Advanced Primary Care Orthopedics: Bridging the Gap in Musculoskeletal Education

Musculoskeletal (MSK) problems account for 10%-20% of primary care visits,1,2 and 124 million American adults reported a MSK condition in 2015.3 However, studies have shown that family medicine (FM) residents and attendings lack MSK knowledge and confidence.4-6 This may be due to divergent approaches to MSK problems and lack of faculty confidence in teaching the exam.7,8

Various attempts have been made to improve MSK training, and interactive small group sessions are more effective than didactic sessions.9 Both direct observation with feedback and multiday structured interventions improve exam competence and confidence compared to traditional teaching methods.10-12 A standardized approach taught in a concentrated session is effective in obstetrics (ALSO), newborn resuscitation (NRP),13 and life support (ACLS),14 but is uncommon outside of emergent care situations.

We developed Advanced Primary Care Orthopedics (APCO) as an innovative method of teaching the MSK exam in a concentrated session combining small group interactive learning and direct observation with the proven pedagogical principle of intentional repetition. In APCO, a standardized approach is taken for each joint exam and repeated using multiple modalities to maximize learner engagement and retention of material. We conducted this study to assess the effectiveness of APCO in improving MSK exam knowledge and confidence.

APCO has been taught annually as a 1.5-day course to residents at our urban community hospital-based FM residency program since 2012. Teaching faculty include four FM residency faculty with an interest in MSK education and one sports medicine physician. The course primarily consists of small group sessions that include a brief presentation, demonstration of a standardized physical exam with clinical correlations, and exam practice with direct observation and feedback (Table 1; course details: https://swedish-fh.squarespace.com/apco). Repetition occurs through cases, exam demonstrations, and assessment of participants’ physical examination skills using clinical cases. We did not cover treatment to limit the course length, and instead focus on establishing competency in physical exam and diagnostic skills. After internal work to refine APCO, two sports medicine fellowship-trained physician educators comprehensively reviewed course material in 2018. Further, an orthopedic surgeon has participated as course advisor and reviewed the material for accuracy. The 2018 and 2019 courses had a combined 30 participants (19 PGY1’s, 10 senior residents, 1 nurse practitioner). A 1-day version of APCO was conducted as a preconference workshop at the 2018 STFM Annual Spring Conference with 36 participants, primarily faculty physicians at FM residency programs. The workshop included all core exam skills and content areas, but excluded the elbow, imaging, the pre/posttest, exam review, and the case-based exam testing.

In the 2018 and 2019 resident courses, participant knowledge was assessed before and after the course through a written knowledge assessment comprised of 32 multiple-choice questions. Participants were asked one question to assess overall confidence in their MSK examination skills using a 5-point Likert scale (1–not confident at all; 5–very confident) before and after the course. Participants in the preconference workshop were asked to assess their confidence only. Our institutional review board reviewed our methodology and determined the project to be exempt.

We compared pre- and postcourse knowledge and confidence assessment results using mean differences and paired t-test statistics using Stata.

In the 2018 resident course, 11 of 17 participants (65%) completed pre- and postcourse knowledge assessments and 12 of 17 participants (71%) completed pre- and postcourse assessments of MSK exam confidence. In the 2019 resident course, 12 of 13 participants (92%) completed the knowledge assessments and 13 of 13 participants completed the confidence assessments. In the 2018 preconference workshop, 23 of 36 participants (64%) completed pre- and postcourse confidence assessments.

After completion of the resident course, participant scoring on the knowledge exam improved by 9.5 points (95% CI: 7.85–11.11; a 30% increase) and confidence improved by a mean difference of 1.6 points (t[24]=13.86, P<.05) on a 5-point scale. Prior to APCO, 36% of participants reported a confidence score of 3 (somewhat confident) or higher with the MSK exam. This improved to 100% after APCO (Table 2).

In the preconference workshop, participant confidence in the MSK exam improved by a mean difference of 1.43 points (t(22)=10.38, P<.05) on a 5-point Likert scale. Prior to the course, 39% respondents reported a confidence score of 3 (somewhat confident) or higher with the MSK exam, which improved to 100% after APCO (Table 2).

APCO is a unique solution to improving MSK education that provides a standardized approach to the MSK physical exam and helps participants confidently diagnose their patients’ MSK conditions. Our approach builds on existing literature that demonstrates the value of mixed educational methods and small group learning,9-11 and is innovative in its condensed length, integration of multiple joint exams and intentional repetition of material.

This study demonstrates that APCO significantly improves resident knowledge and confidence with the MSK exam. Offering the course at the beginning of FM residency training establishes a standardized physical exam and helps early trainees gain confidence with their exam skills. Further, our experience suggests that APCO can also be applied to teach FM faculty and improves faculty confidence in their own exam skills.

There are several limitations to this study. Our sample size was small and included participants from only three courses run by a single program without an external comparison group. Further, only 70% of participants completed the assessments and there may have been differences between those who did and did not complete them. We assessed participant confidence and knowledge immediately after the APCO course, but did not assess long-term effects and whether improvements persist. We plan to repeat annual knowledge assessments as residents progress through training to better assess long-term knowledge retention. Finally, our study focused on a course that has been refined over several years prior to this assessment; it is difficult to extrapolate how our findings might apply at other locations when first implemented. Further efforts will focus on assessing knowledge and confidence over time and the benefits of utilizing the APCO model for faculty development.