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Two Educational Interventions to Improve Pediatricians' Knowledge and Skills in Performing Ankle and Knee Physical Examinations
Albert C. Hergenroeder, MD;
Joseph N. Chorley, MD;
Larry Laufman, EdD;
Amy Fetterhoff, BS
Arch Pediatr Adolesc Med. 2002;156:225-229.
ABSTRACT
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Background Methods are needed to improve pediatricians' skills for physical examination
of the ankle and knee.
Objective To compare the effect of 2 methods of teaching the physical examination
of the ankle and knee on the knowledge and skills of pediatricians.
Design Prospective intervention trial with preintervention and postintervention
tests.
Setting Pediatricians' offices.
Participants Twenty-three practice groups of community pediatricians, including 75
pediatricians (74% of the eligible sample).
Interventions Practice groups were assigned by clustered randomization to 1 of 2 teaching
interventions: (1) a videotape showing correct performance of the ankle and
knee physical examinations (videotape only; 15 groups) and (2) the same videotape
plus a skills building session (18 groups). The randomization was stratified
by practice size.
Main Outcome Measures Knowledge of ankle and knee examinations and ankle and knee physical
examination skills, assessed by means of a Clinical Skills Assessment Examination
(CSAE), at 18 weeks.
Results The pediatricians' baseline mean ankle CSAE score was 26% correct in
both groups. These scores improved to 44% and 59% correct in the videotape
and videotape plus skills instruction groups, respectively, at 18 weeks (P<.001 for both). The baseline mean knee CSAE score was 25% in both
groups and improved to 30% (P = .02, videotape group)
and 41% (P<.001, videotape plus skills instruction
group) at 18 weeks. The change in CSAE scores was greater in the videotape
plus skills instruction group. Written test scores improved significantly
in both groups.
Conclusions Pediatricians' skills were lacking at baseline. Both teaching interventions
were associated with improved skills and knowledge.
INTRODUCTION
MUSCULOSKELETAL sports injuries in children and adolescents are common
in primary care settings and can have important sequelae. The national cost
of initial medical care for persons younger than 19 years who were injured
in sports was estimated to be $22 billion in 1994.1
Functional limitations persist indefinitely after some musculoskeletal injuries.2-3 A knee injury in adolescence increases
the risk of osteoarthritis in those older than 65 years.4
Young athletes drop out of sports after injuries.5
Residual musculoskeletal deficits from injury are associated with increased
risk of subsequent musculoskeletal injury.
Assuming that the physician evaluating the injury is skilled in making
the correct diagnosis, injuries can be rehabilitated and, in doing so, subsequent
injuries can be prevented and athletes can return to exercise without restriction.6-10
Deficits in physicians' training in diagnosing and treating musculoskeletal
injuries can have undesirable effects, including (1) inappropriate referrals,11-12 (2) delayed referrals,13
and (3) suboptimal management of musculoskeletal problems and errors in distinguishing
organic and psychogenic pain.10, 13-14
Pediatricians report that training in the care of routine musculoskeletal
injuries is lacking.11, 15-16
There is a need to improve pediatricians' diagnostic and management skills
for routine musculoskeletal injuries. The first step in diagnosing a musculoskeletal
injury is performing a correct physical examination of the injured structures.
Investigators reported that general and family practitioners' participation
in continuing medical education (CME) interventions for management of arthritis
was associated with improved knowledge and skill in diagnosing and treating
arthritis.12, 17-20
However, these studies have tended to use biased samples: groups of general
practitioners without rheumatology experience, 15 "educationally influential
physicians," 36 local practitioners who volunteered (38% of the eligible physicians
in the area), and 529 family practitioners (68% of the eligible sample). In
addition, the published reports do not describe their educational methods
to the extent that they could be replicated and do not include an assessment
of or training for physical examination skills. In one randomized trial of
CME in primary care, no assessment of physical examination skills was mentioned;
rather, physicians' "quality of care" provided was assessed.21
There is no published method that has been demonstrated to improve pediatricians'
knowledge and skills in performing the musculoskeletal examination.
The purpose of our study was to compare the effect of 2 methods (videotape
only and videotape plus skills instruction) of teaching the physical examination
of the ankle and knee on the knowledge and skills of pediatricians. The ankle
and knee were selected as the focus of the teaching intervention in this project
as they are the 2 most common sites of injury in young athletes.22
Our hypothesis was that pediatricians' knowledge and skills in performing
the physical examinations of the ankle and knee would be improved with the
use of both methods.
