The recommendations have been developed through workshops and wide internet based consultation that was coordinated by the Bone and Joint Decade Education Task Force. The experts who participated in the focus group discussions and consultative process came from backgrounds of orthopaedics, rheumatology, rehabilitation, and osteoporosis and had interest and experience in education. They came from 29 countries from all parts of the world and formed the Bone and Joint Decade Undergraduate Curriculum Development Group (see “Acknowledgements”). The recommendations have been developed with the support of international and national societies for orthopaedics, rheumatology, and rehabilitation.
As an initial step, a structure for the recommendations was agreed. To be able to recommend which are the core competencies for all doctors, an inventory was initially made of all possible knowledge and skills that might be relevant in an undergraduate musculoskeletal course. In addition, the appropriate attitudes were considered. As a second step, each item was scrutinised by the experts during two workshops and the content reduced to include only those items that were considered by all to be essential competencies for all doctors. This prioritisation had to reflect the prevalence and impact of different conditions as well as the urgency to recognise or be aware of their possibility (red flags). The options allowed for defining the level of competency and ranged from knowledge, comprehension, application, analysis, and synthesis to the ability to evaluate.17 These proposals were then disseminated among all the experts for further comment until a consensus was reached. The final recommendations have been given the support of the major relevant organisations.
RESULTS
Core recommendations for an undergraduate curriculum in musculoskeletal conditions
It is recommended that the major emphasis of an undergraduate “Musculoskeletal course” should be on clinical skills and competencies relating to the musculoskeletal system. This must be supported by knowledge of the relevant basic science. Such a course must mirror the diversity and relative importance of the various musculoskeletal conditions in the different communities around the globe, from fracture to chronic degenerative disorders. In developing the proposals for the curriculum, we therefore structured the recommendations with these considerations in mind.
The initial focus of the recommendations (table 1) is on the basic skills necessary to assess and diagnose the person with a musculoskeletal problem, which is the ability to take an appropriate history and examine the musculoskeletal system to identify any relevant abnormalities. It is recommended that one method of assessing the musculoskeletal system should be taught irrespective of which specialty is teaching it. As this is a basic skill, it should be taught early in the curriculum along with the methods to assess other organ systems. Professional attitude should be included as an integral part of all teaching and professional development (fig 1).
Basic competencies in clinical assessment and diagnosis
The underlying principle for developing competency in the musculoskeletal conditions.
The second level of the structure of these recommendations is the competency to assess specific problems of the musculoskeletal system (table 2) and this is related to prevalence and urgency of the specific conditions (fig 2). Emergencies may not be common, but it is essential for everyone to recognise them and to manage or refer as appropriate. It is recommended that the most common problems should receive greater emphasis in order to increase proficiency and confidence in managing them, and these may be adjusted according to local epidemiology. Examples are (a) the ability to assess someone with an upper limb injury: the student must have knowledge of the common upper limb fractures that may have been sustained, and be able to outline the immediate and long term management; or (b) the ability to assess someone with hip joint pain, to recognise if it is due to osteoarthritis, and to be able to outline the principles of management.
The assessment of specific problems (specifically related to urgency, importance, and/or prevalence)
The structural levels related to prevalence and urgency used when developing the recommendations.
The third level of the recommendations specifies the theoretical background knowledge required of the conditions and their management (table 3). Finally, the recommended knowledge that is required not only relates to the conditions encountered but also, importantly, considers the core knowledge necessary to support diagnosis and management (table 4). This includes basic knowledge of anatomy, physiology, cell biology, pathology as well as methods for appropriate management and treatment, including investigation.
The knowledge of main characteristics and the principles of management and rehabilitation of common musculoskeletal conditions (the theoretical background)
The core knowledge to support diagnosis and management
It is recommended that basic competencies such as taking a screening history and performing a screening examination should be part of standard teaching of these skills for other systems. Clinical experience should be gained of all stages of the most prevalent conditions.
The ultimate goal of these recommendations is that at the end of such a musculoskeletal course all students should be able to assess, by appropriate history and examination, a patient with locomotor symptoms. They should be able to differentiate normal from abnormal structure and function, determine relevant investigations and interpret the results, formulate a limited differential diagnosis, recognise the impact of the problem on the individual patient and make an appropriate management plan (medical, surgical, rehabilitation). They should also know how common the various conditions are in their own society.
