Developing a Comprehensive Longitudinal Musculoskeletal Curriculum: OSCE, Cadavers, and Ultrasound
By Chris Williams, MD
The use of musculoskeletal ultrasound (MSUS) in clinical practice is rapidly expanding and there is a growing desire for increasing physician exposure. This coupled with the fact that in July 2015 the Accreditation Council for Graduate Medical Education (ACGME) now requires a minimum number of ultrasound procedures for Physical Medicine and Rehabilitation (PM&R) residents for graduation, is driving the need for the standardization of MSUS during residency training. Faculty from the Emory Department of Rehabilitation Medicine and Emory Sports Medicine, Under the supervision of Dr. Kenneth Mautner, helped with the develop a curriculum for MSUS which has been integrated with a comprehensive longitudinal musculoskeletal curriculum (MS-C) for the Emory PM&R residency program. As our foundation, we modified published curriculums by the PM&R residency programs at Mayo and Spaulding.
Previously, only the PGY-4 residents were able to get guaranteed exposure to MSUS while on a 2 month Sports Medicine rotation with Dr. Mautner, but there was no formal education done (with the exception of one non-mandatory weekend course) prior to the development of our new curriculum. At baseline, the majority of the incoming PGY-2 residents had very little exposure to ultrasound and virtually no MSUS exposure.
Since ultrasound relies on a sound knowledge of anatomy, we decided to institute a month long anatomy module that focused on the upper extremity, back, and lower extremity. This included 3 weekly two-hour didactic sessions taught by a senior resident, 12 hours of cadaveric dissection, and clinical anatomy review with a PM&R faculty member.
The second major component of the MS-C was to ensure that residents were confident in their physical exam skills so that MSUS could truly be an extension of the physical examination. We structured the components of the physical examination on the PASSOR Musculoskeletal Competencies List to include seven sessions that coincided with the anatomical MSUS sessions (i.e. shoulder, elbow, wrist/hand, spine, pelvis, knee, ankle/foot). At the completion of the 9-month MS-C, each resident was tested on their musculoskeletal physical examination skills competency via a proctored examination, akin to the objective structured clinical examination (OSCE).
The MSUS sessions were structured in a longitudinal approach over 9 months (1 two hour session per month) to ensure the highest yield and allow resident exposure three times prior to the completion of residency (i.e. once each of the 3 years from PGY-2 through PGY-4 years). The first session was an introduction to ultrasound session, which included a review of the basic principles (knobology, etc.) and physics, followed by 6 anatomical sessions (i.e. shoulder, elbow, wrist/hand, pelvis, knee, ankle/foot), and a final session on interventional procedures. To maximize reinforcement, we reviewed all of the relevant anatomy at each MSUS session.
Each of the MSUS anatomical sessions included a 15–20 min presentation reviewing the relevant anatomy and PASSOR exam maneuvers and viewing of a 10-minute demonstration video on the scanning principles for that session. Residents were then split into 3 small groups for a hands-on practice session. Small group sessions were moderated by two Sports-Medicine trained attending physicians (Drs. Lee Kneer and Oluseun Olufade) and a Sports Medicine Fellow (Dr. Walter Sussman), with structural checklists provided for each session. Sonosite graciously provided 3 or 4 ultrasound machines for each session. Prior to each session, the residents were assigned required and recommended.
Going forward, we will incorporate more peer-to-peer teaching to build upon baseline level of knowledge of trainees. Developing this curriculum has been extremely rewarding for me and was one of the primary goals that I wanted to accomplish during my tenure as the Academic Chief Resident. We would love to share our comprehensive curriculum with other PM&R residency programs throughout the country.
I would like to give a special thanks to several individuals that were also instrumental in the development of our curriculum, including: Anna Cruz, MD; Stephanie Meager, Sonosite Representative; and Regina Bell, Emory PM&R Residency Program Coordinator.
