What works best for teaching musculoskeletal clinical skills?
Jens Foell, IAMMM-Chairman Educational Committee
MD MRCGP DFFP Dipl.Med.Ac.
NIHR Clinical Lecturer
Blizard Institute
Centre for Primary Care and Public Health
Queen Mary, University of London
Barts and the London School of Medicine and Dentistry
Yvonne Carter Building
58 Turner Street
London E12AT


A systematic review from Canada supports the use of patient educators, computer-assisted learning and teaching in small groups
Disability with significant components from the locomotor system is troublesome for patients and healthcare systems alike. Performing an adequate musculoskeletal examination is a core skill for clinicians looking after patients complaining of pain in their limbs. As part of the Bone and Joint decade the Association of American Medical Colleges noted the underrepresentation of musculoskeletal medicine in undergraduate curricula and demanded valid, standardised and age-appropriate examination techniques. But how should they get taught?

O’Dunn and Hartling set out to answer this question using the systematic reviewing strategies. They screened 5089 titles and included 24 studies in their final report. The methodological selection criteria were risk of bias and the Newcastle-Ottawa scale for cohort studies. Kirkpatrick’s evaluation framework provided the outcome criteria: change in attitudes/perceptions, change in knowledge, change in skills, change in behaviour. Some areas where easier to measure than others .
Changes in exam marks are comparable and easily measurable, whilst changes in patient outcomes require longitudinal data collection and are subjected to multiple external confounders. The most effective educational strategies were computer-assisted learning, teaching in small groups and the inclusion of patient educators. Patient educators provided the contextual relevance of the learning opportunity.

In my role as medical educationalist I found this piece of secondary research useful and informative. It is promising to see how a joint venture between the charity Arthritis Research UK and the Royal College of General Practitioners uses a combination of self-directed computer-assisted learning and deliberate practice with expert feedback in teaching musculoskeletal core skills (http://www.elearning.rcgp.org.uk/course/info.php?id=118).

Working with patient educators is a core component of my musculoskeletal undergraduate teaching. When it comes to palpation skills and how to develop the craft of handling bodies, handling joints the feedback from patients is of invaluable importance. Students appreciate the experience of being touched when they learn to practise therapeutic touch.<<


O'Dunn-Orto, A., Hartling, L., Campbell, S., & Oswald, A. E. (2012). Teaching musculoskeletal clinical skills to medical trainees and physicians: a Best Evidence in Medical Education systematic review of strategies and their effectiveness: BEME Guide No. 18. Medical teacher, 34(2), 93–102. doi:10.3109/0142159X.2011.613961
BACKGROUND:Musculoskeletal (MSK) complaints make up 12-20% of primary health visits and are a source of significant expenditures and morbidity. Despite this, MSK examination is an area of weakness among practising physicians. Several studies have highlighted the need for increased MSK physical exam teaching. However, increased teaching time alone does not guarantee improvement in these skills. Thus, we aimed to identify interventions that are effective in promoting transfer of MSK clinical skills.

METHODS:The review protocol was approved by the Best Evidence in Medical Education (BEME) organization. A comprehensive search was conducted and systematic review methods were applied. Data were not pooled statistically due to heterogeneity.

RESULTS:About 5089 titles were screened; 24 studies were included. Eighteen of 24 studies focused on undergraduate medical education. Five of nine studies favoured patient educator. Five of six studies favoured interactive small groups, two of four studies favoured computer-assisted learning, and two of two studies favoured peer learning. Individual studies demonstrated effectiveness of reminder sheets and Gait Arms Legs Spine teaching, respectively.

CONCLUSIONS:This study supports the use of different instructional methods that engage learners and provide meaningful learning contexts. The majority of the studies support patient educators and interactive small group teaching.