Effectiveness of an Interprofessional and Multidisciplinary Musculoskeletal Training Program

Musculoskeletal (MSK) problems are common, and in 2006, codes for MSK diseases were the most frequently selected conditions for primary care office visits in the United States.^1–3  Despite this prevalence, MSK education is inadequate across the continuum of medical education in the United States and throughout the world.^4–11  The 2011 US Bone and Joint Initiative Summit called for improved MSK education and emphasized the need to demonstrate competence in performing MSK physical examinations.¹² 

Although recent reports emphasize innovative MSK education at the undergraduate level, less is known about interdisciplinary, multilevel structured MSK training experiences in graduate medical education.^13,14  The purpose of this study was to determine whether an experimental interdisciplinary immersion MSK curriculum would be acceptable to residents from internal medicine (IM), orthopaedic surgery, physical medicine and rehabilitation (PM&R), and other specialties; feasible within existing rotations; and effective in strengthening clinical skills.

In 2011, the George E. Wahlen Department of Veterans Affairs (VA) Medical Center in Salt Lake City, an affiliate of the University of Utah Health Sciences Center, established a Center of Excellence (COE) in MSK care and education, with initial support from the Veterans Health Administration Office of Academic Affiliations and the Office of Specialty Care. The goal of the COE is to train students and trainees of medical, nursing, and allied health professions to provide patient-centered care to patients with MSK diseases while learning and working in an interdisciplinary and interprofessional health care system.

Curriculum development was informed by Kern's systematic approach.¹⁵  The target group was IM residents, anticipating that the program would be adaptable to other trainees. In the first year, our cohort was a convenience sample of IM, PM&R, and orthopaedic surgery residents, a physical therapy resident, a senior medical student, and several physician assistants and advance practice nursing students, all of whom had been assigned to VA clinic rotations. The MSK Education Week replaced what would otherwise have been traditional clinical experiences. After the first year, we scheduled all postgraduate year (PGY) 1 categorical IM residents to participate during their required ambulatory rotation.

In development, we drew from Kolb's theory of learning cycles, in which abstract conceptualization is followed by active experimentation, followed in turn by concrete experiences, and completed with reflective observation.¹⁶  Our planning was informed by systematic reviews supporting the use of small groups, peer learning, and simulation, and by published projections of potential cost-effectiveness of a course to train primary care providers to perform joint injections, and the initial experience of the program that followed.^{10,11,17–20}  The schedule for the MSK Education Week, including requirements for faculty participation, is shown in figure 1.

Physical examination of the shoulder is presented, including demonstrating a systematic approach (provided as online supplemental material). Participants receive a checklist outlining the method (provided as online supplemental material) and practice this examination under faculty supervision, using the checklist as a memory aid.

Next, the evaluation and management of shoulder pain are discussed, including appropriate use of imaging. Faculty then simulate cases; participants solicit history, perform the focused physical examination, provide a differential diagnosis, and propose a plan.

This sequence is repeated on the second day, with sessions for the knee (provided as online supplemental material).

Discussions of risk factors, screening recommendations, definitions, diagnosis, and treatment options for osteopenia and osteoporosis are facilitated by an endocrinologist with expertise in bone health.

We teach the “No-Touch” technique described by Wittich et al,²¹  focusing on injections of the subacromial space of the shoulder and the suprapatellar pouch of the knee. Anatomy and external landmarks identifying portals for safe and effective aspiration and injection are discussed at length. Indications, contraindications, and complications of these procedures are emphasized. Informed consent, patient positioning, sterilization of the injection site, technique of aspiration and injection, and postprocedural care are presented by an orthopaedic surgeon. Participants practice using knee and shoulder arthrocentesis simulators (Limbs & Things Ltd, Savannah, GA).

Case-based discussions review gout, osteoarthritis, rheumatoid arthritis, acute monoarthritis, and spondyloarthropathies, as well as interpretation of serologies and acute phase reactants.

The latter portion of the week involves supervised experiences with patients in outpatient settings: (1) an orthopedic injection clinic; (2) a PM&R clinic; (3) a primary care MSK clinic; (4) 2 rheumatology clinics; and (5) an interdisciplinary MSK clinic.

