Pediatric residents' performance of ankle and knee examinations after an educational intervention

The Impact of a Gamified Curriculum Using Kahoot! on Musculoskeletal Knowledge and Skill Acquisition Among Pediatric Residents

OBJECTIVE

To determine whether a musculoskeletal curriculum involving gamification via Kahoot! (an online classroom response system) was acceptable and more effective at teaching pediatric residents musculoskeletal knowledge and skills than a nongamified curriculum.

METHODS

A prospective, randomized controlled trial was conducted at an urban, academic pediatric clinic. All participants received a curriculum that included brief didactics and knowledge questions. The knowledge questions were delivered via Kahoot! to the intervention group and administered via paper to the control group. The primary outcome was knowledge and skill acquisition following curriculum participation.

RESULTS

A total of 73 of 85 (86%) residents completed the study (intervention group: 46; control group: 27). Following participation in the curriculum, intervention and control residents demonstrated an improvement in musculoskeletal knowledge (P < .05) measured via questionnaire, as well as an improvement in physical exam skills during a standardized patient encounter (P < .05). There was no difference in knowledge or skill improvement between groups. Intervention participants indicated positive attitudes toward Kahoot!.

CONCLUSIONS

Our musculoskeletal curriculum demonstrated improvements in knowledge and skills among residents, though inclusion of Kahoot! did not enhance the experimental effect. Further research is needed to identify strategies to optimize gamification for learning.

Providing optimal care for active youth in Canada

Sports are important activities for youth, with millions of children and adolescents participating in organized sports and recreational activities every year. Sports participation has many benefits but can also cause injuries, accounting for two-thirds of all injuries in Canadian adolescents and resulting in hundreds of thousands of medical visits annually. Despite the frequency of sport-related injuries in youth, many practising pediatricians are not comfortable managing these issues, citing lack of teaching and clinical exposure during training. Many studies have found deficits in musculoskeletal (MSK) and sport and exercise medicine (SEM) training in residency programs in North America, including Canadian pediatric residency programs. To address this learning gap, Canadian pediatric residency programs should incorporate more MSK/SEM training and clinical exposure to these issues. A standardized national curriculum in MSK/SEM will help ensure that community pediatricians practicing in Canada are adequately prepared to care for active youth.

Incorporating interactive workshops into bedside teaching: completion of a multi-modal rheumatology rotation significantly increases internal medicine residents' competency and comfort with comprehensive knee examinations

BACKGROUND

Studies have elucidated the lack of competency in musculoskeletal (MSK) examination skills amongst trainees. Various modalities have been studied, however, there remains a dearth of literature regarding the effectiveness of bedside teaching versus dedicated workshops. Our aim was to determine if incorporating a workshop into a rheumatology rotation would be effective in increasing medicine residents' competency and comfort with knee examinations when compared to the rotation alone.

METHODS

Over 16 months, rotators were randomized to workshop plus rotation versus rotation alone. Participants were tested on their knee examination skills using an objective structured clinical examination (OSCE). Surveys were administered assessing to what degree the rotation was beneficial. Comfort and helpfulness were measured using a 5-point Likert scale. Paired and independent samples t-tests were used for comparisons.

RESULTS

Fifty-seven residents participated. For both groups, there were improvements between pre- and post-OSCE scores (workshop p < 0.001, no workshop p = 0.003), and levels of comfort with examination (workshop p < 0.001, no workshop p < 0.001). When comparing groups, there were differences favoring the workshop in post-OSCE score (p = < 0.001), mean change in OSCE score (p < 0.001) and mean change in comfort with knee examination (p = 0.025).

CONCLUSION

An elective in rheumatology augmented residents' MSK competency and comfort. Incorporation of a workshop further increased knowledge, skills and comfort with diagnosis and treatment. Current educational research focuses on alternatives to traditional methods. This study provides evidence that a multi-modal approach, combining traditional bedside and interactive models, is of benefit.

Musculoskeletal and Sports Medicine Curriculum Guidelines for Pediatric Residents

ABSTRACT

Musculoskeletal (MSK) and sports-related conditions are relatively common in the pediatric population. Pediatric residencies should provide residents with the knowledge and skills to assess and manage both acute and chronic MSK and sports injuries and complaints. Residents should develop the competencies and attitudes to safeguard and promote a healthy and active lifestyle for youth. Programs can use a variety of educational tools, both in the clinic and on the field, to provide a well-rounded MSK curriculum throughout the residency years. This article provides a review of general pediatric sports medicine curriculum guidelines and suggested implementation strategies.

