Orthopedic Residents Are Incompetent To Diagnose or Manage Musculoskeletal Complaints
Chiro.Org Editorial Commentary:
Chiropractors pride themselves in their ability to diagnose and manage neuro-musculo-skeletal (NMS) complains. According to all the surveys, this is our bread and butter, and no one on the planet is better trained to diagnose (locate) and treat (correct) neck, low back, or peripheral joint (knee, elbow etc) complaints. But, don’t take my word for it.
Orthopedic surgeons are supposed to be the *gods* of medicine, the pinnacle of medical knowledge. First they become MDs, then rotate through a variety of specialties, and finally take residence in a highly competitive orthopedic residency program. You may want to review this interesting description of the requirements for the UCLA Orthopedic Surgery Residency Program.
This is a long and sad tale about the weakness of modern medicine. And the following articles were all published in the prestigious Journal of Bone and Joint Surgery, the number one journal for orthopedic surgeons.
In 1998, two medical doctors at the University of Pennsylvania School of Medicine in Philadelphia, contacted all 157 chairpersons of orthopedic residency programs in the United States. Together they developed and validated a basic-competency examination in musculoskeletal medicine to give to the first year residents. The results were astounding, because 82% of the eighty-five medical school graduates failed this BASIC competency exam!
Four years later they redesigned the exam and again gave it to all the residents. Even though the passing grade was LOWERED from 74% to 70% (plus or minus 9.9 percent), 78% of them again failed the exam, with a mean test score average of 59.9 percent!
To add insult to injury, this exact test was given to a group of 51 chiropractic students during their last semester of schooling. The results? 70% of the students passed the test. This is in contrast to an 80% failure rate for the MDs.
For clarity sake, you need to distinguish the difference between the chiropractic and the medical participants in these studies.
- The medical group had already graduated medical school, been awarded their MD degrees, completed all their hospital rotations and residencies, and finally been accepted into a highly competitive orthopedic program.
- The chiropractic group were still JUST STUDENTS
One would expect that, during their 5 years of medical training, endless hospital rotations, and residency programs, that this group doctors *could have* picked up a little more musculoskeletal knowledge along the way. Evidently this is just NOT the case.
These medical authors concluded that residents in orthopedic surgery programs are not provided with sufficient training in NMS analysis. The truth is, they are incompetent in musculoskeletal assessment or treatment. This situation was not corrected during the 4-year interim between the publication of the 1st and 2nd article, and most likely has not been corrected by today, 13 years later.
The solution? If you have spinal pain, seek care from someone who is properly trained to assess and manage your care. That person would be a chiropractor.
Funny thing when I sat for Abime in February of 2009 by the end of the conference every Doc I spoke with including the DO’s stated we are the hands down experts when it comes to this!!! Why are we not the only ones allowed to treat it then?? Also the PT’s I have worked with in the past 5 years that are the most vocal against what we do, are very, very bad with the same types of Dx’s
Dr. Martin
So far as I know, the only State that precludes PTs from “manipulating” is Kansas.
My concern is that PTs are not doctors, are not trained to diagnose, and work under Masters who likewise do NOT understand the problem.
What we do, the adjustment, is a mechanical trick that can be learned. However, to accurately determine *which* joint is the *cause*, rather than a compensation, is why our educational program is 5 years, with almost 1000 hours devoted solely to find-it and fix-it.
The World Health Organization (WHO) recently crafted and published the WHO Guidelines on Basic Training and Safety in Chiropractic (FULL TEXT Adobe Acrobat 512KB.) in consultation with the World Federation of Chiropractic, the Association of Chiropractic Colleges and various chiropractic, medical, osteopathic, and other groups.
The Guidelines make it clear that chiropractic is a separate profession rather than a set of techniques that can be learned in short courses by other health professionals.
They also make it clear that medical doctors and other health professionals, in countries where the practice of chiropractic is not regulated by law, should undergo extensive training to re-qualify as chiropractors before claiming to offer chiropractic services.
In some countries there have been recent efforts by medical groups to provide short courses of approximately 200 hours in chiropractic technique. UGH!
The World Health Organization guidelines indicate that a medical graduate should a require an additional minimum of 1800 class hours, including 1000 hours of supervised clinical training, before claiming to offer chiropractic services
Frank,
I saw two things that gave me great concern, I was watching a Russian SMT specialist adjust a patients upper cervicals with an SEMG attached and he showed that the adjustment “immediately negated the pathological condition” He was touted as a “genius” a ” pioneer”
Approximately 2 months ago in Pain Mangagement an MD was discussing “his new science of Spinal segmental Dysfunction and Chronic Pain Syndrome” I almost fell off my chair..lol…you have to be kidding me! I just wrote the ACA about this website, they need to spend 3 days here… I have been writing them constantly about the wholesale theft of our profession. You know why??? It has been estimated that the fastest growing part of healthcare is what we do. Neuromusculoskeletal. The deep cuts they are making in Healthcare have brought their kind to the DC table and they just sat down without asking and we let them, we let the PTs steal what we did first, The late Dr Shaeffer said it best we perfected the art of therapeutic modalities before the profession of PT even existed!!!! They stole that already manipulation is right around the corner.. I guarantee it..
