Regional Examination of the Musculoskeletal System (REMS): a core set of clinical skills for medical students

D. Coady, D. Walker and L. Kay

Rheumatology Department, Freeman Hospital, Newcastle upon Tyne, UK.

Correspondence to: D. Coady, Rheumatology Department, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK. E-mail: d.a.coady{at}ncl.ac.uk


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 References
 
Objectives. The aim of this study was to determine an agreed set of core regional musculoskeletal examination skills for medical students to learn.

Methods. Initially focus groups were undertaken amongst Rheumatologists, Orthopaedic Surgeons, Geriatricians and General Practitioners. These findings were used to inform the production of a questionnaire survey. The findings from both the questionnaire survey and focus groups were assessed using a group nominative technique with national representation from each of the four specialities involved.

Results. This process has led to the identification of 50 items, considered to be core regional musculoskeletal examination skills for medical students.

Conclusions. This core set of musculoskeletal clinical skills may now be used to inform the production of teaching materials aimed at medical students.

KEY WORDS: Clinical, Regional examination, Musculoskeletal, Undergraduates, Skills, Curriculum, Education, Core.


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 References
 
Medical students’ competence in selecting and performing appropriate clinical examination skills has been increasingly recognized as a priority for medical education [1]. Despite this and the high prevalence of musculoskeletal disorders in all fields of clinical practice [24], doctors continue to describe poor confidence in their musculoskeletal clinical skills [5, 6]. There is also evidence to support the neglect of musculoskeletal examination skills in clinical practice [7]. Factors leading to poor performance in clinical assessment have been suggested [8], and include the disparity in the approach to examination between rheumatologists and orthopaedic surgeons.

There are signs of change for the better. One example includes the adoption of the Gait Arms Legs and Spine (GALS) examination [9] by rheumatology training departments. This is a rapid, validated screening examination of the musculoskeletal system with high sensitivity and specificity for the detection of joint abnormalities, and is now widely taught throughout UK medical schools [10]. The teaching of this screening examination appears to have made a difference. There has been shown to be an increase in the frequency of musculoskeletal assessment of emergency inpatient admissions by junior doctors [11].

The next step—a more detailed regional examination once an abnormality has been identified on the initial history and examination—is less well described [12]. Little work has been done to make specific recommendations, although broad curriculum aims have been identified in a joint British Society of Rheumatology and British Orthopaedic Association publication [13]. We know that medical students complain about being taught a confusing array of clinical tests in musculoskeletal examination [14] and that students perceive a lack of consistency in the teaching they receive [15]. Lead rheumatology teachers from UK medical schools have expressed a wish for national agreement on the core requirements of musculoskeletal undergraduate education [16]. For teachers and potential examiners in medical school finals, there is currently no agreement about which competencies we expect students to learn. If we could agree what to teach there would be less confusion and standards in examinations would be easier to set.

The aim of this study was to determine an agreed set of core regional musculoskeletal examination skills for medical students to learn.


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 References
 
In order to ensure wide ownership of the findings, it was felt that the process of defining the core musculoskeletal examination skills for medical students should involve a wide spectrum of clinicians involved in their teaching: general practitioners as well as geriatricians, rheumatologists and orthopaedic surgeons, and those who practise in a variety of settings, including district general and teaching hospitals, rather than only the academic leaders in the field. This study involved four main phases (Fig. 1): a qualitative phase; a pilot questionnaire phase; a national questionnaire phase; and a group nominative phase.



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FIG. 1. Illustration of the four phases of the study.

 
Qualitative phase
Focus groups were used to explore the views of clinicians with regard to which musculoskeletal examination skills medical students should learn. The focus group discussion was also used to inform the content of a national questionnaire (see below).

Recruitment to the focus groups was through letters of invitation sent to all of the rheumatologists (n = 32), orthopaedic surgeons (n = 97) and geriatricians (n = 92) listed in the Northern Region. Four hundred and twenty-six general practitioners (as listed by practice) working in the Newcastle area were also invited. A timetable grid of availability was also sent.