Beginning in the second year, self-assessments were incorporated. These were developed by faculty (M.J.B., A.M.B., M.P.G., J.M.B., G.W.C.) and did not undergo validity testing. Before the course, participants used Likert scales anchored at 5 points (1, strongly disagree, to 5, strongly agree), rating proficiency relative to course goals. On the final day of the program, the same dimensions are used to self-rate postcourse proficiency and retrospectively rate precourse proficiency—in effect, capturing information that trainees “didn't know they didn't know.”^22–24  The domains of the instruments map to course goals (1) to evaluate and manage common MSK conditions; (2) to develop skills of joint aspiration and injection; and (3) to screen patients for osteopenia and osteoporosis. Responses specific to knee, shoulder, and arthrocentesis were pooled for each of these categories, and averaged responses were dichotomized.

Added in the second year, the objective structured clinical examination (OSCE) involves 2 stations—the shoulder and the knee. The OSCE and the self-assessments were completed on the last day of the course. Validity evidence of these has been reported; interrater agreement was 87% (k = 0.61) and 97% (k = 0.88) for the knee and shoulder, respectively.²⁵ 

This project was reviewed by the Institutional Review Board of the University of Utah and was classified as exempt.

The course was implemented in July 2012. Over the 3-year period to date, we have seen increasing numbers of participants, as well as a growing diversity of the training programs that learners represent (table 1). We found improvement in participants' confidence in evaluating and managing common MSK conditions, and competence in performing and interpreting shoulder and knee physical examinations was confirmed by the OSCE. Self-assessment ratings are shown in table 2, with 153 precourse and 135 postcourse surveys collected (response rates of 100% and 88%, respectively). Figure 2 shows percentages of responses indicating agreement with items relating to the evaluation and management of shoulder and knee complaints, and figure 3 shows the distributions of OSCE scores.

Our interprofessional, multidisciplinary curriculum for MSK care for residents and senior medical and health professions students has been used for more than 3 years, and is now sustained without external funding.

The most innovative aspect of our curriculum is the multispecialty character of the trainee cohort and the interdisciplinary faculty. Although we cannot directly measure the impact of these, our participant cohort has both increased and grown more diverse. When the scheduling of IM residents became systematized, other disciplines may have been able to schedule their trainees to best fit their programs.

The IM residency is the largest at the institution, and it is not surprising that IM residents are the majority of participants. At the same time, there is strong interest from other program directors in having their trainees participate. The MSK experience is now required for all first-year “preliminary” neurology and PM&R residents.

Our study confirms earlier work that used a monthly program of two 1-hour workshops, supervised practice with joint injection simulators, and structured experiences in an MSK injection clinic to train 27 IM residents (PGY-2 and PGY-3) in physical examination skills and knee and shoulder injections.⁸  Similar to their results, we found that participants' confidence increased after the course, which was confirmed with OSCEs. Our methods differed in that, although we included joint injections as a key component of the course, we emphasized the performance and interpretation of the physical examination through supervised peer-practice sessions and evaluated clinical reasoning and medical decision-making skills in the OSCEs. We also demonstrated sustainability, and the increase in participation rates over a 3-year period indicates feasibility and a durable interest across a range of training programs. An ideal model for MSK education in postgraduate settings would combine these approaches, using an intensive foundational program early in training, followed by focused “booster” experiences to reinforce and expand skills in subsequent years.

We acknowledge several limitations. First, this innovation was implemented at a single site, thus reducing generalizability. Second, our intervention lacked a comparison group, and third, learning outcomes were measured at the conclusion of the course, and we do not know the durability of these skills or whether competence in the OSCE predicts proficiency in patient care. Finally, our self-assessment survey lacks validity evidence.

Next steps include examining experiences with implementation of this curriculum at other sites and comparing cost-effectiveness to other educational strategies. For our program, the next development phase involves 2 elements: (1) expanding outcome measures to include written knowledge assessments, and (2) evaluating durability of skills by OSCE 1 year later.

The MSK Education Week is a multidisciplinary initiative developed within a primary care rotation for IM residents. It is well received by residents and other learners from a range of specialties and health professions training programs. As confirmed by OSCEs, there is a self-reported increase in ability to evaluate and manage shoulder and knee pain and increased competence in performing shoulder and knee examinations.