Musculoskeletal (MSK) problems account for 10-20% of primary care visits and 124 million American adults reported a MSK condition in 2015. However, studies have shown that family medicine residents and attendings lack MSK knowledge and confidence. To address this, we developed Advanced Primary Care Orthopedics (APCO), an intensive MSK medicine course in which hands-on physical exam instruction and interactive cases are utilized to teach anatomy, a standardized exam, and important MSK diagnoses.

We have conducted APCO as an annual course in September for 1st year residents since 2012 and have offered the course as a pre-conference workshop at STFM in 2018 and 2022 with a focus on teaching faculty these same skills.

Curriculum:

APCO is a 2-day course that teaches physical exam skills and diagnoses for the most common musculoskeletal complaints seen in primary care. We focus particularly on the following joints: knee, shoulder, back, foot/ankle, neck, hand/wrist, elbow and hip. The course uses the proven pedagogical principles of intentional repetition and hands on practice to improve participants’ knowledge and confidence in the musculoskeletal exam. The curriculum is built around small group sessions that include a brief presentation, demonstration of a standardized physical exam with clinical correlation to important diagnoses, and multiple opportunities for exam practice with direct observation and feedback. We further explore common diagnoses and important imaging findings through patient cases. Throughout the course, repetition occurs in cases, exam demonstrations, and assessment of participants’ physical examination skills using clinical cases. Treatment options are not covered and should be explored with the faculty preceptor during clinic sessions using various resources.

Sample 2-day course schedule

Outline of a sample small group session:

·         Relevant Anatomy - Including particular focus on bones, muscles, nerves.

·         History – We outline important questions to ask to help arrive at the correct diagnosis.

·         Important conditions – We include the most common and the most consequential diagnoses related to a joint. We review exam findings and common patient histories for each diagnosis.

·         Physical exam – We use a standardized exam structure for each joint area (observation, range of motion, palpation, strength, sensation, special tests, vascular). We walk through each exam together and then provide multiple opportunities to practice. Participants receive immediate direct feedback.

·         Imaging – We review relevant imaging modalities and when to consider each method.

·         When to refer – We discuss diagnoses that may need specialist referral and the timeline for such referrals.

Cases:

Case review sessions are scheduled after each half-day and are an opportunity to review and synthesize material from the small group sessions. Each session consists of 3-4 patient cases for each joint area. In an interactive session, learners are asked to gather a history, review relevant exam findings, determine the need for any additional imaging, and generate an appropriate differential. These discussion-based cases often focus on the important conditions outlined in the small group sessions and present an opportunity for learners to synthesize the material.

Case-based Exam Testing:

At the conclusion of the course, learners participate in hands-on simulated patient cases that require them to synthesize and apply the course material. In pairs, each learner is presented with a brief chief complaint and then gathers additional history, performs an appropriate physical exam, generates a differential diagnosis and arrives at a final diagnosis. Case-based exam testing is observed by course faculty and provides an additional opportunity for direct observation and feedback of physical exam and critical thinking skills.

Pre- and Post-Tests

Participants complete a brief knowledge and confidence assessment both before and after the course. These assessments help faculty better assess knowledge deficits and evaluate the effectiveness of the course. These assessments are voluntary. Data from these assessments is currently being used in a study evaluating APCO’s effectiveness in improving learner’s musculoskeletal exam knowledge and confidence. This study has been evaluated by our institutional review board and determined to be exempt.

Interested in learning more? Read this article on the effectiveness of APCO. You can also contact Dr. Miranda Lu (miranda.lu@swedish.org) for more information.