Dr. Martin
I understand your concern. This has been happening for many years, but not at the level it is today.
Unfortunately, it has nothing to do with us *letting them*. The MD license is unlimited…and we have no say over what they do or don’t do…only their licensing boards can control that.
PTs typically work under the MDs license (and supposed supervision), so we can’t control that either, UNLESS the PT does something that the PT Practice Act precludes. In Kansas they are prohibited from manipulating.
So, if you want to halt this *threat*, all you need to do is to mobilize your profession locally, and do what they did in Kansas. Cut them off at the knees. Complaining won’t change anything. Take action. Change the rules.
This should be put out into the media and the state associations and the schools – also, just send to all health-oriented magazines. And definitely to the legislature. Post also on chirovoice (the grassroots website). The powers that be need this info to be directly in their face during this time of national healthcare reform – hopefully we (the choir) are not the only ones being preached to? Please get this info out, and any supportive docs (like the actual surbey) disseminated.
Thanks!
PT’s are disallowed for manipulation in the State of Washington, as well. You can see they are trying to change that :
The Washington State Chiropractic Association and probably eventually will, as they have the full backing of the AMA. Our dispute is simply this: If you take the classes that chiropractors do (x-ray)+(adjusting)= you should be able to do “adjustments”. Even then, it’s who greases the wheels, not who is best suited. Just my two cents.
You are finally seeing the beginning of the end of our inclusion in the healthcare system as portal of entry providers. I guarantee that, soon they will try and tell us that we can only diagnose subluxations and we will need referrals.
The sad truth is that less than 15% of our profession are members of a National Association. That leaves them with minimal funding to do the work you propose.
My personal opinion is that I am not dependent on the Insurance industry. If insurance coverage stopped tomorrow, I would still see patients because I deliver a VERY high quality product that cannot be found elsewhere. I may not drive a Mercedes, but I’ll still be living.
You know what Frank I am in agreement with you on that. I think the best thing sometimes is that we do lose all insurance inclusion, then only the people that love what we do will be around. I believe the greatest DC’s that gave the most to our profession were from the non-insurance days…
Hi Peter
I wouldn’t go that far…if someone’s insurance will pay for care, why force them to pay out-of-pocket?
But meanwhile, we also need to educate the patient that their health is their responsibility, and if their insurance company puts unreasonable limitations on the care they can receive, they shouldn’t let the bean-counters dictate what care they get.
I have been on both sides of the fence in regards to insurance. I do have to say that the patients that pay out of pocket really do show better results. They take responsibilty, show up, and follow through with instructions. I think we would fare better if insurance was eliminated.
Hmmm. I have lots of cash patients and lots of insurance patients…and I find that a percentage from both groups get the big idea about care, and that most from both groups remain grounded in symptoms…as soon as they are gone, so is the patient. I believe I do a good job “educating”, but the truth is that a lifetime of exposure to the allopathic treat-symptoms approach is a hard model to topple. Cash patients do vote with their wallet however, so I have a lot of respect for them!
This is a really interesting finding and I think that they are trying to rectify their shortcoming; http://www.ncbi.nlm.nih.gov/pubmed/18829928
RESPONSE from Frank:
It’s great seeing them put forth an effort. It’s less clear what the impact of this will be in the medical arena.
It’s one thing to get a passing score on a multiple-choice test, and it’s something else completely to accurately assess loss of joint function, and to know what to do to correct it.
You imply in your article that there were two separate exams for the study. This is not true. The exam was given once to a group of recent medical school graduates. The second study simply surveys internal medicine program directors over what they think the passing score should be. The conclusion of the study is that the musculoskeletal curriculum of many MEDICAL SCHOOLS is likely deficient. This can probably be said for most subspecialties since such a broad area of knowledge is taught in medical school that it is nearly impossible to become an expert in one area.
The study, however, does not comment on the proficiency of orthopaedic residents. While the test-takers in the study were technically in their first years of residency, this year is almost exclusively within the realm of general surgery.
RESPONSE from Frank:
The first Freedman article (1998) described the design of the test and the abysmal results of testing.
The second article (2002) conclusion sounds like the test was given again, but I agree it could also suggest they merely lowered the failing grade and then revisited the results of the 1998 testing. Not having access to the full-text I can’t say whether you are correct.
The article clearly describes the testees as first year residents. I disagree that it’s “nearly impossible to become an expert in one area” because that’s in fact what being a chiropractor is all about.
The reason I posted this is to distinguish between medical management of NMS conditions (which IMHO and experience is extremely weak) and the chiropractic approach, which IMHO is superb.
That’s not the same as saying that every Orthopedist is incompetent, or that every DC is a Wizard…the Bell Curve applies to every profession. However, the training in DC Programs is sooooo much more extensive that, on average, a patient with any NMS complaint would be much better off seeking assessment and care from a DC.
