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Initiative Builds Musculoskeletal Curriculum

While some pieces of the new integrated curriculum are getting lots of attention, behind the scenes HMS faculty are spearheading smaller changes that will have a big impact on what and how students learn during their four years at HMS.

As an orthopedic surgeon, Charles Day, an HMS assistant professor in that department at Beth Israel Deaconess Medical Center, has a particular interest in musculoskeletal (MSK) medicine. The field is increasingly becoming a concern for doctors of all stripes. Recent national surveys have shown that musculoskeletal pain is the top reason patients visit a doctor in the office, and this will likely continue as the Baby Boomers age.

Yet medical schools are not reflecting this trend in their curricula. In 2005, the Association of American Medical Colleges (AAMC) released a Medical School Objectives Project (MSOP) report on the inadequacy of musculoskeletal education at medical schools across the country.

Concerned about this lack in the HMS curriculum, Day had issued his own HMS-specific study across all four years, shortly before the AAMC report. He found that, overall, students were not confident in their knowledge of the musculoskeletal system, and most did not receive a passing grade on a validated basic competency exam given as part of the study. In addition, HMS students scored lower on the MSK section of the USMLE Step I board exam than any other section.

Simultaneously, Ron Arky, the Charles S. Davidson distinguished professor of medicine, was putting together an MSK task force, from which Day assembled a list of educational objectives across all four years based on the recommendations from the MSOP report. He began to approach individual course directors about including a musculoskeletal curriculum in their classes.

He quickly got the go-ahead to integrate a surface anatomy section into the first-year Human Body course. Bill Taylor, director of the Patient–Doctor II course, was also eager to include a physical examination component as part of that class.

A lecture alone, however, would not suffice for learning surface anatomy and physical examination. Taylor and Day envisioned hands-on teaching with a student-to-faculty ratio of about six to one.

“Well, PD-II is a mandatory course, so you just do the math. We needed 30-some faculty members,” Day said.

Gathering that many faculty in one place at one time was a big task, but when Day approached the chairs of the orthopedic departments at Massachusetts General Hospital, Brigham and Women’s Hospital, BID, and Children’s Hospital Boston, he said he found they were enthusiastically supportive.

“The only way this could have happened was because the chairmen all value [musculoskeletal education],” said Day. “Every one of them said, yes, we will support you.”

With the help of a medical education representative from each hospital, Day was able to recruit 55 orthopedic faculty for a total of two centralized PD-II sessions this year teaching about the examination of the upper extremity, lower extremity, and low back. About 16 participated in the Human Body MSK surface anatomy course.

Day has gotten feedback from both faculty and the students in the PD-II course. While the faculty responded positively, the students requested even more time for instruction.

“As with anything else, things need fine-tuning,” Day conceded. He said he hopes that the surface anatomy unit in this year’s Human Body course will better prepare students for the MSK unit in next year’s PD-II course.

Day is currently working on a one-week pathophysiology block for the Human Systems course, as well as integrating MSK objectives into other courses, including pathology and clinical epidemiology. Eventually, Day hopes to integrate some of these objectives into the third- and fourth-year rotations, as well.