A Musculoskeletal Medicine Clerkship for Medical Students


Medical schoolcurriculum requirements

2003

2011

Schools with a required preclinical course

42% (51/122)

79% (100/127)

Schools with a required clerkship

20% (25/122)

24% (31/127)

Any required instruction

53% (65/122)

83% (106/127)


Modified from Bernstein J, Garcia GH, Guevara JL, Mitchell GW: Progress Report: The Prevalence of Required Medical School Instruction in Musculoskeletal Medicine at Decade’s End. Clinical Orthopaedics and Related Research 469(3), March 2011



In an ideal world, musculoskeletal medicine would have a prominent place in the preclinical and clinical curricula of all schools. Further, in this ideal world, instruction in musculoskeletal medicine would transcend departmental lines: a community of musculoskeletal educators compromising not only orthopaedic surgeons, but also rheumatologists and physiatrists, anatomists, emergency physicians, general surgeons, internists, pediatricians, and many others, would come together to develop coherent curricula ideally adapted to the individual school’s unique circumstances.

In the meantime, it is not unreasonable for departments of orthopaedic surgery to take their own initiative and create course offerings that will fill the gap. After all, departments of orthopaedic surgery have the greatest concentration of musculoskeletal expertise (though certainly not a monopoly on it).

There are a few options for new courses in musculoskeletal medicine/orthopaedic surgery: a traditional fourth-year elective is orthopaedic surgery ; a selective option as part of the surgery clerkship; and a free-standing required clerkship in musculoskeletal medicine/orthopaedic surgery.

The first option, the traditional fourth-year elective in orthopaedic surgery, is one in which a student spends about a month on the service, working alongside the resident teams. This is probably the easiest course to offer, though it is also likely the least helpful with regard to the greater aim of improving musculoskeletal education for all students. For one thing, an elective course by its nature will not be assuredly taken by all students. Also, by the time the fourth year has arrived, many students have committed to their chosen field, and thus a course then is likely to only “preach to the converted.” Last, because many orthopaedic surgery electives serve the dual role of education-endeavor and audition-experience, they are likely to be particularly unrewarding for students not planning a career in orthopaedics . (In this auditioning environment, there is little pressure on faculty members to exert themselves in teaching, and the eager auditioning students, sharing the space with those participating just to learn, may be bit insufferable in the eyes of the latter.)

The selective option is typical in many schools. Traditionally, surgery was one of the major rotations of the clinical year, with students spending 3 months or so on the general surgery service. Over time, owing to increased specialization as well as decreased lengths of stay for hospital patients, these rotations have now devoted less time to inpatient general surgery, with greater opportunities for specialty rotations. Of the standard 12-week block, at least a few weeks are usually available for students to rotate on a specialty service—including not only orthopaedic surgery but also urology, neurosurgery, and plastic surgery, among others.

The selective experience is a little less intense that the fourth-year elective—not all students are auditioning—though it too is imperfect. For one thing, only a fraction of the class can take the selective. Also, because the selective is usually running within the surgery clerkship, the students’ primary allegiance is to that course (and the final exam that might be waiting at the end of the 12-week block). It is also the case that this selective probably cannot cover the full gamut of musculoskeletal medicine, but rather emphasize those topics overlapping with surgery experience.

The other option is a required clerkship in orthopaedics . This option is not employed at many schools (for a variety of reasons), though it is one we have at our institution, the University of Pennsylvania. We currently offer a 1-week required clerkship for all students. We hope to share below a description of our course, not as much as an example for emulation—though that would be nice!—but to present some of the issues we’ve faced and why we have included certain things and omitted others. By so doing, we hope to identify some general principles and helpful suggestions that will allow a school to build its own coherent self-contained course.



Two Caveats


It is important to note two important caveats at the outset. The first is that a coherent clerkship experience cannot be “business as usual,” if the baseline is simply to offer a tourist experience for the student. To be sure, a student interested in orthopaedic surgery as a career (the typical participant in an orthopaedic surgery course) will be highly motivated to please, and unduly acquiescent; these students traditionally have placed few demands on the residents and faculty. By contrast, students with other career plans will demand more attention. A new course, therefore, must be built with the understanding that more effort may be needed from the faculty. The second caveat is that a new course should not be undertaken on the assumption that it will necessarily improve recruitment to orthopaedic residency programs. It might [3], but that is gravy: in general, by the time a clerkship rolls around, students have already begun to shape their career plans. (Many students still have an open mind in the first year of school—and that’s a strong argument for having orthopaedic surgeons participate in anatomy and other first-year courses.) These caveats sum to a simple recognition that offering any new or improved course will require orthopaedic surgery departments to do more, with few immediate rewards. Only with the larger perspective (of improving patient care and musculoskeletal outcomes) in mind does making this effort this make any sense.


The University of Pennsylvania Clerkship


Instruction at the University of Pennsylvania is divided among modules, but the general form of the four curriculum is 18 months of preclinical instruction; 12 weeks of clinical clerkships; and 18 months or more of additional study, covering a few additional requirements, electives, sub-internships, research opportunities, and others (about half of the students in any one entering class graduate more than 4 years after the start, many of whom earn a second degree).

Within the 18 months of preclinical instruction, there is no formal course in musculoskeletal medicine at the University of Pennsylvania, but, of course, musculoskeletal topics are covered in anatomy, pathophysiology, and other blocks.

The clinical year, which begins in January of the student’s second year at the University of Pennsylvania , is devoted to ten required clerkships (Table 6.2). Orthopaedics 200, a required clinical rotation in orthopaedic surgery, is offered within the 3-month-long surgery block, but educationally independent of it. In addition to orthopaedics, students are required to spend 1 week in otorhinolaryngology and ophthalmology—together these are known as “the three Os”—and 1 week in anesthesia.


Table 6.2
Required clinical clerkships at the University of Pennsylvania




























































Clerkship

Duration (weeks)

Setting

Internal medicine

8

Inpatient

Family medicine

4

Outpatient

Obstetrics/gynecology

6

Combined in- and outpatient

Pediatrics

6

Combined in- and outpatient

Surgery

8

Combined in- and outpatient

Anesthesia

1

Inpatient

Ophthalmology

1

Combined in- and outpatient

Otorhinolaryngology

1

Combined in- and outpatient

Orthopaedic surgery

1

Combined in- and outpatient

Psychiatry

4

Combined in- and outpatient

Neurology

4

Inpatient

Emergency medicine

4

Emergency department

University of Pennsylvania has approximately 160 students, such that in each quarter 40 students are in the surgery block. Thirteen students then perform their specialty rotations in any given month. Orthopaedics 200 is then offered 1 week every month (12 times a year), carrying approximately 13 or 14 students in each iteration.

Although Orthopaedics 200 is technically a week-long course, the surgery didactics curriculum runs throughout the entire 12-week block—the students take a high-stakes shelf examination at the end of the 3 months—and half of every Friday is reserved for a general surgery education program that all 40 students participate in. Thus, there are 4 days available for clinical instruction (Table 6.3).


Table 6.3
Sample schedule of orthopaedics 200 at the University of Pennsylvania

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Mar 10, 2018 | Posted by in ORTHOPEDIC | Comments Off on A Musculoskeletal Medicine Clerkship for Medical Students
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