We thank Dr. Gardner for his thoughtful comments concerning our paper and we agree that this issue warrants further study.

Dr. Gardner’s first concern is that the 25-item test originally created by Drs. Freedman and Bernstein does not accurately reflect the musculoskeletal knowledge required of practicing primary care physicians. The specific issue is that some questions concerned topics in orthopaedic trauma, which may be beyond the scope of practice of some primary care providers. Indeed, a minority of the questions do refer to musculoskeletal trauma (36%, 9 of 25 questions). However, these particular questions do not ask the primary care physician for management decisions; rather, they test the ability of the physician to recognize orthopaedic emergencies and identify the anatomic structures that might be in jeopardy when these emergencies occur. While this might not be relevant to the practice of every provider, certainly these issues are likely to come up in the practices of primary care physicians whose scope of practice includes covering high school sports teams, urgent care facilities, and walk-in clinics. Perhaps more importantly, it is worth recognizing that the remainder of the examination – approximately two-thirds of the overall test – covered what would be considered “general practice” by any definition, including diagnoses such as arthritis, compressive neuropathies, back pain, health maintenance screening as it relates to the musculoskeletal system, and common infectious and oncological concerns. The initial evaluation, treatment, and appropriate referral of these conditions are routinely performed by primary care physicians. In fact, the physicians tested in this study performed worse on questions dealing with office-based musculoskeletal care than they did with orthopaedic emergencies. For instance, 89% of participating physicians were able to recognize compartment syndrome as a surgical emergency needing appropriate referral; however, only 58% of the providers understood the difference between osteoporosis and osteomalacia. This must be considered within the purview of a primary care physician, given that osteoporosis in one study was the third most common musculoskeletal problem addressed by primary care physicians(1). Lastly, to our knowledge, the test instrument created by Drs. Freedman and Bernstein is the only previously published, field-tested examination of musculoskeletal knowledge that has been endorsed by program directors of internal medicine programs from across the country, who, incidentally weighted the importance of this test more heavily than originally weighted by the test’s creators(2).

Of course, Dr. Gardner is right that no exam can cover all topics, and none can be completely relevant to all providers. We also agree that there might be other examinations that could be developed to test particular groups of primary care providers, or examinations that emphasize different kinds of musculoskeletal content. We encourage Dr. Gardner and others interested in these topics to write – and importantly, to validate – other test instruments; and to examine perhaps other populations to see whether the findings we observed at a top academic primary care program generalize well to other physician populations. If such validation can be made, perhaps it will prompt the changes not only to medical school education, but to graduate medical education and continuing medical education that our work suggests is also necessary.

Again, we thank Dr. Gardner for his interest, and encourage his work toward the creation of evidence-based assessment tools that will help improve the musculoskeletal knowledge and confidence of primary care providers.

References:

1. Lynch, J. R.; Gardner, G. C.; and Parsons, R. R.: Musculoskeletal workload versus musculoskeletal clinical confidence among primary care physicians in rural practice. Am J Orthop, 34(10): 487-91, discussion 491- 2, 2005.

2. Freedman, K. B., and Bernstein, J.: Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am, 84-A(4): 604-8, 2002.

To The Editor:

I applaud the efforts of Lynch and colleagues for further enlightening us on the crisis in musculoskeletal education in the US. Their article indicates the lack of a consistent basic fund of musculoskeletal knowledge for our medical providers that our medical schools should be providing to every graduate. I do have several comments.

As a rheumatologist who has spent his entire career educating internal medicine residents in the area of musculoskeletal medicine, I do not think the Freedman and Bernstein 25 item assesment test (1) accurately reflects the issues most primary care internist face in practice. It is a one size fits all test and is really an orthopaedic assessment that is heavily weighted toward orthopaedic trauma (9/25 items). While this may be more relevant to certain primary care providers (family practice physicians or rural internists) it does not reflect the musculoskeletal problems seen on a daily or weekly basis by most primary care internists. I know chairs of mecical departments endorsed the test but I am not sure in most cases they would be the best group to evaluate orthopaedic issues. I understand a more directed assessment is under study currently.

My second comment is more general. In Lynch's previous paper on this topic (2), he deliniated what a rural internist was actually seeing in clinic with regard to musculoskeletal problems. I think this type of information should be our starting point for teaching future generations of primary care providers. Teaching should address their future needs rather than be based on a hypothetical curriculum generated by expert opinion and panels. While a good place to start, this cannot substitute for evidence based curriculum development. Knowing what they need to know will help us know what to teach and allow us to develop more useful assessment tools.

The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

References:

1. Freedman, KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80:1421-7.

2. Lynch Jr, Gardner GC, Parsons RR. Musculoskeletal workload versus musculoskeletal clinical confidence among primary care physicians in rural practice. Am J Orthop. 2005;34:487-92.