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Implementation of a novel musculoskeletal physical exam curriculum in an internal medicine residency

A novel musculoskeletal physical exam curriculum implemented during the 2023-2024 academic year significantly improved internal medicine residents' confidence and, for shoulder and lumbar spine workshops, their objective physical exam competence, though the knee workshop did not yield a statistically significant improvement in observed skills.

Original authors: Marc Gutierrez, Elizabeth Willis, Akruti Prabhakar, Timothy Lo, Amie Kim, Nicholas Zingas, Kelsey R Wilson, Kathryn M Burtson

Published 2026-07-07

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CC BY 4.0

Original authors: Marc Gutierrez, Elizabeth Willis, Akruti Prabhakar, Timothy Lo, Amie Kim, Nicholas Zingas, Kelsey R Wilson, Kathryn M Burtson

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine that being a doctor is like being a mechanic for the human body. While mechanics are experts at fixing engines, many of them haven't been taught how to fix the "suspension system" (joints and muscles) because their training focused mostly on the engine itself.

This paper describes a project where a group of medical teachers tried to fix that gap for Internal Medicine residents (doctors in their final years of training). Here is the story of what they did and what happened, explained simply:

The Problem: The "Missing Manual"

Even though joint pain (like a sore shoulder or bad knee) is one of the most common reasons people visit a doctor, many doctors-in-training feel shaky about how to examine these areas. It's like a mechanic who is great at diagnosing a flat tire but has never been shown how to check the brakes. The authors wanted to give these residents a "user manual" for the shoulder, the lower back, and the knee.

The Solution: The "Muscle Gym" Workshops

Instead of sending residents to a specialty clinic for months (which is hard to schedule), the team created a longitudinal workshop series. Think of this as a "muscle gym" for doctors, held once a month for two hours.

The workshops had three parts, like a cooking class:

The Recipe Book: A big-group review of how the joints work and what goes wrong.
The Chef's Demo: Instructors showed exactly how to move the joints and check for problems.
The Tasting Session: Residents practiced on real people (healthy volunteers) while getting immediate feedback, like a student chef tasting their own dish and getting corrected.

They ran these classes twice during the year so everyone could attend, even if they were working night shifts.

The Test: Before and After

To see if the "gym" worked, the researchers did two things before and after the classes:

The Confidence Survey: They asked the residents, "On a scale of 1 to 5, how confident do you feel checking a shoulder?"
The Skill Check: They watched the residents perform the actual exam on a volunteer and scored them on a checklist (like a teacher grading a test).

The Results: What Worked?

Out of 52 residents, 38 completed the whole program. Here is what happened:

Shoulder & Lower Back (The Big Wins):
- Confidence: Residents went from feeling "a little unsure" to "pretty confident."
- Skill: Their actual exam scores jumped significantly. It was like going from a C- to an A- on a driving test. They learned the moves and could do them correctly.
The Knee (The "Ceiling Effect"):
- Confidence: Residents felt much more confident about knees after the class.
- Skill: Their scores went up slightly, but not enough to be statistically significant. The authors suggest this might be because the residents were already pretty good at checking knees before they started, so there wasn't much room to improve (like a runner who is already fast and can't get much faster).

The Takeaway

The paper concludes that a short, focused, hands-on workshop series is a great way to boost a doctor's confidence and improve their actual skills for checking shoulders and backs.

Important Note: The study only measured if the residents learned the skills and felt confident. It did not track whether they actually used these skills more often with real patients in the future. The authors say that is the next step to figure out.

In short: They built a small, practical training course, and it successfully turned unsure trainees into more confident and skilled examiners for two out of three major body areas.

