Australian medical students report poor confidence managing common orthopaedic sports‐related injuries: findings of a multi‐site survey

It has been estimated that musculoskeletal issues comprise around 15–30% of primary care visits in the United States and Canada,1 and an Australian audit identified that 17% of presentations for injuries to Victorian emergency departments from 2012–2013 to 2014–2015 were related to sport or active recreation.2 Furthermore, a study of older adults identified that a majority of emergency department presentations related to a musculoskeletal diagnosis.3 These factors translate to a demand for medical schools to produce graduates with a strong foundation in assessing and managing common musculoskeletal injuries. However, with the continued evolution of medical school curriculum structure, the ability to meet student expectations and provide adequate education in orthopaedics and sports medicine is becoming increasingly challenging. Indeed, several surveys of medical students in the United States have revealed consistent themes recognizing the importance of musculoskeletal education but a lack of clinical confidence and competence in the area.4, 5 Therefore, the aim of this study was to assess the perceptions of Australian medical students regarding their exposure to, and quality of education in, orthopaedic sports medicine, the perceived importance of the field, and confidence in managing common sports-related symptoms and injuries. A cross-sectional online survey was administered to clinical medical students at four Australian medical schools from 2019 to 2021. Students in their clinical years were targeted to complete the survey, who had already had some exposure to musculoskeletal teaching. The questionnaire comprised numerical and Likert-scale items adapted from other surveys with similar areas of focus.4, 6, 7 Questions assessed students' self-reported confidence in performing orthopaedic physical examinations and managing common orthopaedic and sports-related injuries. Comparison was made to other common non-orthopaedic medical conditions. Ethics approval was obtained from the University of Adelaide Human Research Ethics Committee (H-2019-213). Analyses were conducted using IBM SPSS software version 27 (IBM Statistics, Armonk, NY). The Likert-scale item responses were assigned numerical values to allow analyses, and independent t-test and Mann–Whitney U-test were used for parametric and non-parametric variables, respectively. Statistical significance was set at P < 0.05. The survey was completed by a total of 150 students, of whom 60% were female. Ten percent were interested in pursuing a career in orthopaedic surgery. Six students (4%) had previously completed higher degrees or training in Sports/musculoskeletal related-fields. Overall, 44.0% students felt that orthopaedic sports medicine education was very relevant/fundamental to the practice of their preferred career pathway. In addition, 30.0% of students felt it was very/extremely important that their curriculum contained time dedicated to the topic, 54% somewhat important and only 10% believing it was not so important. When considering student confidence, an average 47.6% students reported no confidence or only slight confidence in performing orthopaedic physical examinations. This trend was consistent across each specific orthopaedic examination (Fig. 1). Students were also significantly less confident in performing orthopaedic examinations compared with non-orthopaedic examinations (Fig. 1, P < 0.001). Females were significantly less confident in performing orthopaedic examinations compared with males (P < 0.001). This gender difference was not observed for non-orthopaedic examinations (P = 0.312). In terms of confidence managing common medical conditions, one-third (33.1%) of students indicated that they were ‘not at all confident’ in treating patients with sports-related symptoms/injuries. This lack of confidence was observed consistently across a range of common orthopaedic conditions (Fig. 2). The same students were asked about their confidence regarding non-orthopaedic conditions as a comparator. There was also a statistically significant difference in students' confidence in managing orthopaedic conditions compared to common non-orthopaedic medical conditions (Fig. 2, P < 0.001). Females were significantly less confident in managing orthopaedic conditions compared with males (P < 0.001). This gender difference was not observed for non-orthopaedic conditions (P = 0.210). Overall, 27.6% students felt that their current orthopaedic sports medicine curriculum adequately prepared them to manage sports-related symptoms/injuries in whatever career pathway they intended pursuing. Students estimated that 32.7% of consultations in general practice involve sports-related symptoms/injuries. This survey suggests that assessing and managing common orthopaedic conditions remains an area of relative weakness for medical students around Australia. Findings from this study are largely consistent with those of other studies exploring musculoskeletal knowledge among medical students.4, 5, 8 This survey also confirms a lack of confidence among medical students in assessing and managing common ailments of the musculoskeletal system. This raises questions about the attention given to orthopaedic and sports medicine education in Australian medical curricula. Further, students were significantly less confident assessing and managing orthopaedic conditions compared with other common medical conditions. Female students were significantly less confident with orthopaedics compared with their male counterparts. The reason for this is unknown and warrants further attention. Deficiencies in musculoskeletal education appears to be a prevalent issue,9 with groups advocating for the implementation of global standards and curricula for undergraduate musculoskeletal education.10, 11 Studies have also demonstrated how existing curricula can be effectively adapted to novel settings and the benefits of targeted education,12, 13 as well as the crucial importance of ensuring clinical exposure is incorporated into teaching methods.14 Strengths of this study includes its multi-centre design, capturing students subjected to varying styles of orthopaedic education delivery and curriculum structure around Australia. Response rate was difficult to elucidate due to variable lecture attendance and survey announcement exposure within the private Facebook groups. In addition, demographics of non-responders were not collected. Further, respondent bias is a possibility whereby students with particularly strong views may have been more inclined to participate, and recall bias dependent on when they received their orthopaedics education. The use of Likert-scales for response grading caries the inherent bias of subjectivity among participants. Although all institutions consistently reported a greater lack of confidence with orthopaedic examinations the study was not powered to allow any statistical comparison of responses between universities. Future work would benefit from exploring if differences between universities across Australia can be analysed. It is important to acknowledge that survey responses in this study were collected amidst the global COVID-19 pandemic, and as such, modifications and compromises to medical programs may have resulted in some students undergoing an altered orthopaedic education experience. Additionally, students' current psychosocial wellbeing and stressors in the current environment may have had an influence on their confidence. Orthopaedics covers a wide range of topics including acute, acute-on-chronic and chronic conditions, as well as a spectrum of management options from examinations and counselling to radiographic analysis and emergency fracture management. The wide-ranging tasks and multidisciplinary aspects of orthopaedics means further studies expanding on this may aid policy and teaching strategies. Further local studies building on previous international studies exploring novel orthopaedic pedagogies would be beneficial as well as a recognition by medical schools of the importance of providing adequate time for orthopaedic teaching and assessment. Also of value would be a follow-up study further elucidating the impact of COVID-19 on orthopaedic education nationally. Open access publishing facilitated by The University of Adelaide, as part of the Wiley - The University of Adelaide agreement via the Council of Australian University Librarians. Zachary Bunjo: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; writing – original draft; writing – review and editing. Tiffany K. Gill: Conceptualization; investigation; methodology; project administration; supervision; writing – review and editing. Natalie Enninghorst: Investigation; methodology; supervision; writing – review and editing. Lorcan McGonagle: Investigation; methodology; supervision; writing – review and editing. Francois Tudor: Investigation; methodology; supervision; writing – review and editing. Jaden Bollman: Investigation; methodology; writing – review and editing. Stuart Purdie: Investigation; methodology; writing – review and editing. Terry Farquharson: Investigation; supervision; writing – review and editing. Peter Smitham: Conceptualization; methodology; project administration; supervision; writing – review and editing.

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