SUBJECTS AND METHODS
SUBJECTS
All groups of practicing pediatricians (a total of 101 pediatricians)
in the Texas Children's Hospital health maintenance organization, Texas Children's
Pediatric Associates, Houston, as of October 1998 were eligible to enroll
in the study. The number of participating pediatricians per practice group
ranged from 1 to 8 (mean, 2.3 pediatricians per practice). A pediatrician
was eligible if he or she was an active member of a practice on the day the
practice group was first contacted about the study. We directly contacted
a physician from each practice and asked whether the members of that group
would participate in the study. We went to the physicians' offices to enroll
the participants. A pediatrician was classified as enrolled if he or she completed
the baseline evaluation and received an intervention. The Texas Children's
Hospital Practice Management Committee and the Baylor College of Medicine
Institutional Review Board for Human Research Subjects, Houston, approved
the study. Informed consent was obtained from each subject.
FOCUS GROUPS
Two focus groups of practicing pediatricians were convened before the
study began, to give feedback regarding this project's methods. Specifically,
the focus group participants were asked whether they preferred their knowledge
and skills to be assessed by someone they knew or someone they did not know.
They indicated that being observed by the physician investigators, whom they
might know, would be stressful and preferred evaluation by someone they did
not know. Therefore, the study coordinator (A.F.), whom they did not know,
did all the baseline and follow-up evaluations. The pediatricians indicated
that receiving CME credit for participating in the teaching intervention,
providing lunch for the activity, and conducting the interventions at physicians'
offices would enhance participation. All of these suggestions were incorporated
into the protocol.
STUDY DESIGN
The study design was a prospective, intervention trial using a preintervention
and postintervention test design, with the unit of analysis being the group
practice. Because of the potential problem of physicians interacting within
group practices, if the randomization had been by individual physician rather
than group, physicians receiving the skills training could have discussed
this training with partners who received only the videotape intervention.
Therefore, randomization was by practice. Physician practices were randomly
assigned to 1 of the 2 treatment options by means of a random number table.
This randomization was stratified by practice size to ensure an equitable
practice size distribution between the 2 treatment groups. Assignment was
done by one of the investigators (L.L.) who was blinded as to which group
received which intervention.
BASELINE EVALUATION
A questionnaire was completed with information about sex, years after
residency, and the physician's comfort level in diagnosing ankle or knee injuries
on the basis of history and physical examination. Comfort level was assessed
with a 5-point scale (where 1 indicates very uncomfortable or always refer;
2, uncomfortable, refer most; 3, neutral; 4, comfortable, seldom refer; and
5, very comfortable and almost never refer). The physicians' knowledge and
skills in performing the physical examination of the ankle and knee were evaluated
by means of a written test and Clinical Skills Assessment Examination (CSAE).
The reliability of these methods was established in pediatric residents.23 The written test contained 10 knee and 10 ankle questions.
The written test scores were identified by a unique study number. The written
and CSAE scores were anonymous to the physician investigators.
In the CSAE format, after short clinical scenarios were presented, the
physicians were asked to examine the ankle and knee of a standardized patient,
and this examination was observed by one of us (A.C.H. or J.N.C.). The standardized
patient also functioned as an observer and rated the physician's performance
by means of published checklists.23 The standardized
patient was a certified athletic trainer (A.F.) who had trained with the 2
physician investigators (A.C.H. and J.N.C.) before this study began. Her performance
as a rater was established by interrater reliability for the ankle and knee
( = .99 and .90, respectively) in a previous study of pediatric residents'
performance with the use of the same CSAE used in this study.
INTERVENTIONS
A videotape entitled Musculoskeletal Examination:
Diagnosing Ankle, Knee, Shoulder, and Back Injuries in a Primary Care Setting was produced by one of us (A.C.H.).24
In the first 18 minutes of the videotape, one of us (A.C.H.) demonstrates
correct physical examination techniques of the ankle and knee by using actors
as patients. The script for the videotape was developed with the use of physical
examination checklists for the ankle and knee from our sports medicine clinic.
As secondary reinforcers to the videotape, the physicians were given the outline
for the videotape script and ankle and knee physical examination checklists
on which they could take notes while watching the videotape (checklists are
available from the authors). The videotape was tested for appropriateness
for pediatric residents and practicing pediatricians with a convenience sample
pilot group of 17 health care providers including pediatric residents and
physicians in practice or in full-time academic positions. These reviewers
were asked to grade the videotape by means of a 5-point Likert scale ranging
from uninformative (0) to very informative (4). All reviewers indicated that
there was a need for the information provided on the videotape, and 15 of
the 17 rated the videotape as very informative. One category 1 CME credit
hour for viewing the videotape was obtained through the Office of Continuing
Education at Baylor College of Medicine.
In the videotape-only group, each physician watched the first 18 minutes
of the teaching videotape in his or her office with one of us present to ensure
that the physician watched the videotape. The physicians received the videotape
script outline and physical examination checklist forms at the beginning of
the videotape. They were able to ask us questions about the videotape content,
and we answered these questions.
