Abstract
Objective:
To investigate whether medical students can learn a pediatric musculoskeletal exam independently by studying the Pediatric Gait, Arms, Legs, and Spine (pGALS) assessment.
Methods:
Fourth-year medical students were surveyed regarding confidence and experience with the pediatric musculoskeletal training. Students performed an initial scored musculoskeletal exam on a standardized pediatric patient reporting chronic joint concerns. The total score had a theoretic range from 0 to 42 and scoring was based on the PGALS exam for children presenting with joint pain. Subsequently, students watched training pGALS videos. After this intervention, students completed follow-up physical exams and surveys.
Results:
Fourteen graduating medical students participated. Of these students, 12 students planned to enter a pediatric residency. On the initial survey, participants were the least confident in their pediatric musculoskeletal exam skills compared to all other pediatric physical exam. Before the pGALS training, 21.4% of participants reported being confident or very confident in their pediatric musculoskeletal exam skills, compared to 100% of participants after training (p<0.0001). The pre and post musculoskeletal exam scores were also statistically different (p=0.0001). There were no participants who felt that they received extensive education in the pediatric musculoskeletal exam as part of their medical education. All participants desired further musculoskeletal training. All participants felt that the pGALS tool was beneficial.
Conclusion:
Graduating medical students may not be confident nor proficient at the pediatric musculoskeletal exam. Instruction in the pGALS assessment may be a low cost and efficient way to improve confidence and proficiency in the pediatric musculoskeletal exam.
Keywords: Pediatric Gait Arms Legs and Spine (pGALS), musculoskeletal exam, medical students, pediatric rheumatology
Brief Description:
There has been an emphasis on increased training for the musculoskeletal exam in undergraduate education. The Pediatric Gait, Arms, Legs and Spine (pGALS) exam is a brief assessment (2 minutes) that screens for joint issues from head to foot. This paper describes an intervention with pGALS that increased confidence and proficiency for graduating medical students.
Introduction:
In 2017, the World Forum on Rheumatic and Musculoskeletal Diseases called for more undergraduate education in the musculoskeletal exam.1 Between 25% and 50% of children experience musculoskeletal pain.2 However, pediatric patients with significant musculoskeletal diseases are challenging in that they do not always present with pain and may have subtle swelling or loss of range of motion. Knowledge and clinical skills in assessing for potential musculoskeletal issues is crucial for physicians caring for children, yet many physicians report a lack of confidence and competence in the musculoskeletal exam.3–5
Both pediatric clerkship students and pediatric residents can benefit from increased training in the musculoskeletal exam. Trainees want efficient and effective curriculum. The Pediatric Gait, Arms, Legs, and Spine (pGALS) assessment is a simple and evidence-based tool that may help improve both clinical confidence and competence.6
The pGALS exam is a brief assessment (2 minutes) that screens for joint issues from head to foot. It has ideal sensitivity for detecting musculoskeletal abnormalities, and it also has great acceptability for pediatric patients and families.6 In Thailand, pGALS exam had a sensitivity of 74% and specificity of 100% when performed by pediatric residents to detect musculoskeletal abnormalities (the gold standard was pediatric rheumatologists). 7 The pGALS assessment has been incorporated in some United Kingdom curriculum for students8 and into at least one weekly series on pediatric rheumatology designed for pediatric residents in the United States.9 Additionally, pGALS has been used as the basis of a skills checklist for pediatric residents in the United States.5
The aim of our project was to determine if medical students could independently learn pGALS and then apply the pGALS exam in a standardized clinical setting.
Materials and Methods:
The study design was a voluntary response sample at the Medical University of South Carolina in the spring semester of the 2017–18 academic year, graduating medical students (fourth year) were recruited to voluntarily participate in this project. Institutional Review Board for Human Research approval was obtained for this study. All participants were offered at $20 gift card to a national chain store on completion of the effort. The opportunity was advertised by email to the entire fourth year class of medical students.
Pre and post intervention standardized patient/parent encounters were provided in an OSCE (Objective Standardized Clinical Evaluation) format. The medical students at the Medical University of South Carolina routinely perform OSCEs in both the pre-clinical courses and during clinical rotations. Before graduation for this MUSC medical student class, each medical student performed at least 15 OSCEs.
Standardized patients and parents were trained for the activity. The patient/parent dyads reported a musculoskeletal concern which would trigger the student to perform a musculoskeletal exam. The standardized patients ranged from 8–13 years old. Each student had one standardized patient/parent encounter before the intervention and then again after the intervention. There was approximately two weeks between the patient/parent encounters. All standardized encounters were in a simulated primary care setting.