Developing Physical Exam Skills in Residency: Comparing the Perspectives of Residents and Faculty About Values, Barriers, and Teaching Methods

BACKGROUND

The physical examination (PE) skills of residents are often not improved since medical school. Unfortunately, how residents learn PE is not well understood. There is a paucity of research on the factors involved and the differences between resident and faculty perspectives. The authors sought to determine resident and faculty perceptions about the value of PE, the major barriers to learning PE, and the most effective teaching methods.

METHODS

Based on a rigorous process of literature review and semi-structured interviews, the authors developed an online survey which was sent to 406 internal medicine residents and 93 faculty at 3 institutions. Residents and faculty answered questions about both their own opinions and about their perception of the other group's opinions.

RESULTS

About 283 residents (70%) and 61 faculty (66%) completed the survey. Both residents and faculty rated the importance of PE similarly. Residents rated being too busy, followed by a lack of feedback, as the most significant barriers to learning PE. Faculty rated a lack of feedback, followed by a lack of resident accountability, as the most significant barriers. Both groups rated the availability of abnormal findings as the least significant barrier. Both groups agreed that faculty demonstration at the bedside was the most effective teaching method.

CONCLUSION

This survey can serve as a needs assessment for educational interventions to improve the PE skills of residents by focusing on areas of agreement between residents and faculty, specifically faculty demonstration at the bedside combined with feedback about residents' skills.

Factors Influencing Pediatric Resident Exposure to Adolescents in their Continuity Clinic

Adequate training in adolescent primary care is a challenge for pediatric residency programs. We examined residents' pediatric continuity clinic exposure to and comfort with adolescents, and their knowledge about best practices. Comfort was predicted by patient numbers, training level, and completing the adolescent rotation. Knowledge was predicted by completing the adolescent rotation.

Awareness of common paediatric orthopaedic problems among paediatricians and family medicine physicians

Background

Most paediatric orthopaedic problems referred to paediatric orthopaedists are usually self-limited, requiring observation and reassurance. Higher parental expectations may have resulted in higher referral rates. This study was conducted to assess awareness and knowledge about the diagnosis and management of some common normal variants of musculoskeletal paediatric development among paediatricians and primary health care physicians.

Method

A self-administered questionnaire (tested for validity and reliability) was distributed between November 2016 and June 2017. Of 300 questionnaires, 189 (63% response rate) were obtained from 106 paediatricians, 57 family physicians, and 26 general practitioners (GPs).

Results

Paediatricians accounted for 56% of participants, 30.2% were family physicians, and 13.8% were GPs. Correct answer rates ranged between 9% and 66.1%. Inadequate knowledge of common paediatric orthopaedic problems was found in 87.3% of participants. With parental insistence, 75.7% of physicians referred a case, regardless of necessity, whereas inappropriate referral for medicolegal issues was reported by 62.4%. The study showed that paediatricians were less likely than family physicians and GPs to refer inappropriately (67% versus 87.7% and 84.6%, respectively; p = 0.007). Physicians who reported that more than 10% of their training was in orthopaedics were more likely to inappropriately refer orthopaedic cases compared to those who reported a higher percentage of orthopaedic training (82.1% versus 66.7%).

Conclusion

Inappropriate paediatric orthopaedic referrals are increasing. The results clearly point to the need for increased musculoskeletal education during undergraduate medical and residency training in paediatrics and family medicine. New guidelines should be implemented and updated regularly. Educational material for parents (posters, videos, etc.) should be considered.

What do they need to know: achieving consensus on paediatric musculoskeletal content for medical students

BACKGROUND

Children present commonly with musculoskeletal (MSK) problems, due to a spectrum of causes including potentially life threatening disease, to doctors in varied health care settings. However, doctors involved in the care of children report a lack of confidence in their paediatric musculoskeletal (pMSK) clinical skills and many have little exposure to pMSK teaching. There is no current guidance on the pMSK clinical skills and knowledge required for medical students. The objective of this study was to achieve consensus amongst experts on the learning outcomes for a pMSK curriculum for medical students.