Technical Summary: Implementation of a Novel Musculoskeletal Physical Exam Curriculum in Internal Medicine Residency

Problem Statement
Musculoskeletal (MSK) complaints constitute approximately 20% of primary care and emergency department visits in the United States, with primary care providers (PCPs) performing initial assessments in up to 70% of these cases. Despite this high prevalence, internal medicine residents frequently report low confidence in performing MSK physical examinations. This deficit is attributed to inconsistent and often inadequate MSK training during undergraduate medical education and limited MSK-focused curricula within internal medicine graduate medical education. While previous interventions have demonstrated improvements in self-reported confidence and objective performance, few studies have described feasible, structured curricula embedded within standard internal medicine residency schedules.

Methodology
The authors developed and implemented a longitudinal, hands-on MSK physical examination curriculum targeting three high-yield anatomical regions: the shoulder, lumbar spine, and knee. The curriculum design followed Kern's six-step approach and was delivered during the 2023–2024 academic year at a single mid-sized academic institution.

Intervention Structure: The program consisted of three recurring two-hour workshops delivered by chief residents under faculty oversight. Each workshop followed a standardized format: (1) interactive large-group review of anatomy, physiology, and pathology; (2) live demonstration of examination maneuvers; and (3) supervised small-group practice with real-time feedback. Workshops were repeated twice to accommodate residents on night float or intensive care rotations.
Participants: The study included internal medicine residents across all postgraduate year (PGY) levels. Of 52 enrolled residents, 38 completed both pre- and post-intervention assessments (73% retention).
Assessment Strategy:
- Confidence: Residents completed pre- and post-intervention surveys using a 5-point Likert scale to assess perceived ability to evaluate symptoms in the three target regions.
- Competence: Objective performance was measured via direct observation using standardized checklists. Residents rotated through stations performing examinations on healthy volunteer models, evaluated by trained faculty. Checklists were scored as 2 (correct), 1 (incorrect), or 0 (not performed).
- Reliability: Inter-rater reliability was established using interclass correlation coefficients (ICC), which demonstrated excellent reliability for all regions (Knee: 0.95; Low Back: 0.99; Shoulder: 0.99).
Analysis: Paired two-tailed t-tests were used to compare pre- and post-intervention scores. The study focused on Kirkpatrick's Level 1 (reaction) and Level 2 (learning) outcomes.

Key Results
The curriculum yielded statistically significant improvements in self-reported confidence across all three anatomical regions:

Shoulder: Confidence increased from 2.24 to 3.00 ( $p=0.001$ ).
Lumbar Spine: Confidence increased from 2.47 to 3.40 ( $p<0.001$ ).
Knee: Confidence increased from 2.57 to 3.31 ( $p=0.001$ ).

Regarding objective competence measured by direct observation checklists:

Shoulder: Mean checklist scores improved significantly from 48% to 71% ( $p<0.001$ ), representing a 23% absolute increase.
Lumbar Spine: Mean scores improved from 59% to 76% ( $p=0.015$ ), a 17% absolute increase.
Knee: While confidence increased, the improvement in checklist scores from 77% to 82% was not statistically significant ( $p=0.103$ ).

Significance and Claims
The paper claims that a feasible, workshop-based MSK curriculum embedded within a protected internal medicine residency schedule can effectively address educational gaps in MSK training. The study demonstrates that such an intervention is associated with:

Increased Confidence: Significant gains in resident self-assessed ability to evaluate MSK symptoms across all targeted regions.
Improved Competence: Measurable gains in observed physical examination performance for the shoulder and lumbar spine.

The authors note that the lack of significant improvement in knee examination performance may reflect higher baseline competence, ceiling effects of the assessment tool, or the complexity of knee maneuvers. They modestly suggest that while workshop-based instruction is effective, the gains in confidence were more modest compared to interventions involving specialty clinics, implying that supervised clinical exposure may further enhance outcomes.

The study concludes that this model offers a practical solution for integrating MSK training into internal medicine residency. However, the authors acknowledge limitations, including the single-institution design, the use of locally developed (non-validated) checklists, and the formative, low-stakes nature of the assessments. They state that future evaluation is required to examine the curriculum's impact on resident behaviors in clinical settings (Kirkpatrick Level 3), such as examination frequency and referral patterns.