In the videotape plus skills instruction group, each physician watched
the first 18 minutes of the teaching videotape with one of us and received
the videotape script outline and physical examination checklist forms at the
beginning of the videotape, just as the videotape-only group did. The physical
examinations of the ankle and knee were then demonstrated by one of us in
a clinic examination room, using one of the physician participants as the
model. The physicians used the videotape outlines to follow the investigator
doing the examination. Finally, each physician performed the examinations
correctly by using one of us as the model and guided by the videotape outlines.
There was no difference in the time interval from the baseline evaluation
and the intervention in the 2 treatment groups (videotape only, 13 weeks;
videotape plus skills instructions, 14 weeks; P =
.8). After the intervention, the physicians were asked to complete an evaluation
of the teaching intervention, using a 5-point Likert scale (0, poor; 1, fair;
2, good; 3, very good; and 4, excellent), and complete the written test to
get the 1 CME credit.
FOLLOW-UP EVALUATION
The physicians completed the written test, performed the CSAEs on the
standardized patient, and completed an evaluation of the intervention program,
using a 5-point scale ranging from strongly disagree (0) to strongly agree
(4), in their offices. Follow-up evaluations were originally scheduled for
1 and 6 months after the intervention. However, limited physician availability
resulted in only 1 follow-up evaluation. The design was to blind the rater,
at follow-up, to which intervention the group received. However, the rater
was also the study coordinator and was unable to be completely blinded about
group assignment. The physicians did not receive feedback on their written
test and CSAE scores except when they received their CME certificate indicating
that they had passed the test, ie, at least 50% correct answers.
STATISTICAL ANALYSES
The unit of analysis was the group practice. Pearson correlation coefficients
were calculated between written test scores and CSAE scores at baseline and
follow-up. Spearman correlation coefficients were calculated between the self-rated
comfort level in diagnosing ankle and knee injuries and the CSAE scores at
baseline. Paired t tests were performed for the written
test and CSAE scores at baseline and follow-up. Intervention groups were compared
with respect to the various outcome measures by means of a mixed effects model
to take clustered randomization into account. As independent variables, the
model included the intervention group as a fixed factor, the practice number
nested within intervention group as a random factor, and the baseline value
as a covariate. MINITAB's general linear modeling procedure was used (Minitab
Inc, Cary, NC). The scale for physicians' ratings of the intervention were
modified so that "strongly agree" and "agree" were collapsed into one value
and "strongly disagree" and "disagree" were collapsed into one value, resulting
in a 3-point scale.
RESULTS
SUBJECT CHARACTERISTICS
Forty-two (81%) of the 52 eligible pediatricians in the videotape plus
skills instruction group enrolled in the study. Thirty-three (67%) of the
49 eligible pediatricians in the videotape-only group enrolled in the study.
Therefore, the final study sample included 75 pediatricians (74% of the eligible
sample). There were no statistically significant differences between the 2
groups in sex, years after residency, comfort level in diagnosing ankle or
knee injuries, or written test and CSAE scores at baseline (Table 1). The comfort level in diagnosing ankle injuries was not
related to the ankle CSAE score at baseline in either the videotape-only or
the videotape plus skills instruction group (P =
.86 and .16, respectively). Likewise, the comfort level in diagnosing knee
injuries was not related to the knee CSAE score at baseline in the videotape
and videotape plus skills instruction groups (P =
.71 and .51, respectively).
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Table 1. Characteristics of Subjects by Intervention Group*
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WRITTEN TEST AND CSAE SCORES
There was a significant difference between the 2 intervention groups
at follow-up for the knee and ankle CSAE scores and for the written test scores
(Table 2).
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Table 2. Follow-up Written Test and CSAE Scores by Intervention Group*
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Within the 2 intervention groups, there was a significant increase in
written test scores and CSAE scores between baseline and follow-up. The mean
percentage of correct answers for the written test in the videotape group
at baseline was 44% (8.9/20), and for the videotape plus skills instruction
group, 50% (10.1/20). These scores increased significantly to 65% and 81%
correct, respectively, at follow-up. At baseline, both groups had mean ankle
CSAE scores of 26% (8.7 and 8.8 correct of a maximum score of 34), which significantly
increased to 44% (videotape group) and 59% (videotape plus skills instruction
group) at follow-up. At baseline, the mean knee CSAE score was 25% (7.6 correct
of a maximum score of 31) in both groups. At follow-up, the CSAE scores significantly
increased to 30% (videotape group) and 41% (videotape plus skills instruction
group).
There was no statistically significant difference in the mean ±
SD time of follow-up between the videotape only group (20.2 ± 6.1 weeks;
range, 5-28 weeks) and the videotape plus skills instruction group (mean,
16.4 ± 10.8 weeks; range, 4-45 weeks; P =
.12).
