Letters to the Editor  |   May 2007
Competence Levels in Musculoskeletal Medicine: A Call to Action
Author Affiliations
  • Joseph J. Ruane, DO
    McConnell Spine, Sport and Joint Center, Assistant Clinical Professor of Medicine, The Ohio State University College of Medicine, Team Physician, National Hockey League Columbus Blue Jackets Columbus, Ohio
    Medical Director
Article Information
Medical Education / Neuromusculoskeletal Disorders / Sports Medicine / Graduate Medical Education
Letters to the Editor   |   May 2007
Competence Levels in Musculoskeletal Medicine: A Call to Action
The Journal of the American Osteopathic Association, May 2007, Vol. 107, 197-198. doi:
The Journal of the American Osteopathic Association, May 2007, Vol. 107, 197-198. doi:
To the Editor: I applaud the medical education article by Alan R. Stockard, DO, and Thomas Wesley Allen, DO,1 in the June 2006 issue of JAOA—The Journal of the American Osteopathic Association, particularly in its effort to expose the current unfortunate realities of musculoskeletal training for primary care physicians. It is alarming that musculoskeletal problems are the second most common reason that patients seek medical care,2-4 yet, as pointed out by Drs Stockard and Allen,1 70.4% of osteopathic physicians and 82% of allopathic physicians are inadequately prepared to care for these patients. Drs Stockard and Allen1 surveyed graduating medical students using a standardized basic competency examination on musculoskeletal medicine, yet theirs was not the first study to reveal this training deficit.5,6 Still, little has been done to date to address the deficit. Many physicians continue to feel impotent when patients with musculoskeletal complaints are seeking care from them—and the shortcomings of their training are realized. 
There is a larger issue that the Stockard and Allen1 study speaks to: a void has appeared in the healthcare system that is leaving many patients desperately seeking anyone who can provide routine musculoskeletal care. For today's primary care physicians, the vast knowledge base required to adequately manage the growing burden of cardiovascular (and related) medical conditions—confounded by the time constraints inherent in managed-care systems—has relegated complaints of pain and poor physical function to the lowest priority in a typical office visit. At the other end of the healthcare spectrum, surgical specialists have found it most productive—if not merely more professionally gratifying—to spend their time and expertise offering care for surgically amenable disease conditions. 
The pool of patients left in the middle with inadequately managed musculoskeletal conditions is large and growing,7 as the maturation of the baby boomers has brought upon us their demands to remain physically fit and functional well into their senior years. Beyond this problem, the Centers for Disease Control and Prevention have proclaimed an upcoming “epidemic” of arthritis in the United States as the population ages.8 As indicated by Stockard and Allen,1 the front door for the majority of patients with these medical conditions is the office of the primary care physician. 
I would hope to energize the call for further study on the topic. As a staff physician with two sports medicine fellowships, and as someone who is actively involved in resident teaching, I can testify to the deficit in musculoskeletal training. I have had the opportunity of exposing many senior residents who were just weeks away from private practice to the bare essentials of musculoskeletal medicine. Perhaps musculoskeletal conditions are not elevated to a higher significance in predoctoral studies because they are neither fatal nor easily measured by current quality-of-care standards. 
Somehow it has not yet riled physicians, the public, or insurance providers that basic musculoskeletal skills are not available in many primary care offices. Thus, this currently remains a quiet problem seeking a voice—and the osteopathic medical profession has an opportunity to assume a leadership role in addressing this pressing need. 
I hope to see the worthy study by Stockard and Allen1 lead to immediate discussion, followed by effective action, by those individuals in the osteopathic medical profession in position to influence the design of student and resident programs in family practice and internal medicine. Programs in emergency medicine and osteopathic manipulative medicine may also stand to benefit from improvements in musculoskeletal training, though I cannot speak directly to the quality of the current experiences of students in those programs. Primary care physicians trained in sports medicine are an excellent resource for our profession, qualified to assist in standardizing a curriculum that will ensure clinical competence in office-based orthopedic skills. 
I call out to my colleagues and urge participation in any task force or committee able to work among the appropriate specialty boards to advance an action plan—and I welcome any invitation for the same. 
Stockard AR, Allen TW. Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates. J Am Osteopath Assoc. 2006;106:350-355. Available at: Accessed May 9, 2007.
Craton N, Matheson GO. Training and clinical competency in musculoskeletal medicine. Identifying the problem [review]. Sports Med. 1993;15:328-337.
De Lorenzo RA, Mayer D, Geehr EC. Analyzing clinical case distributions to improve an emergency medicine clerkship. Ann Emerg Med. 1990;19:746-751.
Rekola KE, Keinanen-Kiukaanniemi S, Takala J. Use of primary health services in sparsely populated country districts by patients with musculoskeletal symptoms: consultations with a physician. J Epidemiol Community Health. 1993;47:153-157.
Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am. 1998;80:1421-1427.
Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002;84:604-608.
Freedman M, Hootman JM, Helmick CG. Projected state-specific increases in self-reported doctor-diagnosed athritis and arthritis-attributable activity limitations—United States, 2005-2030. MMWR Morb Mortal Wkly Rep. 2007;56(17):423-425. Available at: Accessed May 11, 2007.
Landers SJ. CDC reports 70 million have arthritis or chronic joint pain. Physicians can help by promoting a program of physical activity that patients can adhere to. AMNews [serial online]. November 18, 2002. Available at: Accessed May 9, 2007.