METHODS

This was a two-phase study. In Phase one, pMSK educational topics and categories were identified from UK medical students and experts (recruited from pMSK medicine, child health, education and primary care) utilising focus groups and interviews. These themes and concepts informed the structure of learning outcomes that were presented to a Delphi panel in Phase two, with the aim of achieving consensus on the final content of the curriculum.

RESULTS

In Phase 1 participants identified pMSK skills, knowledge and attitudes relevant for medical students. This content was translated into learning outcomes. In Phase 2, the proposed outcomes were submitted to scrutiny by a two-iteration Delphi process with experts in the field. The agreed learning outcomes (n = 45) were either generic to child health or specific to pMSK medicine, and related to history taking and examination, knowledge about normal development, key clinical presentation and conditions, approaches to investigation and referral pathways.

DISCUSSION

This study has identified evidence and consensu based content for a pMSK curriculum for medical students, derived from key stakeholders and to be integrated into medical student pMSK teaching.

CONCLUSION

It is envisaged that implementation of this content will equip graduating doctors with relevant and important skills and knowledge to assess children with MSK presentations, and facilitate early diagnosis and referral to specialist care.

Physiological referrals for paediatric musculoskeletal complaints: A costly problem that needs to be addressed

BACKGROUND/OBJECTIVE

Referrals to paediatric orthopedists for physiologically normal conditions consume limited resources and delay care for patients. The goal of the present study was to formally define such referrals and determine their prevalence.

METHODS

A retrospective review evaluated consecutive referrals to a single tertiary paediatric orthopedic centre over two eight-month periods. Referrals from family physicians and paediatricians were retained for analysis. Physiological referrals were defined as a final orthopedic diagnosis of 'within physiological norms'; and no scheduled follow up.

RESULTS

Physiological conditions represented 22.5% of referrals. The type of referring physician did not determine referral quality. Flat foot, intoeing and genu varum/valgum exhibited physiological referral rates that exceeded 40%.

CONCLUSION

Physiological referrals constitute a large portion of the outpatient paediatric orthopedic practice and represent a substantial unnecessary cost to the Canadian medical system. Future strategies to improve referral quality should target undergraduate and postgraduate musculoskeletal education.

Development and validation of a musculoskeletal physical examination decision-making test for medical students

OBJECTIVE

Despite a renewed emphasis among educators, musculoskeletal education is still lacking in medical school and residency training programs. We created a musculoskeletal multiple-choice physical examination decision-making test to assess competency and physical examination knowledge of our trainees.

DESIGN

We developed a 20-question test in musculoskeletal physical examination decision-making test with content that most medical students and orthopedic residents should know. All questions were reviewed by ratings of US orthopedic chairmen. It was administered to postgraduate year 2 to 5 orthopedic residents and 2 groups of medical students: 1 group immediately after their 3-week musculoskeletal course and the other 1 year after the musculoskeletal course completion. We hypothesized that residents would score highest, medical students 1 year post-musculoskeletal training lowest, and students immediately post-musculoskeletal training midrange. We administered an established cognitive knowledge test to compare student knowledge base as we expected the scores to correlate.

SETTING

Academic medical center in the Midwestern United States.

PARTICIPANTS

Orthopedic residents, chairmen, and medical students.

RESULTS

Fifty-four orthopedic chairmen (54 of 110 or 49%) responded to our survey, rating a mean overall question importance of 7.12 (0 = Not Important; 5 = Important; 10 = Very Important). Mean physical examination decision-making scores were 89% for residents, 77% for immediate post-musculoskeletal trained medical students, and 59% 1 year post-musculoskeletal trained medical students (F = 42.07, p<0.001). The physical examination decision-making test was found to be internally consistent (Kuder-Richardson Formula 20 = 0.69). The musculoskeletal cognitive knowledge test was 78% for immediate post-musculoskeletal trained students and 71% for the 1 year post-musculoskeletal trained students. The student physical examination and cognitive knowledge scores were correlated (r = 0.54, p<0.001), but were not significantly different for either class.

