Background/Purpose
Musculoskeletal (MSK) complaints are among the most common complaints evaluated by primary care physicians. Thus, it is imperative that Internal Medicine (IM) residents learn how to perform and interpret a thorough MSK exam. Research suggests that IM residents lack confidence in performing a detailed MSK exam. If physicians find performing a procedure or exam difficult, they tend to avoid that behavior, which in the case of MSK complaints, could lead to over imaging and unnecessary referrals. Formalized clinical education has been shown to improve resident exam skills. To help improve IM residents’ competence and confidence in the MSK exam, a dedicated MSK workshop was performed by the Rheumatology fellows at The Ohio State University with a Rheumatology faculty attending supervisor.
Methods
A single, 3 hour quality improvement workshop for IM residents was conducted by Rheumatology fellows supervised by an attending Rheumatologist. The residents were broken into small groups and rotated through twenty minute stations focusing on joint exams of the knee, hip, shoulder, wrist and hand. A validated pre-test survey created by Dr. Lisa Criscione-Schreiber assessing confidence and ability in the MSK exam was given to the residents in paper form prior to the workshop. The survey consisted of 10 questions, with 1-6 ranking system (1 being the lowest or no confidence in the listed skill). The same survey, in an on-line version was then administered to the residents 1 month after the workshop in to assess a change in proficiency. The data was analyzed by ANOVA with repeated measures since each subject answered 10 questions. The primary tests compare the scores between post and pre-workshop for question 1 and question 9. Multiplicities were adjusted by the Bonferroni method.
Results
40 residents completed the pre-test and 20 residents completed the post-test. As shown in Table 1, there is a statistically significant improvement in confidence scores from the pre and post survey ( P< 0.05) in most questions one through ten after completing this work shop.
Conclusion
Comfort and confidence in performing the MSK exam is an essential tool for Internists. There is a need for an efficient and cost effective way to teach IM residents clinical skills during their busy schedules. Using a validated survey created at Duke University, we found that a short, dedicated MSK exam workshop performed by Rheumatologists improved IM residents’ confidence and ability to perform an MSK exam in statistically significant matter. Limitations were the small size of our study group and poor response rate to the post-survey evaluation. We were also unable to collect a sufficient number of responses from residents who did not participate in the workshop for a control comparison. We hope to perform this workshop on a larger scale with adequate control groups.
Table 1:
|
Survey Questions |
Pre-test Average Ranking |
Post-test Average Ranking |
Adjusted p-value |
|
Question 1: Identifying and naming common musculoskeletal deformities |
3.4 |
4.3 |
0.014 |
|
Question 2: Taking a MSK pain history from a patient with pain in the following joints: Knee Spine Shoulder Hand/Wrist Hip |
3.6 3.7 3.4 3.4 3.4 |
4.7 4.5 4.3 4.4 4.5 |
0.0007 0.0162 0.0032 0.0008 0.0004 |
|
Question 3: Describing the basic structure and function of the following joints: Knee Spine Shoulder Hand/Wrist Hip |
3.6 3.6 3.4 3.5 3.6 |
4.7 4.5 4.2 4.3 4.5 |
0.0007 0.0036 0.0089 0.0091 0.0015 |
|
Question 4: Identifying the important surface markings when examining the following joints: Knee Spine Shoulder Hand/wrist |
3.1 3.2 3.0 3.0 |
4.7 4.5 4.4 4.5 |
<.0001 <.0001 <.0001 <.0001 |
|
Question 5: Assessing the following joint area for soft tissue swelling and/or effusion: Knee Spine Shoulder Hand/wrist |
3.5 3.1 3.1 3.2 |
4.9 3.8 4.1 4.8 |
<.0001 0.029 0.0005 <.0001 |
|
Question 6: Assessing the stability of the following joints: Knee Shoulder |
3.3 3.0 |
4.7 4.4 |
<.0001 <.0001 |
|
Question 7: Assessing the following joints for range of motion: Knee Spine Shoulder Hand/wrist Hip |
3.8 3.7 3.6 3.4 3.6 |
5.0 4.8 4.7 4.8 4.7 |
<.0001 0.0001 0.0005 <.0001 0.0005 |
|
Question 8: Using information gained from physical exam of the following joint areas to make diagnoses: Knee Spine Shoulder Hand/Wrist Hip |
3.1 3.1 2.9 3.0 3.0 |
4.6 4.0 4.2 4.2 4.0 |
<.0001 0.0064 <.0001 <.0001 0.0003 |
|
Question 9: Using information gained from physical exam of the following joint areas to guide medical decision making: Knee Spine Shoulder Hand/Wrist Hip |
3.1 3.2 2.9 3.0 3.0 |
4.7 4.3 4.5 4.4 4.3 |
<.0001 0.0021 <.0001 <.0001 <.0001 |
|
Question 10: Performing and interpreting special diagnostic maneuvers on the following joints: Knee Spine Shoulder Hand/Wrist Hip |
3.0 2.9 2.8 2.9 2.9 |
4.5 4.1 4.3 4.0 4.1 |
<.0001 0.0001 <.0001 <.0001 <.0001 |
|
Net Average All Questions |
3.2 |
4.4 |
|
Disclosure:
K. Fisher,
None;
A. Meara,
None;
B. LaMoreaux,
None;
H. Madhoun,
None;
I. Rosenberg,
None;
X. Mo,
None;
L. G. Criscione-Schreiber,
None;
N. Bundy,
None.
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-resident-confidence-with-the-musculoskeletal-exam-through-a-rheumatology-dedicated-musculoskeletal-workshop/