Session Title: Medical Education
Session Type: Abstract Submissions (ACR)
Background/Purpose: University of Michigan (UM) medical students participate in integrated musculoskeletal sequences during their preclinical years, but subsequently there are few opportunities for assessment of their diagnostic and physical examination skills. The purpose of this study was to evaluate the effectiveness of the longitudinal UM musculoskeletal curriculum in preparing graduates to evaluate patients with musculoskeletal disorders.
Methods: IRB exemption was obtained for this project. A multidisciplinary group of musculoskeletal specialists developed a three station objective structured clinical exam (OSCE) based on the “Hypothesis-Driven Physical Exam” (Yudkowsky, et al.) focusing on the shoulder, back and knee. 4thyear students from the class of 2012 were invited to participate in the OSCE. For each station, students were provided a clinical vignette with three plausible diagnoses to consider, and were instructed to anticipate physical examination maneuvers or findings that would discriminate between the different diagnoses. They then examined a professional patient simulating findings associated with only one of the diagnoses. Trained faculty members directly observed students and scored performance of discriminatory physical examination maneuvers for each station. Each encounter was videotaped and independently scored by another faculty member. Inter-rater reliability for each maneuver was estimated using type-2 intra-class correlations. Percentages of perfect scores for anticipation (A) and performance (P) of each maneuver were calculated. Pearson’s correlation between A and P scores was computed for each maneuver.
Results: 30% of the graduating class of 2012 participated. Inter-rater reliability was good to excellent for scoring of 6 exam maneuvers: herniated disc (disc ICC = .81), sacroiliac dysfunction (sac. ICC = .85), shoulder impingement (imp. ICC = .69), glenohumeral arthritis (arth. ICC = .76), anterior cruciate ligament tear (acl. ICC = .87), and knee osteoarthritis (ost. ICC = .87). Rater scores were averaged for each student. For the shoulder and knee stations, students could anticipate the necessary discriminatory exam maneuver for each diagnosis more frequently than they could actually perform the maneuver: (disc r = .45, p < .005, sac. r = .67, p < .0001; imp. r = .38, p < .025; arth. r = .32, p < .05; ost. r = .33, p < .05). A notable exception was the ability to perform maneuvers needed to diagnose a torn anterior cruciate ligament (ACL r = .05, n.s.).
Conclusion: A substantial percentage of graduating UM M4s are not able to perform core examination skills needed to diagnose common disorders of the shoulder, back and knee. Accurate anticipation of a discriminatory exam maneuver correlates with ability to perform the maneuver; however, students were more able to anticipate maneuvers than to actually perform them. Thus, direct observation is critical to ensure competence of students in evaluating musculoskeletal disorders.
S. U. Monrad,
R. B. Stansfield,
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/assessment-of-examination-skills-of-4th-year-medical-students-using-a-novel-objective-structured-clinical-examination/