What A New Study Reveals About The Knowledge Of Musculoskeletal Medicine Among Podiatric Surgical Residents

An interesting study from the Temple University Podiatric Surgical Residency Program just appeared in the Journal of Foot and Ankle Surgery (JFAS).¹ The authors report the results of a basic competency examination in musculoskeletal medicine that 117 residents took at 15 podiatric surgical residency programs. The exam consists of 25 questions that cover very basic conditions and injuries affecting the upper extremities, the lower extremities and the spine. The results and comparisons between podiatric surgical residents and other medical specialties are quite fascinating.

As a background, a group of medical and surgical residents previously took the same basic competency exam at a single academic healthcare center in 1988.² Over 75 percent of the M.D. residents failed the exam. This led to a conclusion that medical students were not getting adequate education in musculoskeletal medicine.³

In 2005, researchers gave this same exam to a broader group of medical students, medical residents and practicing physicians in a wide range of specialties.⁴ Only 5 percent of the medical students and 21 percent of the medical residents passed the exam. Of the staff physicians, 52 percent passed the exam with orthopedic surgeons having the highest pass rate.

In terms of comparing the mean scores, orthopedic surgeons had the highest score of 94 percent. The mean score then dropped drastically to 61 percent for family practitioners, 59 percent for general surgeons and 54 percent for internal medicine physicians.

The newly published study in JFAS attempted to compare podiatric surgical residents to other medical disciplines in their performance in the same basic competency examination in musculoskeletal medicine.¹ The 117 podiatric surgical residents achieved a mean score of 60 percent. According to previous pass/fail criteria, 75 percent of the podiatric surgical residents failed the exam.

Of further concern, there appeared to be no advantage in performance of this exam for those podiatric surgical residents who had already completed an orthopedic surgery rotation as part of their training.¹   Whether they were first-year residents or senior residents, there was no significant difference in scores comparing these two subgroups.

Of interest, physical therapists have also taken this same exam of competency in musculoskeletal medicine.⁵ Students of physical therapy scored 66 percent on the exam while board-certified physical therapists scored 81 percent. Remember that podiatric surgical residents scored 60 percent on this same exam.

One can interpret the results of this recent JFAS study in several ways.  The American Podiatric Medical Association (APMA) set out years ago in Vision 2015 to achieve parity between podiatric medical education and allopathic medical education.⁶ When looking at competency in musculoskeletal medicine, it is clear that recent graduates of podiatric medical school have similar levels of achievement as medical doctors who are enrolled in some post-graduate residency training programs such as general surgery and internal medicine. However, in comparison to medical doctors who have completed orthopedic surgery residency training programs, podiatric surgical residents lag far behind in general understanding of musculoskeletal medicine.

Vision 2015 had mandated that podiatric medical school curriculum change to mirror allopathic medical schools’ curriculum. In order to achieve this, podiatric medical schools have been forced to drop courses in biomechanics and orthopedics in favor of epidemiology and behavioral science. I have previously written my opinion of this in a DPM Blog.⁷

When I graduated from the California College of Podiatric Medicine in 1980, I had completed five courses in biomechanics and one course in orthopedics. These courses covered all aspects of musculoskeletal medicine, not limited to the lower extremity. I looked at the 25 exam questions in the basic competency examination in musculoskeletal medicine and could answer 90 percent of the questions correctly without any review. I knew the answers based upon my podiatric medical education, not my residency training program. 

Podiatric surgical residency training, which includes rotations in orthopedics, does not appear to improve basic knowledge in musculoskeletal medicine, according to the JFAS study by Creech and colleagues.¹ This suggests that the critical time of education in this subject matter must occur during podiatric medical school. Unfortunately, there have been severe cutbacks in the number of courses in biomechanics and orthopedics in all podiatric medical schools across the country.

My question to readers of Podiatry Today is whether they think podiatric surgical residents and practicing podiatric physicians should have the same level of competency in general knowledge of musculoskeletal medicine as orthopedic surgeons? Should we have the same or better competency as physical therapists? Should we have better competency than family practitioners?

Since we do not, what measures should we take to correct this troublesome situation?

References

1. Creech CL, Pettineo SJ, Meyr AJ. Podiatric resident performance on a basic competency examination in musculoskeletal medicine. J Foot Ankle Surg. 2015; 55(1):45–4.
2. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1988; 80(10):1421–1427.
3. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002; 84-A(4):604–608.
4. Matzkin E, Smith EL, Freccero D, Richardson AB. Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am. 2005; 87(2):310–314.
5. Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists’ knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005; 17(6):32.
6. American Podiatric Medical Association. Available at https://www.apma.org/WorkingForYou/content.cfm?ItemNumber=4471 .
7. Richie D. Are we still ‘uniquely qualified’ to treat sports injuries? Podiatry Today DPM Blog. Available at https://tinyurl.com/l2qy4rt. Published May 5, 2015. Accessed Jan. 8, 2016.