Eighty-seven clinicians returned the grids. Purposive sampling, using the grids as the basis of availability, was undertaken to produce four mixed-speciality groups and two single-speciality groups. Final group sizes ranged in size from three to six participants. Final groups consisted of nine rheumatologists, five geriatricians, five orthopaedic surgeons and four general practitioners.

The focus groups were held over a 4-week period and were facilitated by the author (DC). Two in-depth interviews were also held involving a consultant orthopaedic surgeon and consultant rheumatologist in order to triangulate the findings from the groups. A topic guide was used to direct the group discussion. The general principles of examination, followed by the examination of each joint in turn, were discussed in each group. In addition, the barriers to effective musculoskeletal examination teaching and the ways of overcoming them were also discussed. Each group and interview was taped and transcribed verbatim.

Framework analysis was carried out on the transcripts using the phases outlined by Ritchie and Spencer [17] in order to identify common themes by the lead researcher. Applying framework analysis to all transcripts allowed data on similarities, differences and associations between individual experiences and specialities to be pulled out. Further triangulation occurred by the use of independent researchers. They reviewed the original transcripts, charting process and identification of themes. Respondent validation was also undertaken by feeding back the focus group analysis to a selection of participants. Neither of these measures resulted in any changes to the identified themes.

Pilot questionnaire phase
Results from the qualitative work were used to inform the content of a national questionnaire. Cognitive pretesting of the questionnaire was performed with clinicians from the rheumatology department and a selection of general practitioners. The questionnaire was then piloted in the Northern region among 19 consultant rheumatologists, 101 consultant orthopaedic surgeons, 62 consultant geriatricians and 168 general practitioners. In an attempt to improve the response rate following this initial pilot, the size of the questionnaire was reduced by the identification and exclusion of redundant questions. This revised questionnaire was then repiloted amongst 55 general practitioners from the North West Deanery of Scotland.

National questionnaire phase
The final questionnaire was then sent out nationally to a total of 3373 clinicians, consisting of consultant orthopaedic surgeons, consultant rheumatologists and consultant geriatricians (these represented all consultants nationally, as identified through their respective society handbooks and cross-referenced with an NHS directory [18] where necessary) and a selection of general practice trainers.

The questionnaire asked doctors to assign a value to each regional musculoskeletal clinical skill, as identified through the qualitative phase of this study, on a five-point Likert scale ranging from ‘definitely not required’ to ‘essential’. One follow-up reminder was sent after a 2-week period to non-responders. Numerical values were then assigned to each point on the Likert scale (1 representing ‘definitely not required’ and 5 representing ‘essential’). A mean score (between 1 and 5) was calculated for each clinical skill by speciality.

The proportion of each speciality assigning each clinical skill either a 4 or 5/5 (i.e. ‘desirable or essential’) was also calculated and expressed as a percentage. This allowed the data to be ranked twice for each speciality: by their mean and by the percentage agreement. Space was also available for free-text comments.

Group-nominative phase
The findings from both the qualitative and quantitative phases were then presented to a national group of six members with representation from each of the involved specialities (two rheumatologists, two general practitioners, one geriatrician and one orthopaedic surgeon). A modified group-nominative technique [19] was used.

Participants were given an overview of the study through a 15-min presentation by the lead researcher. This included the list of clinical skills accepted at the pilot phase as well as the response rates of the national questionnaire. They were also introduced to the modified group-nominative technique. Each participant was then given a booklet. This contained each of the clinical skills. The ranking of each clinical skill (by mean) was presented for each speciality, along with the direct focus group transcripts relating to the skill. The booklet also contained the ranking of the skills by percentage agreement (which proportion of each group deemed specific aspects of the examination to warrant a 4 or 5/5). The ranking of skills by each speciality (by percentage agreement and by the overall mean), presented during the group nominative phase is available as supplementary material (at Rheumatology Online). Each clinical skill was then assessed in turn through a process of voting and discussion (see Results).


    Results
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 References
 
Qualitative phase
This initial qualitative work has been published elsewhere [20]. A broad and diverse set of views amongst specialities was exposed and is summarized below.