CONCLUSIONS

The physical examination decision-making test was found to be internally consistent in exposing the deficiencies of musculoskeletal education skills of our medical students and differentiated between ability levels in musculoskeletal physical examination decision-making (residents vs recently instructed musculoskeletal students vs 1 year post-musculoskeletal instruction).

Improving postgraduate clinical assessment tools: the introduction of video recordings to assess decision making

BACKGROUND

Competency in the management of acutely unwell patients has not previously been formally assessed as part of an objective structured clinical examination (OSCE).

AIM

The reliability of the paediatric postgraduate OSCE was calculated. An objective structured video examination was designed to assess candidates' clinical decision making ability when managing acutely unwell children.

METHODS

The performance of 3522 postgraduate paediatric trainees was assessed (2006-2008). OSCE reliability was determined using Cronbach's alpha and mean inter-item correlation. Performance in the video station was compared with overall performance (not including video station; Mann-Whitney U) and video station scores correlated with individual station scores (Spearman's Rho correlation coefficient).

RESULTS

Clinical examination pass rates for the 684 UK graduates, 1608 overseas candidates training in the UK and 1104 overseas candidates training overseas were 69.7%, 28% and 22.3%, respectively (graduation information not available for 126 candidates). Cronbach's alpha was 0.62. Mean inter-item correlation was 0.15. Candidates who passed the OSCE overall had significantly higher scores on the video station (t(3520) = 14.48); p < 0.001). There was significant positive correlation between scores on the video station, individual stations and overall total score (r's = 0.300; p = 0.001).

CONCLUSIONS

The postgraduate paediatric OSCE provides a sound and valid means of assessing clinical skills at the postgraduate level. The video station provides an important new method of assessment. Its use in other postgraduate clinical examinations should be explored.

Acceptability and practicality of pGALS in screening for rheumatic disease in Malawian children

The pGALS (paediatric Gait, Arms, Legs, Spine) Musculoskeletal (MSK) screen is validated in English-speaking school-aged children and has been shown to be useful in acute paediatric practice in the UK. The aim of this study is to evaluate the practicality and acceptability of pGALS in children in an acute hospital setting in Malawi. School-aged inpatients and children presenting to the Queen Elizabeth Hospital Blantyre, Malawi, participated. Practicality (time taken, degree of completion) and patient/parent assessed acceptability (time take, discomfort) were assessed using a 'smiley face' visual analogue scale. Fifty-one children (median age 8 years) were assessed; 23 out of 51 (45%) in the emergency department and the remainder were inpatients. Most presentations were infection or trauma related (n = 35, 69%). Practicality of pGALS was good [median time to complete pGALS--4 min (range 1.8-7.4)] and completed in 48 out of 51 children (94%). Acceptability was high; 98% of parents considered the time taken to be acceptable, 84% of children deemed little/no additional discomfort. Abnormalities using pGALS were found in 21 out of 51 (41%), mostly in the lower limbs. The pGALS MSK screen was practical and acceptable in this acute setting. Abnormal findings were common.

Pediatric regional examination of the musculoskeletal system: a practice- and consensus-based approach

OBJECTIVE

Competent examination of the pediatric musculoskeletal (MSK) system is a vital component of clinical assessment of children with MSK presentations. The aim was to develop a regional MSK examination for school-age children that is age appropriate and reflects clinical practice.

METHODS

Qualitative and quantitative analyses involving video observation of clinical examination technique, systematic review, and expert consensus were employed to reveal descriptions, frequencies, and variations in technique for joint regions in various clinical scenarios. Systematic review and data from clinical observation were combined with feedback from a group of pediatric MSK experts through a web-based survey. All results were collated and discussed by consensus development groups to derive the pediatric Regional Examination of the Musculoskeletal System (pREMS).

RESULTS

A total of 48 pediatric MSK expert clinicians were involved to derive pREMS. Systematic review revealed a paucity of evidence about regional pediatric MSK examination. Video observations of MSK examinations (a total of 2,901 maneuvers) performed by pediatric MSK experts (n = 11 doctors and 8 therapists) of 89 school-age children attending outpatient clinics in 7 UK pediatric rheumatology centers were followed by semistructured interviews with 14 of 19 clinicians. Video observation showed variation in examination techniques, most frequently at the hip and knee in the context of mechanical and inflammatory clinical scenarios.

