Recommended Elements of a Musculoskeletal Course for Fourth-Year Medical Students: A Modified Delphi Consensus

A widely recognized mismatch exists between the burden of musculoskeletal (MSK) concerns in the primary care setting and the adequacy of training provided to primary care physicians to manage those concerns. ^1-5 A recent Council of Academic Family Medicine Educational Research Alliance study suggested that most family medicine interns begin residency with inadequate MSK physical exam skills, ⁶ a finding consistent with previous reports that 80% of medical school graduates were deficient in basic MSK medicine. ⁷ Preclinical MSK education does not improve MSK knowledge assessed at the time of graduation, ⁸ but primary care MSK rotations can be as effective as orthopedic rotations for training emergency medicine residents. ⁹ A fourth-year MSK rotation might increase medical school graduates’ competence.

Competency-based training^{10, 11} requires recurrent, meaningful experiences. The American Medical Society for Sports Medicine has reimagined MSK training in undergraduate medical education (UME), focusing on domains of competence and entrustable professional activities (EPAs). ¹² MSK education should be longitudinal, emphasizing basic exam skills in preclinical years with additional sports medicine training in years three and four. ¹³ To address clinical deficiencies, clinical training opportunities can be redesigned, ¹⁴ and outpatient exposure alone can improve trainees’ confidence and willingness to provide care. ¹⁵ Inspired by the flexible curriculum outline for family medicine subinternships,¹⁶ this study aimed to identify the elements of a meaningful educational experience in MSK medicine for fourth-year medical students.

The Delphi technique is an established method to derive consensus, and modified methods have been used previously in curricular development. ^17-19 We employed the modified technique of three rounds, foregoing statistical stability analysis and aiming to achieve consensus regarding which elements should be included in a fourth-year medical student MSK course.

A group within the Society of Teachers of Family Medicine Musculoskeletal and Sports Medicine Education Collaborative identified and invited panelists based on prior involvement in scholarly work on similar topics, academic reputation, and experience with curriculum development. Recruitment was by direct invitation from the lead author. A description of the panel’s composition appears in Table 1.

We solicited ideas by telephone and email communication (see online Appendix for outreach email) for components and learning objectives of a meaningful fourth-year elective. The lead author coded these responses and identified latent themes to organize the elements. ^{20, 21} Themes with sorted elements were submitted for member checking, ²² and the participants confirmed the following categories prior to beginning the Delphi ranking: scheduling, learning objectives, technical skills, and clinical entities. The institutional review board deemed approval for this study unnecessary.

An initial list of 103 items was submitted to the panelists via electronic survey. The panelists were instructed to “rate the importance of incorporating each item into the elective” using a 5-point Likert scale (5, very important; 4, fairly important; 3, undecided; 2, fairly unimportant; 1, not important).

Three total rounds of ranking were completed, with no attrition among the panelists. Between rounds, we used statistical analysis to determine the mean and mode of each item, which were provided as feedback to the panelists, along with added elements for consideration and comments in round 2. Panelists were instructed to rate each item with a goal of achieving consensus. For the final round, only items that had not yet achieved consensus or recommendation for inclusion were included, along with the mean, mode, and comments. The schematic of the process appears in Figure 1.

Consensus for the purpose of this group was defined as an item receiving unanimous ranking from all participants. Recommendation for inclusion in the curriculum required an item to receive scores of 4 or 5 from all participants (fairly important or very important, respectively); a unanimous score was not required.

The panel generated 118 curricular elements for consideration: 39 reached consensus, and 78 were recommended for inclusion. One element was later deemed redundant and eliminated. The elements for consideration are listed in Table 2. A total of 28 items received a unanimous ranking of 5, indicating very important elements to include in a fourth-year MSK preceptorship. Another 42 items received mixed rankings of 4 or 5, indicating that all panelists found these items to be at least fairly important. Seven items received a unanimous ranking of 4, with all panelists agreeing these items were fairly important; and 3 items received a unanimous ranking of 3 (undecided). For another 37 elements, the panel could not agree on their importance after 3 rounds.

This study provides a valuable resource for family medicine educators aiming to enhance MSK medicine training in UME. Despite recent outlines of EPAs in sports medicine for UME,¹² the curriculum remains broad. This study distills the subject into specific, clinically observable, and attainable mini-EPAs, serving as a framework to address MSK insufficiencies prior to medical school graduation. While extensive, this list can be personalized based on students’ strengths and weaknesses, promoting a learner-centered and growth mindset-driven educational model. The list is designed to be used in creating a fourth-year elective or in redesigning fourth-year family medicine internships, preinternship boot camps, and residency transition courses, and adds value to family medicine education by bringing educators’ attention to the unmet need in the competency-based medical education framework: integrating UME and graduate medical education (GME) curricula to foster clinical competency in MSK medicine.

The consensus curricular elements include clinical anatomy review, particularly the shoulder and knee, and emphasize a systematic and differential-informed approach to evaluation and management of MSK issues seen by family physicians. Key recommendations include longitudinal practice of physical exam skills at the bedside, reinforcement of relevant anatomy, specific frameworks for MSK medical care, and a consensus-driven selection of high-yield clinical entities from which to choose.

For validity and expertise,²³ we included members of the group that revised the American Academy of Family Physicians reprint on MSK education topics ²⁴ to derive the most useful elements for graduating medical students. To balance potential bias, curriculum design experts without specialized sports medicine training were included. The specific mention of the shoulder, knee, back, and hip examinations by the expert panel is worth noting. Interestingly, the hip exam was ranked very important, despite no proposals for differential diagnoses of hip pain, indicating a possible bias in the panel’s expertise.

The panelists strongly recommended time in a primary care MSK clinic for repeated, supervised physical exam practice. This repetition of numerous joint examinations, in conjunction with anatomy review and structured workshops, should help learners review, reinforce, and expand their knowledge as intended within a spiral curriculum. This approach, based on constructivist educational theory that active learning connects new knowledge to preexisting knowledge, ²⁵ has shown improved physical exam skills in preclinical medical education;²⁶ and the clinical context of this experience should associate a catalog of diagnostic entities with those physical exam findings.

While the modified Delphi technique classically involves real-time discussion, this project was conducted asynchronously via telephone and email. Nevertheless, the panel agreed on the inclusion of a substantial number of curricular components. Future studies should explore how to implement these recommendations, particularly without an integrated sports medicine fellowship, and assess the outcomes of a curriculum targeting these elements.

This study adds novel perspectives to family medicine education by preparing soon-to-be GME trainees to confidently practice MSK medicine, reducing reliance on specialists and improving health care utilization. Implementing MSK-focused educational experiences with real patients and real pathology, rather than standardized patients, could close the gap between MSK knowledge and required competence for GME settings.