Inadequacies of musculoskeletal medicine curriculum for undergraduate medical students: a cross-sectional study

ABSTRACT BACKGROUND: Musculoskeletal disorders account for up to one in four of general-practice consultations and almost one third of complaints in primary-care clinical practice. However, an insufficient amount of time and importance is given to their teaching in most medical schools. OBJECTIVE: To evaluate the acquisition of musculoskeletal competences in our institution, in order to identify flaws and propose changes to correct and improve the musculoskeletal curriculum. DESIGN AND SETTING: Cross-sectional study conducted in São Paulo, Brazil. METHODS: First to fifth-year medical students were enrolled in a survey using the Freedman and Bernstein musculoskeletal examination, in order to evaluate the acquisition of musculoskeletal competencies. Categorical data were analyzed using the chi-square test. Continuous data were analyzed using one-way analysis of variance (ANOVA). The level of significance was set as P < 0.05. RESULTS: A total of 545 students completed the questionnaire: from year 2, 115/167 (29.6%); from year 3, 118/138 (30.4%); from year 4, 98/130 (25.3%); and from year 5, 57/110 (14.7%). None of the students achieved the pass mark (established as 70%). The level of confidence in performing musculoskeletal examination was very low (3.7 ± 2.2; n = 386) and bore no relationship to the percentage of correct answers in the questionnaire (r = 0.331; 95% confidence interval, CI: 0.239-0.417; P < 0.001). CONCLUSION: Undergraduate teaching is the only exposure most general practitioners have to orthopedic problems. Universities are concerned about the adequacy of the musculoskeletal programs taught in their institutions. Student scores were found to be unsatisfactory in all the topics evaluated.


INTRODUCTION
Musculoskeletal disorders account for up one in four general-practice consultations 1 and almost one third of complaints in primary-care clinical practice. However, an insufficient amount of time and importance is given to their teaching in most medical schools. 2,3 Moreover, the knowledge acquired is not always in line with what professors desire or plan. Active techniques have been included in undergraduate training as a powerful teaching tool for improving the quality of learning.
Knowledge of the basis of musculoskeletal disorders is fundamental for general practitioners, family practitioners, pediatricians, emergency physicians, interns and, of course, rheumatologists and orthopedists. Thus, a very well-structured curriculum is necessary in order to achieve the competences desired.
One way to evaluate the basic competency attained by medical school students in relation to the musculoskeletal system is the Freedman and Bernstein examination. This was developed and validated by 124 chairs of orthopedic residency programs in the United States and the pass mark for physicians has been set at 70%. 4

OBJECTIVE
The objective of this study was to evaluate the acquisition of musculoskeletal competences in our institution, in order to identify flaws and propose changes to correct and improve the musculoskeletal curriculum. A tool asking about their confidence in performing orthopedic physical examinations and making diagnostic hypotheses for musculoskeletal disorders was applied using a 10-point scale.
The testing was performed with the cooperation of the professors of each year. Written informed consent was obtained from the participants and the examination was anonymous. No time limit was imposed.
The distribution of academic content, according to the semester taught, is shown in Table 1. Anatomy content is taught by the end of the second year, while major clinical and therapeutic content is taught by the end of the fourth year.
The general characteristics of the sample are shown in Table 2.
In total, 388 (71.2%) out of 545 students completed the question- to be recognized by general physicians so that patients with these conditions can be referred to an orthopedic surgeon immediately.
The examination was scored anonymously using an answer key. The pass mark was set as 70%, based on recommendations from previous studies. 4,5 Each question was worth a maximum of one point and the raw scores were multiplied by four to obtain a final score between zero and 100.
The lesson plans of the previous year were evaluated and used as a reference to determine whether the topic had been taught to the students and in which year of the medical curriculum this had been done.
The results were analyzed using the R software (version 3.3.2, 2016; Vienna, Austria) and graphs were compiled using the ggplot2 package. Descriptive data and confidence intervals were determined. Categorical data were analyzed using the chi-square test.
Continuous data were analyzed using one-way analysis of variance (ANOVA). The significance level was set as P < 0.05.

RESULTS
None of the students achieved the pass mark, which had been established as 70%. There was no difference in the percentage of correct answers between the third-year students (16.2 ± 9) and the fifth-year students (16.3 ± 14.4). The students' overall performance was very low (Figure 1). They were answered most successfully by the fifth-year students (Figure 2), albeit with a low incidence of correct answers. On the other hand, basic anatomy questions were answered most successfully by the third-year students, and the percentage of correct answers decreased over the subsequent years (Figure 3).

Out of all
Excluding second-year students, no difference in the proportion of correct answers was found in relation to the miscellaneous questions among the other school years (Figure 4). The level of confidence in performing musculoskeletal exam-   classes are shown in Table 3. The majority (83.7%) of the students considered that the amount of time spent on theoretical classes was reasonable or good (83.7%). Theoretical classes were the most commonly used teaching methodology (44.5% ± 23.4; n = 349).

DISCUSSION
In this study, we evaluated students in the second to the fifth academic years of medical school using a survey based on the The burden of musculoskeletal problems within primary-care medical practice and on healthcare resources is well known. [6][7][8] However, undergraduate teaching is the only exposure that the majority of general practitioners will have to orthopedic problems.
Many universities are concerned about the adequacy of the musculoskeletal programs taught in their institutions. 1,4,5,[7][8][9][10][11] The present study serves to aid in understanding and proposing changes since our students correctly answered fewer than 20% of the questions.
However, it is important to look not only at the curriculum but also, and sometimes even more importantly, at the way in which the curricular content is being taught. At our institution, we use the spiral curricular model, in which students see content more than once ( Table 2). However, although active methodologies are used, students are not retaining that knowledge.
Third-year students performed better on basic or anatomical questions, which they had just finished studying through the spiral curriculum, but the level of correct responses decreased over the subsequent years. This may have been due to many factors, such as the methodologies used or differences in the way in which the content was taught, since some changes to the teaching staff occurred during this period.
Fifth-year students performed better in the so-called red-flag set of questions. This was because the major clinical and therapeutic content had been taught that year. Unfortunately, students in the sixth year were not evaluated in this study: this would have enabled analysis on the students' learning.
Attention needs to be given to curricular competencies. In Brazil, competencies have been well described in relation to the medical curriculum but not for curricular subjects. 12 Thus, there is no standardization regarding the musculoskeletal curriculum for all universities and each professor or institution can decide what is important to teach, and sometimes they do not cover all the core subjects. There is also the possibility that professors are not fulfilling the lesson plan. Since this study was conducted in only one institution, we are unable to say whether this is the case throughout the country, but our study sheds light on an area that deserves attention.

CONCLUSION
In summary, the way in which musculoskeletal disorders are being taught in medical schools today needs to be reviewed.
There is scope for progress in relation to some points, such as the standardization of content, commitment of teachers to teaching this content, improvement of active teaching methodologies, use of sound in-depth lesson plans and supervision and confirmation that these plans are being fulfilled.