Journal of General Internal Medicine

, Volume 32, Issue 11, pp 1261–1265 | Cite as

Competency based clinical shoulder examination training improves physical exam, confidence, and knowledge in common shoulder conditions

  • Michal Kalli Hose
  • John Fontanesi
  • Manjulika Woytowitz
  • Diego Jarrin
  • Anna Quan
Innovation and Improvement: Innovations in Medical Education



Deficiencies in musculoskeletal knowledge are reported at every stage of learning. Medical programs are looking for effective ways to incorporate competency-based training into musculoskeletal education.


To evaluate the impact of bedside feedback on learner’s shoulder examination skills, confidence, and knowledge of common shoulder conditions.


Four-week musculoskeletal clinic rotation.


UCSD third year medical students and internal medicine residents.

Program description

Learners completed three baseline evaluations: videotaped shoulder examination, attitude survey, and knowledge test. During the 4-week intervention learners received bedside observation and feedback from musculoskeletal experts while evaluating patients with shoulder conditions. Post-intervention learners repeated the three assessments.

Program evaluation

Eighty-nine learners participated. In the primary outcome measure evaluating the pre/post videotaped shoulder examination, significant improvement was seen in 21 of 23 shoulder examination maneuvers. Secondary outcomes include changes in learner confidence and knowledge. Greatest gains in learner confidence were seen in performing the shoulder examination (61.5% improvement) and performing injections (97.1% improvement). Knowledge improved significantly in all categories including anatomy/examination interpretation, diagnosis, and procedures.


Direct observation and feedback during clinical evaluation of patients with shoulder pain improves shoulder examination competency, provider confidence, and knowledge of common shoulder conditions.


Musculoskeletal Shoulder examination Direct observation Competency-based medical education Primary care 



The authors would like to offer appreciation to Leonie Heyworth in the General Internal Medicine Department of the San Diego VA Medical Center for her editorial assistance. Funding for the standardized patients was supported by the Center for Applied Research in Education through the UCSD Department of Medicine, Division of General Internal Medicine. The authors received no funding for this study and report no declarations of interest. A poster of this article was presented at the Society of General Internal Medicine California-Hawaii Regional meeting on 1/21/17, where it received first place in the innovations category.

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.

Supplementary material

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Online Appendix A(DOCX 15 kb)
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Online Appendix B(DOCX 13 kb)
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Online Appendix C(DOCX 15 kb)
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Online Appendix D(DOCX 15 kb)
11606_2017_4143_MOESM5_ESM.docx (73 kb)
Online Appendix E(DOCX 72 kb)