The strongest theme to emerge by far was the desire to simplify and standardize the regional examination as much as possible. All specialities feared that too many complex and specialist tests would confuse the medical student and perhaps lower their overall confidence in examining the musculoskeletal system. General practitioners and geriatricians favoured the functional aspect of the examination and were unaware of many of the special and eponymous tests. Orthopaedic surgeons were aware of the confusion created by the use of special tests and eponymous terms and felt that they were often unhelpful in the clinical assessment of a patient, and there was dubious advantage in teaching them to medical students.

However, a variety of other reasons for performing a thorough physical examination emerged. Not all were simply related to achieving an accurate diagnosis. These included the enhancement of the doctor–patient relationship. For example, it was deemed important that at the end of a consultation the patient should feel they had been thoroughly examined. This is despite the dubious sensitivity and specificity of many of the examination ‘tests’. Certain examination skills, such as Thomas’s test, were also felt to have additional advantages in that they ‘made for a good OSCE (Objective Structured Clinical Examination)’. It was also suggested that having a standardized regional musculoskeletal examination would help raise the profile of musculoskeletal examination.

Pilot questionnaire
Sixty-six items were identified from the qualitative data and included in the pilot questionnaire. The overall response rate for all specialities was 35.5%. Individual response rates for each speciality in the pilot phase were 94.7% for consultant rheumatologists, 42.5% for consultant orthopaedic surgeons, 45% for consultant geriatricians and 25.6% for general practitioners.

Results from the pilot questionnaire showed that 17 clinical skills reached a level of over 90% agreement amongst specialities. These were therefore accepted at this stage as being ‘core’ and excluded from the revised questionnaire. This revised 49-item questionnaire was repiloted among 55 general practitioner trainers from the North West Deanery of Scotland (the lowest response group to the initial pilot). This resulted in an improved response rate of 54.5% amongst this group. No further changes were made to the questionnaire at this stage and the results from the repilot were included in the final analysis.

National questionnaire
The response rate for the national questionnaire amongst all doctors was 46% (1502 returned). The distribution and responses for each of the four groups are shown in Table 1. Eighty-three questionnaires were returned due to retirement or incorrect addressing and were therefore excluded from the analysis. A summary of results is shown in Table 2.


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TABLE 1. Distribution and return rates for national questionnaire

 

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TABLE 2. Summary of results

 
When we looked at the ranked data (by mean score and proportion of agreement) there were clear differences in how certain specialities regarded certain clinical skills. For example, orthopaedic surgeons appeared to rank Thomas’s test higher than the remaining three groups. Rheumatologists ranked the detection of synovitis, an objective measurement of lumbar flexion and the correct use of Heberden’s and Bouchard’s nodes higher than all other groups. General practitioners appeared to favour clinical tests of the knee, in particular the assessment of collateral and anterior cruciate stability, along with specific tests for cartilage tears. The consistently least popular skills included thoracic spine examination (which was only popular amongst rheumatologists) and examination of the feet (including a lateral squeeze across the metatarsophalangeal joints).

Group-nominative technique
Participants were given several minutes to examine the ranking and focus-group transcripts pertaining to each skill. They then completed a voting slip identifying that skill as ‘core’, ‘not core’ or ‘undecided’. In turn, each participant was then asked to present their decision and reasons for it to the group. In many cases there was unanimous agreement to accept or reject a skill as being ‘core’. However, in cases were there was not unanimous agreement a period of discussion took place, facilitated by DC. In certain instances this led to a rephrasing or modification of the required skill (see Fig. 2 for examples). A second round of voting was then conducted in the light of the discussion and/or rephrasing. By this method the group was able to weight the qualitative and quantitative data relating to each skill and arrive at a consensus.



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FIG. 2. Examples of modification occurring at the group nominative technique.

 
The group-nominative technique identified 12 items as not being ‘core’ and produced a core regional examination skills set for medical students consisting of 50 items (Table 3).


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TABLE 3. The core set of regional musculoskeletal examination skills appropriate for a medical student at the point of qualification

 

    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 References
 
The results from this study show that an agreed core set of regional musculoskeletal clinical skills for medical students is achievable. This core set, which we have called REMS (Regional Examination of the Musculaskeletal System), may now be used to inform the production of teaching materials aimed at medical students as well as in the setting of examinations.