The intervention consisted of reviewing pGALS by videos online (website used not currently available; indicated references provide pictures of the pGALS exam).6,10 Students were given time and computer access immediately after the pre-intervention OSCE to view the videos. They were encouraged to access pGALS resources (videos and pictorial guide (pictorial guide contained as Figure 1 in the article by Foster et all 2013)6 for review before the post-intervention OSCE.
Figure 1:
Pre and post survey results on confidence in performing the pediatric musculoskeletal exam among all students. Prior to pGALs training only 21% of students reported being either confident or very confident in their musculoskeletal exam compared to 100% after training (p-value <0.0001).
Outcome Metrics:
The student performance was scored based on the physical exam maneuvers and techniques that they used. The performance scale ranged from 0 to 42. One rheumatology fellow at the end of her third year of training scored the performances for both the pre-intervention and the post-intervention standardized encounters. The scoring was based on the recommended exam techniques in the pGALS exam for children presenting with joint pain. The students were surveyed about their knowledge and confidence with the pediatric musculoskeletal exam pre- and post-intervention.
Data Analysis:
Fisher’s exact test was used to find the difference in the percentages between pre and post confidence levels among all students. The Wilcoxon signed rank test was used to find the difference between the pre and post confidence levels for each student. The Wilcoxon signed rank test was also used to find the difference between the pre and post exam scores for each student.
Results:
Fourteen fourth-year students participated in this study in their final semester of medical school. Twelve of the 14 planned to enter a pediatric residency (Table 1). On the initial survey, participants were the least confident in their pediatric musculoskeletal exam skills compared to all other pediatric physical exam skills (abdominal, HEENT, pulmonary, and neurological) (Table 2). Before the pGALS training, 21.4% of participants reported being confident or very confident in their pediatric musculoskeletal exam skills, compared to 100% of participants reporting confidence after training (p<0.0001) (Figure 1). The difference between the pre and post confidence levels for each individual student was also statistically significant (p-value = 0.0005). Pediatric musculoskeletal exam scores for each student before and after video instruction of the pGALS screening tool improved during this study. The difference between the pre and post exam scores was statistically significant (p-value =0.0001). The mean pre-exam score was 22.1 with a 95% confidence interval of (19.6, 24.5). The mean post exam score was 32.2 with a 95% confidence interval of (29.4, 35.0) (Figure 2). There were no participants who felt that they received extensive education in the pediatric musculoskeletal exam as part of their medical education. All participants desired further education in the pediatric musculoskeletal exam, and all the participants felt that the pGALS training was beneficial to their medical education.
Table 1.
Participating 4th year medical students and their chosen specialties after medical school
| Future Specialty Choice | 4th year Medical Students |
|---|---|
| Pediatrics (includes Medicine-Pediatrics) | 12 |
| Other (non-Pediatrics) | 2 |
Table 2.
Medical Student Percent Confidence by Type of Pediatric Exam Prior to pGALs Training
| Exam | Confident | Very Confident |
|---|---|---|
| HEENT | 36% | 36% |
| Pulmonary | 64% | 14% |
| Abdominal | 64% | 14% |
| Musculoskeletal | 21% | 00% |
| Neurologic | 29% | 7% |
Figure 2.
Pediatric musculoskeletal exam scores before and after the pGALS screening tool. The difference between the median pre and post exam scores was statistically significant (p-value =0.0001). The mean pre-exam score was 22.1 with a 95% confidence interval of (19.6, 24.5). The mean post exam score was 32.2 with a 95% confidence interval of (29.4, 35.0).
Discussion:
Medical students lack confidence and skills in performing screening musculoskeletal exams. Having these students learn and practice a validated pediatric musculoskeletal screening tool, such as pGALS, may be a practical solution for medical schools. We demonstrated that fourth year medical students can learn the pGALS exam and make improvements in confidence and skills in performing a screening pediatric musculoskeletal exam. Our study did not address whether the confidence and skills are retained throughout residency and the individual ‘s career.
We feel that it is significant that the students were able to learn pGALS independently from materials available on-line. The student participants in this study were provided with links to the pGALS videos. The video link that we provided no longer works (Pediatric Musculoskeletal Matters International). Our current students are provided with the pictorial guide to pGALS.6 We are aware that our medical students utilize a pGALS app.(https://apps.apple.com/us/app/pgals/id1155984218) and videos on YouTube, as well.