Use of the core recommendations: local adaptation
The recommendations have been developed to be relevant to all parts of the globe. They will enable a curriculum to be developed from them that is locally applicable. A curriculum that is developed from these recommendations should meet any national guidelines and must be adapted to reflect local needs, priorities, and opportunities. Priorities within the curriculum should be based on the local prevalence, severity, and urgency of the condition or the clinical problem and the relevance to the geographic and socioeconomic situation.
DISCUSSION
Core recommendations for a musculoskeletal undergraduate curriculum have been developed for application in any country and culture. These recommendations represent the first global standards for a specific area of health. They will serve as quality assurance credentials for doctors wherever they are based and as ways of ensuring adequate educational grounding for migrating doctors,18 but most importantly as a mechanism of quality improvement of medical education to meet health needs in all countries and cultures. By focusing on learning outcomes, these recommendations can take into account the variations among countries in medical education due to differences in teaching tradition, culture, socioeconomic conditions, the health and disease spectrum, and different forms of healthcare delivery systems.18
Recommendations have been made to improve the competency of all doctors in the assessment and management of musculoskeletal conditions. The recommendations relate to all aspects of bone and joint health and disease on a background of basic knowledge in anatomy, physiology, and cell biology, in addition to clinically relevant adjacent areas such as neurology and traumatology. In addition, a holistic approach to clinical care is essential that brings together, for example, primary care, medical, surgical and rehabilitation skills, and other relevant health professionals working as a team. The implementation of these recommendations is therefore well suited to the trend to integrate courses both vertically and horizontally.
The main focus of these recommendations is on clinical competencies. The teaching of general history and examination skills should consider the recommendations for a screening history and examination of the musculoskeletal system. The course will, for the most part, come at the stage of clinical training, commonly during the third or fourth year of training. Even if structure and pathophysiology of the musculoskeletal system are taught at an earlier stage, reference to such knowledge and clinical context lies within the framework of a clinical musculoskeletal course.
Defining the essential content of a course is a challenging task, as experts tend to overestimate the importance of their own field or area of interest. Furthermore, the increase in scientific knowledge is tremendous over the past decades and competence in musculoskeletal conditions is competing with new areas demanding time in a programme. One of our duties is therefore to help to delineate the border between core competence when leaving a medical school and competence that should be deferred to postgraduate training. A consideration is that problems such as chronic disease and pain management, disability, rehabilitation, and community needs are recognised as core to undergraduate education,19 and musculoskeletal conditions can provide ideal experiences of these situations.
We have carefully reviewed all areas of potential content and, through this process, tried to define the level of skill or knowledge that all doctors should have as well as excluding content which is beyond this—that is, suitable for postgraduate or fellowship training. Notwithstanding this, the recommendations need to be tailored to each geographic and socioeconomic area and include the aspects of local prevalence of conditions.
Competency is essential in history and examination and similar approaches are recommended for primary care, rheumatological, orthopaedic, or rehabilitation assessment. It is also essential to be able to recognise and act upon musculoskeletal emergencies. Only conditions that are common or teach general principles have been included and a systematic approach taken as much as possible, because there is little value in a comprehensive but unrealistic set of recommendations. The level of competency has also been carefully set to be appropriate for all doctors.
The approach used to develop the recommendations has relied on a wide consultative process, which is clearly a strength. Professionals from all disciplines have participated in the process, a necessity when dealing with conditions that more than most benefit from multiprofessional care. Furthermore, medical teachers from all parts of the world have had an input, many with a broad knowledge of educational needs within their region, which increases the emphasis on core versus specialist knowledge and allows for a global perspective. Drawbacks of our approach may still be the difficulty of securing the involvement of all stakeholders and thereby their opinions. In reality, selection of participants is inevitable and it is virtually impossible to ensure true representation. However, we believe that through inclusion of representatives from all specialties and with support from major organisations the recommendations are widely acceptable.