COMMENT
This study demonstrated that improvements in physicians' knowledge and
skills in performing ankle and knee physical examinations were associated
with the physicians' participation in either intervention.
The improvements in physicians' knowledge and skills in the ankle and
knee examinations were greater in the videotape plus skills intervention group
than in the videotape-alone group. This was expected, as the material was
presented in a multimedia format and the pediatricians immediately applied
the knowledge and skills presented in the videotape in an interactive format,
allowing the pediatrician to ask questions of a skilled examiner. The videotape
plus skill intervention was labor intensive for the physician investigators,
representing a limitation in the use of this method on a broad scale. However,
physical therapists and medical students can provide training in performing
the physical examination of the musculoskeletal system.25-26
In our study, the standardized patient and rater of the CSAEs was a certified
athletic trainer. In future studies, models of small group training for physicians
directed by physical therapists and athletic trainers could be tested, using
this study as a model.
Baseline CSAE scores were unrelated to physicians' comfort in diagnosing
these conditions. Competence and self-described comfort in diagnosing clinical
conditions may not coincide. The pediatricians' skills in this group were
lacking at baseline, consistent with pediatricians' reports of discomfort
with the musculoskeletal examination in other reports.11, 15
Performing the majority of the examination techniques correctly is necessary
to make a correct diagnosis of an ankle or knee injury. The CSAEs used in
this study were at the level of thoroughness and complexity used by sports
medicine specialists in examining patients. This is a high standard. Although
the CSAE scores improved in both groups, the pediatricians' performance of
the physical examination of the ankle and knee needed further improvement.
Further study is needed to improve the methods presented here. In a concurrent
study, conducted by us, pediatric residents received the same videotape plus
skills intervention as the pediatricians in this study, plus they examined
2.8 ± 3.2 and 2.2 ± 2.3 (mean ± SD) patients with ankle
and knee complaints, respectively, as part of a 1-month rotation with us.27 The residents' mean ankle CSAE score was 77% (of
a possible 100%) and mean knee CSAE score was 55% at 9 months after the rotation
was complete. The improved skills demonstrated by the residents compared with
the pediatricians in this study could be due in part to the learning associated
with examining additional patients during the month. This suggests that, in
addition to the one-time videotape or videotape plus skills intervention described
in this article, physicians could improve their ankle and knee examinations
with further training. The specific activities that best constitute this training
require further study.
That knowledge and skills improved with the use of the videotape alone
implies that CME to teach examination of the musculoskeletal system to pediatricians
in practice could be done via videotape, compact disk, or the Internet. The
teaching intervention described in this article could begin to address the
gap between practicing physicians' need for hands-on demonstration of techniques
and the lack of established methods to do so. This would be an improvement
over the current methods of reading about physical examination techniques
or attending CME didactic conferences to learn techniques in large groups.
A limitation of this study is that we were professionally familiar with
many of the pediatricians in the study, and this may have made recruitment
and implementing the interventions easier than if we had been unknown to the
pediatricians. Familiarity may have favorably biased the outcomes, as the
pediatricians may have had more of an incentive to demonstrate their knowledge
and skills than they would have to investigators whom they would be unlikely
to interact with again. The physician investigators were blinded to the results
for individual physicians.
| What This Study Adds
Musculoskeletal injuries are common in pediatric practice. Pediatricians
report the need to improve their knowledge and skills in the physical examination
of the musculoskeletal system. There are no published methods that address
this need.
This study introduces into the medical literature 2 methods, each provided
as a one-time intervention that improved pediatricians' knowledge and skills.
However, as the methods in this article are a step toward establishing pediatricians'
competence in examining the musculoskeletal system, and not the end point
itself, further refinement of this model is indicated. The implications for
pediatric residency training, with respect to examination of the musculoskeletal
system, are obvious.
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AUTHOR INFORMATION
Accepted for publication November 13, 2001.
We thank Aircast, Inc, Summit, NJ; Ayse McCracken; Kay Tittle, RN; and
the Texas Children's Pediatric Associates, Houston, for their support of this
project.
This study was presented in part before the Society for Pediatric Research,
Boston, Mass, May 15, 2000.
Corresponding author: Albert C. Hergenroeder, MD, Texas Children's
Hospital, 6621 Fannin St, CC 610.01, Houston, TX 77030-2399 (e-mail: alberth{at}bcm.tmc.edu).
From the Adolescent Medicine and Sports Medicine Section, Department
of Pediatrics (Drs Hergenroeder and Chorley), and Department of Medicine (Dr
Laufman), Baylor College of Medicine, and Wyle Laboratories, Life Sciences
Systems and Services (Ms Fetterhoff), Houston, Tex.
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