  1. 1.
    United States Bone and Joint Initiative. Why Is the United States Bone and Joint Initiative Important? Available at Accessed June 23, 2017.
  2. 2.
    Woolf AD, Pfleger B. Special theme – bone and joint decade 2000 –2010: burden of major musculoskeletal conditions. Bull World Health Organ 2003;81:646-656.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Beehler GP, Rodrigues AE, Mercurio-Riley D, Dunn AS. Primary care utilization among veterans with chronic musculoskeletal pain: a retrospective chart review. Pain Med 2013;14:1021-1031.CrossRefPubMedGoogle Scholar
  4. 4.
    Cameron KL, Hsiao MS, Owens BD, Burks R, Svoboda, SJ. Incidence of physician-diagnosed osteoarthritis among active duty United States military service members. Arthritis Rheum 2011;63:2974–2982.CrossRefPubMedGoogle Scholar
  5. 5.
    US Department of Veteran Affairs. 2015. VA Health Care Utilization by Recent Veterans. Available at utilization/. Accessed June 23, 2017.
  6. 6.
    United States Bone and Joint Initiative. The Burden of Musculoskeletal Diseases in the United States. The Big Picture: Health Care Utilization and Economic Cost. Available at Accessed June 23, 2017.
  7. 7.
    March L, Smith EU, Hoy DG et al. Burden of disability due to musculoskeletal (MSK) disorders. Best Pract Res Clin Rheumatol 2014;28:353-66.CrossRefPubMedGoogle Scholar
  8. 8.
    Karpman, RR. Musculoskeletal disease in the United States: who provides the care? Clin Orthop Relat Res 2001;385:52-56.CrossRefGoogle Scholar
  9. 9.
    Uhlig T, Hagen KB, Kvien TK. Why do patients with chronic musculoskeletal disorders consult their primary care physicians? Curr Opin Rheumatol 2002;14:104-108.CrossRefPubMedGoogle Scholar
  10. 10.
    Matheny JM, Brinker MR, Elliott MN, Blake R, Rowane MP. Confidence of graduating family practice residents in their management of musculoskeletal conditions. Am J Orthop 2000;29:945-951.PubMedGoogle Scholar
  11. 11.
    Roberts C, Adebajo AO, Long S. Improving the quality of care of musculoskeletal conditions in primary care. Rheumatology 2002;41:503-508.CrossRefPubMedGoogle Scholar
  12. 12.
    Day CS, Yeh AC, Franko O, Ramirez M, Krupat E. Musculoskeletal medicine: an assessment of the attitudes and knowledge of medical students at Harvard Medical School. Acad Med 2007;82:452-457.CrossRefPubMedGoogle Scholar
  13. 13.
    Day CS, Yeh AC. Evidence of educational inadequacies in region-specific musculoskeletal medicine. Clin Orthop Relat Res 2008;466:2542-2547.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. J Bone Joint Surg Am 1998;80:1421-1427.CrossRefPubMedGoogle Scholar
  15. 15.
    Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am 2002;84:604-608.CrossRefPubMedGoogle Scholar
  16. 16.
    Matzkin E, Smith E, Freccero D, Richardson A. Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005;87:310-314.CrossRefPubMedGoogle Scholar
  17. 17.
    Skelley NW, Tanaka MJ, Skelley LM, LaPorte DM. Medical student musculoskeletal education: an institutional survey. J Bone Joint Surg Am 2012; 94:1-7.CrossRefGoogle Scholar
  18. 18.
    Association of American Medical Colleges. Report VII contemporary issues in medicine: musculoskeletal medicine education. Medical School Objectives Project. Available at: . Accessed June 23, 2017.
  19. 19.
    Chard MD, Hazleman R, Hazleman BL, King RH, Reiss BB. Shoulder disorders in the elderly: a community survey. Arthritis Rheum 1991;34:766-769.CrossRefPubMedGoogle Scholar
  20. 20.
    Solomon DH, Bates DW, Schaffer JL, Horsky J, Burdick E, Katz JN. Referrals for musculoskeletal disorders: patterns, predictors, and outcomes. J Rheumatol 2001;28:2090-2095.PubMedGoogle Scholar
  21. 21.
    Urwin M, Symmons D, Allison T et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998;57:649-655.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Peitzman SJ, Cuddy MM. Performance in physical examination on the USMLE Step 2 clinical skills examination. Acad Med 2015;90:209–213.CrossRefPubMedGoogle Scholar
  23. 23.
    Griesser MJ, Beran MC, Flanigan DC, Quackenbush M, Van Hoff C, Bishop JY. Implementation of an Objective Structured Clinical Exam (OSCE) into orthopedic surgery residency training. J Surg Educ 2012;69:180–189.CrossRefPubMedGoogle Scholar
  24. 24.
    Beran MC; Awan H; Rowley D; Samora JB; Griesser MJ; Bishop JY. Assessment of musculoskeletal physical examination skills and attitudes of orthopaedic residents. J Bone Joint Surg Am 2012;94: e36.CrossRefPubMedGoogle Scholar
  25. 25.
    Akesson K, Dreinhofer KE, Woolf AD. Improved education in musculoskeletal conditions is necessary for all doctors. Bull World Health Organ 2003; 81:677-683.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Bernstein J, Alonso DR, DiCaprio M, Friedlaender GE, Heckman JD, Ludmerer KM. Curricular reform in musculoskeletal medicine: needs, opportunities, and solutions. Clin Orthop Relat Res 2003; 415:302-308.CrossRefGoogle Scholar
