Medical Students Shine on Musculoskeletal Exams (PAs…not so much)
Robert Grunfeld, M.D., a resident in the Department of Orthopaedics and Rehabilitation, Penn State College of Medicine, along with Kevin Black, M.D., the chair of that department, recently told OTW about some interesting work they did regarding the level of musculoskeletal knowledge in graduating medical and physician assistant (PA) students. Dr. Black: “Previous studies had identified significant deficits in musculoskeletal knowledge of graduating medical students and first year residents. Also, we have seen an increasing number of physician assistants practicing in the U.S. and that, in association with the projected orthopedic workforce shortage, implies that they have the potential to assume an increasing role in nonoperative care. And, in our experience, well trained PAs are a vital member of the treatment team.”
Dr. Grunfeld: “We contacted medical schools and PA programs, and we used the National Board of Medical Examiners (NBME) musculoskeletal exam to assess musculoskeletal knowledge. A questionnaire was also utilized to determine the musculoskeletal educational experience of the students.”
Dr. Black: “We were surprised that the medical students performed so well on the exam; whether or not they were interested in a career in orthopedics they performed far better than the graduating PA students and better than what had been reported previously using a different examination. Although several possible explanations exist, one possibility is that they did as well as they did because they had already gone through two major NBME exams for which they prepared extensively. It is concerning that the PA students fared poorly. There is evidently a lack of basic musculoskeletal knowledge amongst graduating PA students, at least for the students in this study…and these individuals are permitted to practice with indirect supervision after passing their certification exam immediately after graduation.”
“The take home message is that many of us, whether in a private practice or in an academic setting, will be increasingly dependent on PAs. Thus it is important for those individuals who are hiring them to understand their level of musculoskeletal knowledge. Even though PAs pass their exams and are licensed to practice with indirect supervision, the supervising doctor needs to pay close attention to what they are doing. We have found that when we hire someone who is a recent PA school graduate it takes a long period of mentoring and additional training to get them to the point where they can truly work with indirect supervision.”
“We also don’t want to imply that doing well on an examination, as the medical students did in this investigation, is indicative on clinical competency. Going forward we want to examine the relationship between these test scores and the overall clinical competency of both groups of students. We will have both groups of students not only take the exam but also do an objective, structured clinical exam (OSCE)—and then correlate the results. We will soon be submitting our proposal for this work to our Institutional Review Board.”
MIS Taken Too Lightly?
Clifford Jones, M.D. is an orthopedic surgeon at Orthopaedic Associates of Michigan in Grand Rapids. He is also an adjunct professor at the Van Andel Research Institute and Research Director at Spectrum Health. He tells OTW, “I’m concerned about a growing number of minimally invasive surgical (MIS) cases. The MIS part sounds sexy but actually requires more thought, expertise, and time (both operative and fluoroscopic exposure). The usual term of open reduction internal fixation (ORIF) can be reduced to an ‘iffy’ procedure without the open (O) or reduction (R) portions. Therefore, traditional procedures requiring anatomic reductions are potentially being compromised in favor of small incisions without true benefits to the patient. Even though traditional low cost implants can be inserted, many surgeons facilitate these procedures with locked plating with percutaneous jigs or guides. The locked plating enhances stability and fixation with locked screws and stiffer plates. The screw-plate interface can give the surgeon a false sense of security and therefore possibly fixing some fractures which should be treated without surgical intervention or with arthroplasty (e.g., proximal humerus and proximal femur). The surgeon thinks the screw is being locked into oak wood when it is actually balsa wood.”
“Clinically, the procedures have expanded the indications of comminuted, periarticular, and metaphyseal fractures of the proximal humerus, distal radius, and distal femur especially in the setting of a compromised soft tissue envelope. Although no clear benefits have arisen from locked plating of the proximal tibia and distal tibia, MIS and locked plates are being utilized at alarming rates. This MIS technique and locked plating implants are not a panacea for complex fractures. Problems of the locked plates stem from high plate/screw costs (similar to total joint arthroplasty implants), non-traditional failure mechanisms (delayed and atrophic nonunions, and prominent plates (thicker plate design). So far we have just accepted these high costs without fully looking at the outcomes or benefits.”