Because of the results of this study, we started a curriculum to help students learn the pGALS exam during the pediatric clerkship. At the orientation to the pediatric clerkship, the students are instructed to study pGALS. They are informed that at the clerkship midpoint, they will have an OSCE to test their ability to take a history and perform an appropriate physical exam. We expanded the history taking component from the OSCE encounter in our study. We also added that the students must perform a brief heart, lungs, and abdomen exam. Students must also discuss their assessments and plans with the standardized family before ending the encounter. After the encounter, students receive feedback from a preceptor who observed the encounter. Students then must complete a partially written History and Physical at a computer station. Written feedback on their note is provided within two weeks after this activity.
Students are scheduled for appointments to see standardized patients (with standardized parents) in our OSCE training facility. These appointments are scheduled at the midpoint (week 3 of 6) of the pediatric clerkship. Initially, we scored the encounters and gave the students a grade. However, the activity was transitioned to a formative activity at the request of the students. These sessions serve as direct observations by faculty members which are required by the Liaison Committee on Medical Education. During the COVID19 pandemic, we learned how to have faculty members remain remote but still directly observe the students’ encounters and provide feedback virtually. Students were very open to receiving feedback from a faculty member present on a laptop screen connection.
Conclusion:
Medical students can learn musculoskeletal screening examination in an independent and efficient manner. Confidence and skills can be increased, and students do agree that a pGALS curriculum is beneficial in their medical education.
Key Points:
The Pediatric Gait, Arms, Legs and Spine (pGALS) exam provides a structure for medical trainees to learn the pediatric musculoskeletal exam efficiently and independently.
By reviewing the pGALS exam, medical students can gain confidence and proficiency in the pediatric musculoskeletal exam.
Financial Acknowledgement:
The Medical University of South Carolina College of Medicine provided the funding for the gift cards for the medical students and any necessary reimbursement and payment of the standardized families. Drs. Nietert and Muhammad received funding from a grant from the National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases grant number 5P30AR072582) that covered their time on this project.
Footnotes
The authors have no conflicts of interest to report
References:
- 1.Al Maini M, Adelowo F, Al Saleh J, et al. The global challenges and opportunities in the practice of rheumatology: white paper by the World Forum on Rheumatic and Musculoskeletal Diseases. Clin Rheumatol. 2015;34(5):819–829. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Sen ES, Clarke SL, Ramanan AV. The child with joint pain in primary care. Best Pract Res Clin Rheumatol. 2014;28(6):888–906. [DOI] [PubMed] [Google Scholar]
- 3.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(5):452–457. [DOI] [PubMed] [Google Scholar]
- 4.Jandial S, Myers A, Wise E, Foster HE. Doctors likely to encounter children with musculoskeletal complaints have low confidence in their clinical skills. J Pediatr. 2009;154(2):267–271. [DOI] [PubMed] [Google Scholar]
- 5.Schultz K, Klein M, Sucharew H, et al. The Impact of a Gamified Curriculum Using Kahoot! on Musculoskeletal Knowledge and Skill Acquisition Among Pediatric Residents. Acad Pediatr. 2022;22(8):1265–1270. [DOI] [PubMed] [Google Scholar]
- 6.Foster HE, Jandial S. pGALS - paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatr Rheumatol Online J. 2013;11(1):44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Sukharomana M, Charuvanij S. The Thai Translation of the Pediatric Gait, Arms, Legs, Spine Tool is Useful for Pediatric Residents in Detecting Musculoskeletal Abnormalities in Children. J Clin Rheumatol. 2020. [DOI] [PubMed] [Google Scholar]
- 8.Baker KF, Jandial S, Thompson B, Walker D, Taylor K, Foster HE. Use of structured musculoskeletal examination routines in undergraduate medical education and postgraduate clinical practice - a UK survey. BMC Med Educ. 2016;16(1):277. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Gillispie M, Muscal E, Rama J, Falco C, Brown A. Pediatric Rheumatology Curriculum for the Pediatrics Resident: A Case-Based Approach to Learning. MedEdPORTAL. 2018;14:10767. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Foster HE, Kay LJ, Friswell M, Coady D, Myers A. Musculoskeletal screening examination (pGALS) for school-age children based on the adult GALS screen. Arthritis Rheum. 2006;55(5):709–716. [DOI] [PubMed] [Google Scholar]