The recommendations are given as learning outcomes. The elements of content, teaching, and learning strategies, assessment processes, and evaluation processes20 need to be developed locally. The structure and time allocation within a curriculum will depend on the degree of integration, vertical and horizontal. From knowledge of medical schools that have a comprehensive curriculum for musculoskeletal conditions, it is estimated that a minimum of between 4 and 6 weeks is necessary to cover the clinical curriculum, with basic non-clinical background given at previous stages of the undergraduate course. However, the aim should be a 6–12 week clinical course in order to provide a more in depth proficiency. Although this is far greater than in most medical schools, it would more appropriately reflect the impact of musculoskeletal conditions on individual subjects, healthcare systems, and society.
It is not within the framework of this document to recommend preferred methods of teaching, while naturally the skills of the teachers should be appropriate to the curriculum. The competencies relate to a wide spectrum of expertise, including orthopaedics, traumatology, rehabilitation, rheumatology, other health professions related to musculoskeletal conditions, and also to primary care. Teaching and training should preferably be integrated, multidisciplinary, and ensure a consistent approach to the learning objectives. The trend towards providing education in a variety of environments, including hospitals, general practices, and community medical services, is also most appropriate to these conditions.
Assessment of competency should relate to the learning objectives of any curriculum that is based on these recommendations. Practical assessments such as objective structured clinical examinations are in particular suitable because many of the learning objectives relate to skills. It is also important to ensure that appropriate attitudes have been developed.
The undergraduate programme provides the foundation for postgraduate training. If management of musculoskeletal conditions is omitted or insufficient, the first stepping-stone for continued professional training will be missing. This is particularly important for those going into primary care or family practice as most patients with musculoskeletal complaints will be assessed and treated within primary care settings. A next step in the area of musculoskeletal education and training is therefore to define measures to improve outcome of care from postgraduate and specialist training, based on the commonality of these conditions.21
CONCLUSION
In conclusion, it is essential that a musculoskeletal undergraduate curriculum be implemented in medical student instruction world wide that reflects the burden of musculoskeletal disease. The aim of these core recommendations is to facilitate this by setting standards for the minimum level of competence for all doctors in managing patients with musculoskeletal problems, from trauma to chronic conditions. They are intended to form the basis when developing a curriculum in musculoskeletal conditions that can be adapted for any medical school in any country. They provide a framework for any medical school faculty, administrator, or curriculum committee to expand the knowledge base for future physicians so that they will be able to provide better and appropriate care for their patients.
Acknowledgments
The Bone and Joint Decade (BJD) Undergraduate Curriculum Development Group are experts from different specialties, organisations, and countries with expertise in medical education.
The participants were G Abelseth (Canada), D Barroclough (Australia), P Cantista (Portugal), J Dequeker (Belgium), M Doherty (UK), K Dreinhoefer (Germany), T El-Hadidi (Egypt), R Handa (India), J Homik (Canada), K Joughin (Canada), G Mody (South Africa), R Rizzoli (Switzerland), S Scherl (USA), J A P da Silva (Portugal), M Speeckhaert (Belgium), O Svenson (Sweden), and members of the EULAR Standing Committee for Education and Training.
Organisations that have been involved in the consultative process include International League of Associations for Rheumatology (ILAR), International Society of Orthopaedic Surgery and Traumatology (SICOT), International Society of Physical and Rehabilitation Medicine, International Osteoporosis Foundation (IOF), European Federation of National Associations of Orthopaedics and Traumatology (EFORT), European League Against Rheumatism (EULAR), European Board of Rheumatology, European Union Of Medical Specialists (UEMS) Sections of Rheumatology, Rehabilitation, and of Orthopaedics, European Board of Orthopaedics and Traumatology, Asia Pacific League of Associations for Rheumatology (APLAR), Pan American League of Associations for Rheumatology (PANLAR), African League of Associations for Rheumatology (AFLAR), American Academy of Orthopedic Surgeons, American College of Rheumatology, American Academy of Physical Medicine and Rehabilitation, American Board of Physical Medicine and Rehabilitation, Association of Academic Physiatrists.
We thank ILAR and the EULAR Standing Committee for Education for supporting the workshops. These workshops were supported financially, in part, by Merck and Pharmacia Corporation.