  27. 27.
    Clawson DK, Jackson DW, Ostergaard DJ. It’s past time to reform the musculoskeletal curriculum. Acad Med 2001;76:709-710.CrossRefPubMedGoogle Scholar
  28. 28.
    DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am 2003;85:565-577.CrossRefPubMedGoogle Scholar
  29. 29.
    Monrad SU, Zeller J, Craig C, DiPonio L. Musculoskeletal education in US medical schools: lessons from the past and suggestions for the future. Curr Rev Musculoskelet Med 2011;4:91–98.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Murphy RF, LaPorte DM, Wadey VM, American Academy of Orthopaedic Surgeons Orthopaedic Education Study Group. Musculoskeletal education in medical school: deficits in knowledge and strategies for improvement. J Bone Joint Surg Am 2014;96:2009-2014.CrossRefPubMedGoogle Scholar
  31. 31.
    Woolf AD, Walsh NE, and Akesson K. Global core recommendations for a musculoskeletal undergraduate curriculum. Ann Rheum Dis 2004;63:517-524.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Frank JR, Mungroo R, Ahmad Y, Wang M, De Rossi S, Horsley T. Toward a definition of competency-based education in medicine: a systematic review of published definitions. Med Teach 2010;32:631-637.CrossRefPubMedGoogle Scholar
  33. 33.
    Frank JR, Snell LS, Ten Cate O et al. Competency-based medical education: theory to practice. Med Teach 2010;32:638–645.CrossRefPubMedGoogle Scholar
  34. 34.
    United States Bone and Joint Initiative. Project 100: undergraduate musculoskeletal education. Available at Accessed June 23, 2017.
  35. 35.
    Bernstein J, Garcia GH, Guevara JL, Mitchell GW. Progress report: the prevalence of required medical school instruction in musculoskeletal medicine at decade’s end. Clin Orthop Relat Res 2011; 469:895–897.CrossRefPubMedGoogle Scholar
  36. 36.
    Fromme HB, Karani R, Downing SM. Direct observation in medical education: a review of the literature and evidence for validity. Mt Sinai J Med 2009;76:365-71.CrossRefPubMedGoogle Scholar
  37. 37.
    Houston TK, Connors RL, Cutler N, Nidiry MA. A primary care musculoskeletal clinic for residents—success and sustainability. J Gen Intern Med 2004;19:524–529.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Vernec, A, Shrier, I. A teaching unit in primary care sports medicine for family medicine residents. Acad Med 2001;76;293-296.CrossRefPubMedGoogle Scholar
  39. 39.
    Wilcox T, Oyler J, Harada C, Utset T. Musculoskeletal exam and joint injection training for internal medicine residents. J Gen Intern Med 2006;21:521–523.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    StatSoft, Inc. Electronic Statistics Textbook. Tulsa: StatSoft; 2013.Google Scholar
  41. 41.
    Vivekananda-Schmidt P, Lewis M, Coady D, Morley C, Kay L, Walker D. Exploring the use of videotaped objective structured clinical examination in the assessment of joint examination skills of medical students. Arthritis Rheum 2007;57:869-876.CrossRefPubMedGoogle Scholar
  42. 42.
    Altschuler EL, Cruz E, Salim SZ et al. Efficacy of a checklist as part of a physical medicine and rehabilitation clerkship to teach medical students musculoskeletal physical examination skills: a prospective study. Am J Phys Med Rehab 2014;93:82-89.CrossRefGoogle Scholar
  43. 43.
    Shayne P, Gallahue F, Rinnert S et al. Reliability of a core competency checklist assessment in the emergency department: the standardized direct observation assessment tool. Acad Emerg Med 2006;13:727-32.CrossRefPubMedGoogle Scholar
  44. 44.
    Halman S, Dudek N, Wood T et al. Direct observation of clinical skills feedback scale: development and validity evidence. Teach Learn Med 2016; 10:1-10.Google Scholar
  45. 45.
    Hauer KE, Holmboe ES, Kogan JR. Twelve tips for implementing tools for direct observation of medical trainees' clinical skills during patient encounters. Med Teach 2011;33:27-33.CrossRefPubMedGoogle Scholar
  46. 46.
    Holmboe ES, Hawkins RE, Huot SJ. Effects of training in direct observation of medical residents' clinical competence: a randomized trial. Ann Intern Med 2004;140:874-881.CrossRefPubMedGoogle Scholar
  47. 47.
    Kogan JR, Holmboe ES, Hauer KE. Tools for direct observation and assessment of clinical skills of medical trainees. a systematic review. JAMA. 2009;302:1316-1326.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine (outside the USA) 2017

Authors and Affiliations

  • Michal Kalli Hose
    • 1
    • 2
  • John Fontanesi
    • 3
  • Manjulika Woytowitz
    • 1
    • 2
  • Diego Jarrin
    • 1
    • 2
  • Anna Quan
    • 1
    • 2
  1. 1.VA San Diego Healthcare SystemSan DiegoUSA
  2. 2.University of California San DiegoLa JollaUSA
  3. 3.Family and Preventive MedicineUniversity of California San DiegoLa JollaUSA

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