I came across this page by chance. I have to say this is one of the most bizarre attempts to misrepresent the orthopaedic surgery profession. You are basically trying to compare a PGY-1 or 1st year resident, who hasn’t done a single day of orthopaedic training. You are now trying to compare a PG-1 on the first day of residency to a Chiropractor who is in their final semester. I would equate this to a PGY-5 which would be the final year of orthopaedic residency. The whole basis of this article is propaganda. If you would like to compare DC’s to MD/DO students it would perhaps make sense. The article is in fact describing the deficiencies of orthopedic training in medical school as whole. Would you like to compare a chiropractic student on the 1st day of class to an Orthopaedic PGY-5? Also, the PGY-5 scores were way higher than DC’s close to finishing traing. Orthopaedics is just part of the whole spectrum of medicine as whole. Clearly orthopaedics could be integrated into medical school on a broader spectrum. However, there is absolutely no basis for false claims of superior knowledge of DC’s over Orthopaedic Surgery Residents.
BA:
This editorial reports on a series of articles published in the bible of orthopedics: the Journal Bone and Joint Surgery. It clearly reports those authors findings:
“We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.”
That is a statement made by an MD, not a chiropractor. And, it was based on solid evidence…not opinions, like yours.
As I wrote in my other editorial [1]
For clarity sake, you need appreciate the actual difference between the chiropractic and the medical participants in these studies.
The chiropractic group were still JUST STUDENTS in their last undergraduate year
The medical group had already graduated medical school, been awarded their MD degrees, completed all their hospital rotations, and finally been accepted into a highly competitive orthopedic residency program.
One would expect that, during their 5 years of medical training, followed by endless hours of hospital rotations and residency programs, that those new residents *might have* picked up a little musculoskeletal knowledge along the way. Evidently this is NOT the case.
1. End Medical Mis-Management
of Musculoskeletal Complaints
http://www.chiro.org/ChiroZine/End_Medical_Mis-Management_of_Musculoskeletal_Complaints.shtml
Mr. Painter,
You are correct that there is insufficient musculoskeletal education in medical schools. In the average US medical school curriculum, there are no dedicated MSK rotations apart from a few weeks early on where the physical examination is taught. This is especially problematic, since family physicians will encounter MSK complaints in their practice and not know how to deal with them.
But lets be clear…your statement that ‘orthopaedic residents are incompetent to diagnose and treat MSK complaints’ is quite simply FOOLISH. You have NOT PROPERLY read the study you quote.
Here is what the study says: First year orthopaedic residents scored 59%.
How much training in MSK medicine has a first orthopaedic resident received? Answer: Perhaps 1-2 Months.
Why? Because they get a few weeks in medical school PLUS one or 2 month rotations in their 1st year of residency. The first year of residency is often a mix of medical and surgical rotations (general surgery, radiology, rheumatology, etc)
Now second year to fifth year of residency is different. Its ALL orthopaedics, ALL the time!
What the study said: Fifth year residents scored >98% on the exam.
Why? Because they have received years and years of dedicated orthopaedic rotations!
I sincerely suggest you get your facts straight.
By the way, I am an MD (therefore this preceding statement has been made by an MD, and is based on actual curriculums from accredited orthopaedic programs in North America).
As a fourth year resident, I am happy to challenge any chiropathy student or practitioner to compete with my MSK exam knowledge!
Here is another paper from 2005 that shows that if medical students take a one month elective in orthopaedics, their exam score jumps 20%. Incredible that one month exposure would bring them up to what final year chiropractors students acheive…that must explain why some people get into medical school, and some people do not!
Hi BoneDoc!
BTW, it’s Dr. Painter.
My commentary is accurate. Freeman designed a study and gave it to 1st year ortho residents: folks with a full MD, having already taken their full complement of Hospital rotations. I made no mention of orthopedists.
Even so, these Residents are supposed to have MSK knowledge surpassing the average MD, with their incomplete MSK training. Evidently the vaunted Hospital Rotations do NOT provide significant increased MSK knowledge.
If you actually reviewed the test, you would find that is not very demanding, for anyone who has taken a full spectrum of anatomy classes, as did all the DC students. The fact that a full-graduate orthopedist passes the test is no big accomplishment. Worse yet, it’s a MULTIPLE GUESS TEST, and the correct answer is right there in front of them!
This test is a MMIMIMUM COMPETENCY exam. I only mention it, because it emphasizes the VAST difference in thinking between chiropractors and medical specialists, as well as their preparedness to assess MSK issues.
Orthopedics has it’s place, doing hip replacements etc, but if we are talking about the average patient who has experienced whiplash or non-specific low back pain, I believe non-invasive, conservative chiropractic care will provide those individuals more benefit and will garner higher satisfaction scores. That’s what the studies show, over and over again.
Finally, I had to grin at your comment about “chiropathy student(s)” As an educated doctor, one would hope you would be aware of the proper names of other licensed healing professions.
Would you like to guess what percentage of my patients already sought care from a full-blown orthopedist BEFORE they came to me?