The sensitivity and specificity of individual clinical tests did not appear to influence the decision of clinicians in accepting it as ‘core’ for students. For example, despite several studies in the literature suggesting that Lachman’s test is superior to the anterior draw test in assessing for anterior cruciate ligament damage [2123], there were perceived advantages in continuing to teach the anterior draw test alone. These included the opportunity for students to look for a posterior sag, suggesting posterior cruciate ligament damage, but also the fact that studies comparing Lachman’s test with the anterior draw test have only been done in the hands of experts, and that the sensitivity and specificity of Lachman’s test in the hands of medical students is unknown. This is likely to be true for other clinical examination skills.

It is recognized that the response rate to the national questionnaire was less than we initially hoped for. We believed that a large proportion of the poor response was due to inaccurate addressing. The source of addresses for consultant geriatricians relied heavily on the NHS directory from 2001 [18], and this group were subsequently the lowest responders. There may be other factors contributing to the geriatricians’ low response rate, one of which may be a lack of direct involvement with musculoskeletal clinical teaching. One aim of the national questionnaire, however, was to provide a sense of inclusion for each speciality, and we felt that this was achieved.

The modified group-nominative technique was one way of assessing and weighting both the qualitative and the quantitative data. It was felt important at this stage to maintain input from each of the relevant specialities to prevent bias from the research team in the weighting process. It was also important, as certain items were accepted with minor modifications, that these could be identified and agreed in a face-to-face format rather than through a Delphi questionnaire process. It is possible, however, that participants in the group-nominative technique may have included their own bias at this stage, and more dominant members may have influenced the opinion of the whole group.

We believe that the core list produced is representative of findings from both the qualitative and the questionnaire results. One issue raised throughout this study, during both the focus-group work and the free-text comments from the questionnaire, was the desire to achieve agreement on a core set of skills. We suggest that further modification of the agreed skills set may later be undertaken on the basis of evidence, following a period of testing and validation by both students and teachers of musculoskeletal examination. There is clearly a potential role for both medical students and newly qualified doctors in such an exercise.

It must be remembered that this core set of regional examination skills is the suggested minimum requirement for the undergraduate. We also suggest that further examination skills should be added in later years, perhaps tailored to the specialization of the clinician. At a postgraduate level, for example, there may be a different set of ‘core competencies’ required by a general practitioner compared with a rheumatologist. Topics and skills in orthopaedics for the general practitioner have been identified in North America [24] and should perhaps be identified in the UK and included in the individuals’ higher medical training. Similar work has been done in identifying the competencies in rheumatology for a physiotherapist [25] and broad outlines of more general clinical skills and competencies have been determined for medical students in previous studies [26, 27]. Musculoskeletal clinical skills, however, appear to be somewhat different. Teachers of musculoskeletal examination are united in the desire to produce a structured approach for medical students to learn. This appears to stem from the lack of confidence general physicians and general practitioners have in their own musculoskeletal examination skills as opposed to other systems, such as cardiology and respiratory examination [5].

An important next step in this process of implementing a set of core competencies in musculoskeletal examination skills for medical students is the production and assessment of relevant educational materials and also an assessment of the impact of structured teaching in relation to the performance of students in a clinical setting. An updated version of the Arthritis Research Campaign’s handbook for medical students [28], incorporating the agreed regional examination skills, has been commissioned and will be available in the near future. Finally, a teaching video has been produced, demonstrating this set of core skills. This is awaiting ratification by the British Orthopaedic Association, the British Rheumatology Society and the Arthritis Research Campaign. Further ratification by primary care and the British Society of Geriatrics is also planned.

D. Coady is supported by an educational research fellowship from the Arthritis Research Campaign. The other authors have declared no conflicts of interest.


    Supplementary data
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 References
 

  Supplementary data are available

  at Rheumatology Online.


    References
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Supplementary data
 References
 

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Submitted 15 August 2003; Accepted 19 December 2003