Background/Purpose: The musculoskeletal exam
(MSKE) is an integral part of rheumatology training, both as a diagnostic aid, and
as a predictor of disease activity. Formal structured training in MSKE is not
given priority at various levels of medical education including rheumatology
fellowship. Our aim was to design and implement a formal structured program in
MSKE for rheumatology trainees that would: 1) improve fellows’ comfort and confidence
in performing joint examinations and assessing disease activity and 2) improve fellows’
knowledge of the diagnosis of MSK pathology through physical exam.

Methods: Applying Fleming’s Visual Auditory Kinesthetic model, we devised a structured
program covering a systematic approach to examination of all major joints/joint
areas as well as inflammatory arthritis disease activity indices. Adult and
pediatric rheumatology fellows at a single teaching hospital were invited to participate.
Success of the curriculum was measured by the likelihood of attendees to
recommend the training and by an overall rating of >5 on a 10 point scale. Participants
also completed pre- and post-curriculum questionnaires containing subjective
(comfort and confidence) and objective (knowledge) domains. Content knowledge
was assessed using validated questions in the literature, many of which had an
orthopedic focus.

Results:
Of
the 8 fellows who participated in
the program, 75% reported no prior formal MSKE training. All
participants felt that training in the MSKE should be part of fellowship and
over 80% of fellows were likely or extremely like to recommend the course to
others. The average rating of the curriculum was 8/10. The post-curriculum assessment
showed: 1) modest increase in the percentage of fellows endorsing comfort in
their exam skills and confidence in their ability to assess disease activity;
2) decrease in the percentage of participants endorsing confidence in
diagnosing MSK pathology (Figure 1a); 3) slight improvement in objective scores
(Figure 1b).Over 60% of participants felt they could benefit from more practice
time.

Conclusion: We
successfully implemented a structured MSKE curriculum that was received with
enthusiasm and engagement among participants as reflected in their overall
rating of the program. The modest improvement in both subjective and objective
components of the post course assessment questionnaire may have been due to
limitations of the questionnaire. The decline in the participants’ confidence
in diagnosing MSK pathology may reflect fellows’ heightened awareness of
limitations in their knowledge at the end of the curriculum. An observed
structured clinical assessment may more effectively measure skills relevant to
rheumatology and thus improve trainees’ confidence.