CONCLUSION

pREMS is the first practice- and consensus-based regional pediatric MSK examination for school-age children. The structured approach is an important step toward improved pediatric MSK clinical skills relevant to clinical training.

Acceptability and practicality of musculoskeletal examination in acute general pediatric assessment

OBJECTIVE

To evaluate the practicality and the acceptability of pGALS (pediatric Gait, Arms, Legs and Spine) screening, a simple pediatric musculoskeletal screening examination, when performed as part of an acute pediatric assessment.

STUDY DESIGN

Consecutive school-aged children attending an acute pediatric assessment unit were assessed with the addition of pGALS to the routine clinical examination. Practicality (ie, time taken, degree of completion) and patients/parent-assessed acceptability (ie, time taken, discomfort caused) were recorded.

RESULTS

Fifty consecutive school-aged children (median age 8 years) were evaluated by pGALS. Median time taken was 3 minutes (range 1.2-5.3), and examination was completed in 47/50 (96%) children. Acceptability of pGALS was deemed high: time taken was "about right" (98% children, 94% parents) and caused no or little discomfort (72% of children, 92% of parents). Abnormalities on pGALS examination were common, with most (17/50, 34%) explained by confirmed musculoskeletal disease, and 6 of 50 (12%) had non- musculoskeletal disease.

CONCLUSIONS

PGALS is practical and acceptable to perform in acute pediatric assessment performed by a non expert in musculoskeletal medicine. Abnormal musculoskeletal findings are common as part of the pGALS examination but need to be interpreted in the global clinical context and assessment.

Ensuring that all paediatricians and rheumatologists recognise significant rheumatic diseases

In many health-care systems around the world, many generalists (defined here as a clinician who is not an expert in paediatric musculoskeletal [pMSK] medicine) will be the doctor to whom children with MSK problems are most likely to present. The generalist is likely to have a clinical background in family medicine and paediatrics, but may be a specialist in adult orthopaedics, adult rheumatology or emergency care. Therefore, it is critical that the generalist is able to quickly recognise a child with significant rheumatic disease in order to initiate the proper treatment or referral to a specialist. However, most generalists are ill equipped to be able to do so, because of current deficiencies in education and training. The aims of this article are as follows:

Emergency medicine residents do not document detailed neurologic examinations

OBJECTIVES

Physical examinations performed by residents in many specialties are often incomplete and inaccurate. This report assessed the documentation of the neurologic examination performed by emergency medicine (EM) residents when examining patients with potential psychiatric or neurologic chief complaints.

METHODS

A retrospective chart review of neurologic examinations documented by EM residents was performed. An eight-item neurologic examination score was created and analyzed by resident postgraduate year. A linear mixed model was used to determine if differences in neurologic examination scores existed between resident year, type of complaint, and resident year and type of complaint. A one-point difference in scores was considered clinically important.

RESULTS

A total of 384 charts were reviewed. An average of 4.26 items (95% confidence interval [CI] = 3.91 to 4.62) out of a possible eight were documented that did not vary by resident year of training (p = 0.08). An effect was found for type of complaint. Documentation was lower for psychiatric than for neurologic complaints: mean score for psychiatric complaints 3.97 vs. mean score for neurologic complaints 4.55 (difference -0.58, 95% CI = -1.02 to -0.14). No interaction was found for type of complaint and resident year. A clustering effect was identified for individual residents.

CONCLUSIONS

Emergency medicine residents do not document detailed neurologic examinations on patients with neurologic or psychiatric complaints. Individual resident variation contributes to this documentation.

Undergraduate orthopedic education: Is it adequate?

BACKGROUND

Basic musculoskeletal knowledge is essential to the practice of medicine. The purpose of this study was to assess the adequacy of musculoskeletal knowledge of medical students.

MATERIALS AND METHODS

The validated basic competency examination in musculoskeletal medicine devised by Freidman and Bernstein was administered to final year medical students just prior to their final professional examination. Participants were also required to assess their confidence at making a musculoskeletal physical examination and diagnosis as well as comment on the adequacy of time in the curriculum devoted to Orthopedics.