Building Future Policy Experts
Andrew Wong, M.D. is an orthopedic surgeon at the Tallahassee Orthopedic Clinic, and is a past president of the Florida Orthopaedic Society (FOS). He recently spoke with OTW about a peer education program established by the FOS and the University of Florida College of Medicine. “Our goal was to educate residents on healthcare policy such that as they mature the field has people prepared to take on leadership positions in the state orthopedic societies. We began selecting students and bringing them to the annual meeting of the National Orthopaedic Leadership Conference (NOLC) in Washington, D.C. It was an opportunity for young orthopedists to obtain further knowledge about legislative issues, which included visits with representative of their state. During these meetings we asked the residents to take the lead and we would interject if necessary. The residents always came away with a more nuanced understanding of how health policies come into being. At this point, it is Fraser Cobbe, executive director of the Florida Orthopaedic Society, is the one now leading this effort.”
Cobbe told OTW, “Each year the FOS hosts a Quiz Bowl Competition during the FOS Annual Meeting. The competition pits representatives of the six orthopaedic residency programs in the state against each other in a Jeopardy style format. The winning residency program secures the trophy for the competition but also wins the Health Policy Scholarship for the upcoming year. The scholarship sends one resident of the winning program to the previously mentioned National Orthopaedic Leadership Conference, an event held by the American Academy of Orthopaedic Surgeons.”
“As the NOLC nears, any residents at the winning program who are interested in the scholarship have to apply to the FOS Board of Directors providing their CV and a statement on why they are interested in Health Policy. The FOS Board selects the scholarship winner. The scholarship pays for the resident to participate in the NOLC as a member of the Florida Delegation and covers all the costs of their participation. Following the conference the resident is asked to report back to their program and residents at the other programs on the issues that were discussed during the NOLC and what it means to orthopaedic surgeons in practice and in training. One resident, Eric Stiefel, M.D. from the University of Florida Shands Jacksonville program, created a research project designed to determine the level of understanding his colleagues have of health policy and the impact this will have on their careers. As part of the project Dr. Stiefel traveled to the other programs around the state and presented a Health Policy Program to the residents at those respective institutions. He also developed a pre-test and post-test so he could measure the general understanding the residents had on health policy issues prior to and immediately following his program.”
“Eric’s story is just one example of how we believe our program is successfully exposing Residents to Health Policy and how it resonates with many of them as they continue to develop their leadership within the orthopedic community.”
Musculoskeletal Test Predictive of All-Cause Mortality Forget the Samba…
Some people just want to get off the floor unaided. A recent study, led by Dr. Claudio Gil Araújo and colleagues at the Clinimex–Exercise Medicine Clinic in Rio de Janeiro, has let the world know that if you have trouble sitting and rising unaided from the floor, you may have a problem with mortality. This simple screening test of musculoskeletal fitness has proved predictive of all-cause mortality in a study of more than 2, 000 middle-aged and older men and women. Before starting the test, participants were told, “Without worrying about the speed of movement, try to sit and then to rise from the floor, using the minimum support that you believe is needed.”
Over the study period 159 subjects died, a mortality rate of 7.9%. The majority of these deaths occurred in people with low test scores…only two of the deaths were in subjects who gained a composite score of 10. In the December 13, 2012 news release the investigators said that a high score in the sitting-rising test might “reflect the capacity to successfully perform a wide range of activities of daily living, such as bending over to pick up a newspaper or a pair of glasses from under a table.”
Dr. Araújo told OTW, “There are several potential messages for orthopedists/physical medicine specialists within the study as well as with the application of the sitting-rising test for other populations. Until about 40–45 years of age, most of the subjects should be able to get a 10-score (to sit and rise from the floor without any support or help). This should be the rule for those younger than 20–25 years old. As a simple routine overall musculoskeletal assessment tool, if the subjects perform below an expected score, there are several possibilities that could be related to this failure. More often is a combination of factors, such as excess body weight to a given muscle mass/power, low muscle power per se, low overall body flexibility, decreased balance or suboptimal levels of gross motor coordination. For those underscoring, further measurements or info is needed in order to get more specific orientation—e.g., lose weight, do some weight training etc.”
“The test can be easily performed in an office, during a consultation, since it does not require equipment or large spaces and it takes less than two minutes. One of the major positive features of the test is the easiness to explain the results to the subject that was evaluated, making possible to characterize his/her difficulties and stimulating him/her to adopt soon a healthier lifestyle.”
