Articles by JCS

MSD incompetence

Musculoskeletal incompetence

in medicine



Allopathic medical education has recently been described as "woefully inadequate" in preparing medical doctors for the diagnosis and treatment of musculoskeletal conditions, and these deficits stem from the paucity of educational and clinical training provided to medical students in musculoskeletal diagnosis and treatment.

In their 2004 review published in Physician and Sports Medicine, Joy and Van Hala describe the formal training of a sample of 85 recent medical graduates.

"The average time spent in rotations or courses devoted to orthopedics during medical school was only 2.1 weeks. One third of these examinees graduated without any formal training in orthopedics. As would be expected, these data suggest that limited educational experience contributes to poor performance."[1]

In 1998, Freedman and Bernstein published a landmark study in Journal of Bone and Joint Surgery wherein they administered a validated musculoskeletal competency examination to 85 recent medical graduates who had begun their hospital residency; 82% of these medical doctors failed to demonstrate basic competency on the examination, leading the authors to conclude, "We therefore believe that medical school preparation in musculoskeletal medicine is inadequate." They repeated their study in 2002, and this time the examination questions, which had previously been validated by orthopedic specialists, were validated by directors of internal medicine departments; their conclusions stated, "According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate."[2]

In February 2005, Matzkin et al.[3] administered a standardized test of musculoskeletal competency to 334 medical students, residents, and staff physicians; the conclusion from their study reads as follows: "Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination. This suggests that training in musculoskeletal medicine is inadequate in both medical school and nonorthopaedic residency training programs."

Again in August 2005, Schmale from the University of Washington showed that when a standardized musculoskeletal examination was administered. "Less than 50% of fourth-year students showed competency. Students who completed a musculoskeletal clinical elective scored higher and were more competent (78%) than students who did not take an elective. These results suggested that the curricular approach toward teaching musculoskeletal medicine at this medical school was insufficient..." [4]

These results are particularly alarming because the University of Washington is consistently ranks as the best medical school in America.[5] If medical schools across the nation are failing to prepare doctors to evaluate and thus treat patients with musculoskeletal complaints, then would this not present a danger to the public health?

What might be the consequences of such widespread professional ineptness? Insufficient training in musculoskeletal management might be expected to produce negative clinical consequences and an increased reliance on stereotypic and simplistic (rather than personalized and comprehensive) treatments such as the over-utilization of so-called "anti-inflammatory" drugs, shots and surgery.

Furthermore, such a high level of incompetence among recently graduated medical doctors in basic musculoskeletal assessment may represent a public health risk to patients seeking care.


The overutilization of surgical treatments for musculoskeletal disorders also places an unjustified burden on the nation's healthcare system; for example, arthroscopic knee surgery is performed on at least 225,000 middle-age and older Americans each year at a cost of several billion dollars to Medicare, the Department of Veterans Affairs and private insurers[6] yet the results are no better than those obtained from placebo.[7] In their 2003 review of the literature on this topic, Bernstein and Quach concluded, "Arthroscopy for degenerative conditions of the knee is among the most commonly employed orthopedic procedures, but its effectiveness (like the effectiveness of many surgical operations) has never been proven in prospective trials."[8]

[1] Joy EA, Hala SV. Musculoskeletal Curricula in Medical Education: Filling In the Missing Pieces. The Physician and Sportsmedicine. 2004; 32: 42-45

[2] Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002;84-A(4):604-8

[3] Matzkin E, Smith ME, Freccero CD, Richardson AB. Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am. 2005 Feb;87-A(2):310-4

[4]Schmale GA. More evidence of educational inadequacies in musculoskeletal medicine. Clin Orthop Relat Res. 2005 Aug;(437):251-9

[6] Gina Kolata. A Knee Surgery for Arthritis Is Called Sham. The New York Times, July 11, 2002

[7] Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81-8

Bernstein J, Quach T. A perspective on the study of Moseley et al: questioning the value of arthroscopic knee surgery for osteoarthritis. Cleve Clin J Med. 2003;70(5):401, 405-6, 408-10[8]

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