RESULTS

The response rate was 83% (40/48). The average cognitive examination score was 48.3%. Two participants (5%) obtained a score of >/= 73.1%, the recommended mean passing score. Seventeen students (42.5%) felt orthopedic clinical cases were the most difficult to perform a physical examination and diagnose. Thirteen students (32.5%) felt that the time devoted to orthopedics in the medical curriculum was inadequate.

CONCLUSIONS

Ninety-five percent of the students failed to show basic musculoskeletal competency. A change in medical curriculum and teaching methods is required to address this problem.

Sports medicine training in Canadian paediatric residency programs: Are we doing enough?

OBJECTIVE

To assess sports medicine teaching in Canadian paediatric residency programs and recent paediatric graduates' comfort level with sports medicine.

DESIGN AND METHODS

Recent paediatric graduates were surveyed about the amount of sports medicine training they had received during residency, as well as their comfort level in diagnosing and managing common sports medicine problems. Paediatric residency program directors were surveyed about the sports medicine content in their programs.

RESULTS

Survey response rates for recent graduates and program directors were 52.6% and 81.3%, respectively. Of the recent graduates who responded, 84.7% had 5 h or less of formal sports medicine teaching during residency and 94.9% had no formal clinical rotation in sports medicine. The vast majority of respondents (84.2%) were less than comfortable with their musculoskeletal anatomy knowledge; only 15.8% were comfortable. There were no significant differences between general paediatricians and subspecialists in their reported comfort level with diagnosis (P=0.938) and management (P=0.967) of sports injuries. No program provided more than 5 h of formal teaching in sports medicine, and only one program has a core sports medicine rotation. None of the responding program directors felt that new paediatricians are even somewhat prepared to provide adequate medical care for athletes, and 61.5% felt that a curriculum in sports medicine was necessary.

CONCLUSIONS

Canadian paediatric residents had limited exposure to sports medicine, and many recent graduates were uncomfortable with their skills in sports medicine. Canadian paediatric residency programs should include a curriculum in sports medicine to adequately prepare future paediatricians to care for young athletes.

Musculoskeletal screening examination (pGALS) for school-age children based on the adult GALS screen

OBJECTIVE

To develop and validate a musculoskeletal screening examination applicable to school-age children based on the adult Gait, Arms, Legs, Spine (GALS) screen.

METHODS

Adult GALS was tested in consecutive school-age children attending pediatric rheumatology clinics and was compared with an examination conducted, on the same day, by a pediatric rheumatologist who classified children as having abnormal or normal joints. Adult GALS was tested for validity compared with the pediatric rheumatologist's assessment and deficiencies in adult GALS were identified. Experts proposed amendments to adult GALS, achieving consensus by modified Delphi techniques. The resultant pediatric screening tool (pGALS) was tested (methodology identical to the testing of adult GALS) in an additional group of children.

RESULTS

Adult GALS was tested in 50 children (median age 11 years, range 4-16), of whom 37 (74%) had juvenile idiopathic arthritis. Adult GALS missed important abnormalities in 18% of children, mostly at the ankle, foot, and temporomandibular joints. The pGALS was tested in 65 children (median age 13 years, range 5-17 years) and demonstrated excellent sensitivity (97-100%) and specificity (98-100%) at all joints, with high acceptability scored by child and parent/guardian. The median time to perform pGALS was 2 minutes (range 1.5-3 minutes).

CONCLUSION

The pGALS musculoskeletal screening tool has excellent validity, is quick to perform, and is acceptable to school-age children and parents/guardians. We propose that pGALS be incorporated into undergraduate and postgraduate medical training to improve pediatric musculoskeletal clinical skills and facilitate diagnosis and referral to specialists.

Is musculoskeletal history and examination so different in paediatrics?

Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination require understanding of the child/young person's specific emotional and cognitive developmental stage; interpretation of the findings requires knowledge of normal (and abnormal) motor and musculoskeletal growth and development. We specifically describe the different approach, unique skills and knowledge required by all clinicians who assess children and adolescents with MSK complaints; children and adolescents are not 'just little adults'. We emphasize the importance of clinical competence in ensuring that patients with juvenile idiopathic arthritis are diagnosed early and referral to specialist centres is not delayed with consequential suboptimal management and outcome. There is evidence that physician clinical skills in MSK assessment are inadequate, probably as a result of systemic deficiencies in the education process. Current and proposed solutions are discussed.

