Background/Purpose: Musculoskeletal (MSK) complaints comprise 6-15% of general pediatric visits.^1,2 Many MSK complaints can be diagnosed through simple history and physical with limited laboratory and imaging workup. With rapidly rising healthcare costs, there is an increased emphasis placed on high value care in graduate medical education. Our purpose was to create online MSK simulation cases to teach high value care and diagnostic evaluation of MSK complaints.

Methods:  Five simulation cases of pediatric MSK complaints were developed for general pediatric residents, with online learner input allowing tracking of tests utilized to arrive at diagnosis, cost of workup, and the final diagnosis. An anonymous post-simulation survey was given to all subjects. All subjects received online feedback on the correct diagnosis and appropriate workup after each simulated case. Measured outcomes were presumed diagnosis, cost of evaluation, diagnostic testing utilized, and perceptions towards the learning platform and high value care. Simulation outcomes were assessed using Chi Square tests and survey data was assessed utilizing Wilcoxon sign-rank testing.

Results: 29 residents participated in the pilot and 27 completed the survey. Overall, only 46% of simulations were diagnosed correctly, and in 33% of cases, an antinuclear antibody was ordered unnecessarily. There was no difference in the frequency of correct diagnosis or cost of workup depending on order of case presentation: 93.3% and $103.67 versus 76.92% and $39.62 for a case of growing pains (p = 0.22 and 0.06), 42.9% and $244.29 versus 73.3% and $305.67 for a case of leukemia with leg pain (p=0.10 and 0.47). Arrival at the correct diagnosis was not associated with a difference in the cost of workup of any of the 5 cases. 25/27 (93%) of learners ranked factoring cost into evaluation as somewhat important or very important. 23/27 learners reported feeling more comfortable post-simulation with their knowledge of costs of common diagnostic tools (p < 0.0001).

Conclusion: Regardless of the order of presentation of the cases, there was no increase in the correctness of diagnosis or decrease in the amount spent on workup. Secondly, correctness of diagnosis was not associated with cost of workup. Subjects expressed increased knowledge of costs and recognized high value care as an important component of patient care after the simulation. Further studies are warranted with a greater diversity of cases and larger study groups.

References:

1 deInocencio, J. Musculoskeletal pain in primary pediatric care: analysis of 1000 consecutive general pediatric clinic visits. Pediatrics 1998; 102(6): e63.

2 Vital and Health Statistics. Patient’s reasons for visiting physicians: National ambulatory medical care survey, US 1977–78. DHHS publication 82-1717. Hyattsville, MD: National Center for Health Statistics; 1981