Adequacy of education in musculoskeletal medicine

BACKGROUND

Basic musculoskeletal knowledge is essential to the practice of medicine. A validated musculoskeletal cognitive examination was given to medical students, residents, and staff physicians in multiple disciplines of medicine to assess the adequacy of their musculoskeletal medicine training.

METHODS

The examination was given to 334 volunteers consisting of medical students, residents, and staff physicians. Analysis of the data collected and comparisons across disciplines were performed.

RESULTS

The average cognitive examination score was 57%. Sixty-nine participants (21%) obtained a score of >/=73.1%, the recommended mean passing score. Of the sixty-nine with a passing score, forty (58%) were orthopaedic residents and staff physicians with an overall average score of 94%. Differences in the average scores for the orthopaedic residents compared with all other specialties were significant (p < 0.001). The average score was 69% for the 124 participants who stated that they had taken a required or an elective course in orthopaedics during their training compared with an average score of 50% for the 210 who had not taken an orthopaedic course (p < 0.001). When the scores of those in orthopaedics were excluded, the average score for the participants who had taken an orthopaedic course was 59%; this difference remained significant (p < 0.001).

CONCLUSIONS

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. Among the nonorthopaedists, scores were significantly better if they had taken a medical school course or residency rotation in orthopaedics, suggesting that a rotation in orthopaedics would improve the general level of musculoskeletal knowledge.

Pediatric residency education: is sports medicine getting its fair share?

INTRODUCTION

Sports are the leading injury-related cause for pediatric primary care visits. Pediatric residency education guidelines suggest incorporating sports medicine (SM) education into curricula; however, research is lacking regarding effective teaching methods.

OBJECTIVE

To assess reported US pediatric residency SM curricula, teaching methods, and resident evaluation of SM education.

DESIGN/METHODS

Chief residents (CRs) and third-year residents (PL3s) from 100 randomly selected US Accreditation Council for Graduate Medical Education-accredited residency programs, stratified by size and geographic location, received surveys regarding programs' SM curriculum and teaching methods and individuals' methods for learning SM.

RESULTS

Response rates were 63% and 39% for CRs and PL3s, respectively. According to CRs, 34% of programs had no one in charge of their SM curriculum. Lecture (77%) was the primary method used for teaching SM. Hands-on teaching (37%) was used less frequently. CRs stated that 29% of programs did not include musculoskeletal examination teaching in their curriculums; 24% did not include formal teaching of concussion management, and 29% did not include reasons for medical disqualification. PL3s rated teaching of joint examinations and the preparticipation physical as the most poorly taught components of the physical examination. PL3s rated hands-on teaching and patient experience as the best methods for improving SM education. CRs reported that only 36% of programs have discussed incorporating more SM into their curriculum.

CONCLUSIONS

SM education is deficient in US pediatric residency programs. Standardized curricula should be developed with a focus on hands-on training as a means for teaching SM to pediatric residents.

Recognition and management of pediatric fractures by pediatric residents

BACKGROUND

Competence in basic orthopedic assessment and interpretation of radiographs is important for pediatricians because appropriate initial management of fractures can expedite therapy and minimize morbidity. However, requirements for training in orthopedics and radiology are poorly defined in pediatric residency programs.

OBJECTIVE

To assess the ability of pediatric residents to recognize and to manage appropriately pediatric fractures.

METHODS

This study involved administration of a case-based questionnaire with radiographs to volunteer categorical pediatric residents in 3 geographically diverse training programs. The diagnosis and management of 8 orthopedic complaints were evaluated. Responses were scored according to the number of features identified accurately, including the presence or absence of a fracture. Residents who were able to identify a fracture were assessed with respect to their ability to classify the fracture and to provide initial management. The study was pretested with a group of pediatric emergency medicine attending physicians, to establish the suitability of the cases.

RESULTS

Among the 3 residency sites, 102 of 190 eligible pediatric residents (53.7%) participated, yielding 95 completed questionnaires. The mean number of cases in which a resident correctly answered the question, "Is a fracture present?" and correctly identified the fractured bone (if a fracture was present) was 6.5 +/- 1.2 of 8 cases (81.6%; 95% confidence interval: 78.5-84.7%). The diagnostic accuracy of Salter-Harris classification in cases in which such fractures were present was 40.9%. The mean score of correctly identified features for the resident group was 38.5 +/- 9.4, of a possible 64 points (proportion correct: 60.1%; 95% confidence interval: 57.2-63%). There was a small but significant difference in mean correct responses between first-year residents (proportion correct: 55.4%; 95% confidence interval: 50.8- 60.3%) and third-year residents (proportion correct: 65.1%; 95% confidence interval: 60.7-69.5%). There was no association between the proportion of correct responses and whether or not residents had taken radiology or orthopedics elective courses in medical school. Overall, 43% of cases were both identified and managed correctly by the pediatric residents.

CONCLUSIONS

For residents from the participating training programs, skills in recognizing and managing pediatric fractures were suboptimal. Additional review of training requirements is necessary to identify more clearly areas of improvement for current curricula.

Using children as standardised patients for assessing clinical competence in paediatrics

BACKGROUND

Standardised patients (SPs) have been widely used to assess physicians' clinical competence. However, in paediatrics, the use of children in such a way has long been questioned with regard to ethics and the examination quality (in terms of validity, reliability, and feasibility).

AIMS

To summarise the current state of the use of child SPs, and to highlight the difficulties inherent in the use of children for this purpose.

METHODS

Nineteen articles dealing with the use of child SPs for clinical assessment were reviewed.

RESULTS

Child SPs, ranging in age from infancy to adolescence, were present in varied proportions of paediatric objective structured clinical examination stations (12-27%). In most of these reports, there were several children with cases who could substitute for one another. Child SPs successfully portrayed various roles, although only older children had to learn a scenario. In general, clinical examinations using child SPs were found to be valid and generated reliable scores. Child SPs also provided effective feedback. The experience tended to be considered negative for younger children but was quite positive for a number of older children. The use of young SPs should be avoided for ethical reasons, and the use of child SPs should be limited to assessments that cannot be satisfactorily measured by other methods.

CONCLUSION

Through meticulous attention to detail and careful planning, a clinical examination using children as SPs can be practical, valid, and reliable.

Referral patterns to a pediatric orthopedic clinic: implications for education and practice

OBJECTIVE

Musculoskeletal medicine is becoming an increasingly essential part of primary care medicine. The American Academy of Pediatrics (AAP) Surgical Advisory Panel recently published voluntary guidelines to establish diagnoses that should be referred to a pediatric specialist rather than a general specialist (pediatric orthopedic surgery vs general orthopedic surgery). Given the crisis in pediatric orthopedic surgery manpower and resources, we believe that these guidelines are useful in defining appropriate referrals. The purpose of this study was to compare diagnoses that primary care pediatric providers believe commonly need referral to the AAP Guidelines for Referral to Pediatric Specialists recommendations for referral to pediatric orthopedic specialists.

METHODS

A chart review of successive new referrals (n = 286) to the pediatric orthopedic clinic during a 12-month period was conducted. The following information was collected: 1) diagnosis from referring provider, 2) diagnosis and treatment plan by the pediatric orthopedic surgeon, 3) type of referring provider (eg, pediatrician, family practitioner, resident physician, physician assistant), and 4) patient age. The referring diagnosis, final orthopedic diagnosis, and treatment plan for each patient was compared against the AAP Guidelines for Referral to Pediatric Specialists. The terms "appropriate" and "inappropriate" were used to differentiate those diagnoses that matched versus those that did not match the AAP Guidelines, respectively.

RESULTS

This analysis shows that a significant percentage (64.7%) of definitive diagnoses of referred cases were not consistent with the new AAP recommended guidelines for referral to pediatric orthopedic surgeons. In addition, a 23.8% (68 of 286) false-positive rate of referring diagnoses is noted. Cases that required no treatment or follow-up to monitor demonstrated a 32.8% (60 of 183) [(40 no treatment + 20 monitor inappropriate)/(116 no treatment + 67 monitor total)] false-positive rate.

CONCLUSIONS

Inappropriate referrals create a large use of pediatric orthopedic resources, which delays care of other, more appropriate patients. A large proportion of referrals indicated either a lack of basic textbook knowledge or lack of examination skills and appropriate diagnostic tools as demonstrated by a high number of definitive diagnosis indicating normal variants.