Helping Hands Workshop: Teaching a Focused Rheumatologic Hand Examination With Assessment of Small Joint Swelling in Inflammatory Arthritis

Abstract

Introduction

Prompt, accurate identification of inflammatory arthritis can reduce patient morbidity and health care costs. However, internal medicine residents often do not receive adequate training in how to conduct an effective hand musculoskeletal examination. We created a short interactive workshop to teach the hand exam using our low-cost, easy-to-make 3-dimensional hand model for inflammatory arthritis.

Methods

We designed a 30-minute hand musculoskeletal exam workshop for internal medicine residents rotating through a rheumatology elective. The workshop included a 3-minute video, a hand exam demonstration, hands-on practice, and a 3-station objective structured clinical exam (OSCE) with clinical vignettes and hand models of 3 types of inflammatory arthritis. Participants were scored on OSCE performance by experienced rheumatologists using a 1–5 global rating scale. A survey was used to evaluate participants’ perspectives on the workshop and confidence in performing the hand exam and assessing small joint swelling before and after the workshop.

Results

A total of 36 residents participated in the workshop. The mean global rating scale for OSCEs revealed proficient hand exam performance (4.67 [SD = 0.65] on a 5-point scale). Residents reported significantly higher confidence in performing the hand exam and assessing small joint swelling after participating in the workshop (P < .001). All residents reported being “likely” or “very likely” to use skills learned from this workshop in clinical practice.

Discussion

Our simulation-based workshop for teaching the hand musculoskeletal exam, which included hands-on practice and assessment with an OSCE, shows promise in improving residents’ confidence in performing the hand exam.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Perform a focused hand examination with proper palpation technique on a 3-dimensional hand model simulator.
• 2.Differentiate between normal and swollen small joints characteristic of inflammatory arthritis on the hand simulator.
• 3.Increase their confidence in performing a focused hand musculoskeletal exam and ability to palpate small joint swelling in the hand.

Introduction

Musculoskeletal hand pain is a common condition that affects about 20% of adults,^1–3 and improper management of hand pain due to delayed or inaccurate diagnosis can lead to high health care resource use and cost.^4,5 Hand pain can stem from numerous causes, such as trauma, neuropathies, infections, osteoarthritis, tendonitis, and inflammatory arthritis, and an effective clinical examination to accurately determine the underlying cause of hand pain is essential for prompt and proper treatment. An appropriate hand examination is crucial for diagnosis and treatment of patients; however, there is a lack of standardized teaching of the hand examination.⁶

Despite the importance of effective hand examinations, many trainees are insufficiently trained in this skill, underscoring an urgent need for more timely and effective instruction in performing the hand exam. One study reported that primary care doctors, including internal medicine (IM) physicians, scored less than 70% in an objective structured clinical examination (OSCE) for the musculoskeletal physical exam.⁷ More than 80% of these physicians reported that their postgraduate training for this skill was inadequate and that they were unconfident in performing the musculoskeletal physical exam. Similarly, in another multicenter study, 80% of IM residents reported that their postgraduate training did not sufficiently teach musculoskeletal skills.⁸ Although IM residents report low confidence levels in the musculoskeletal exam, rheumatology experts have identified the musculoskeletal exam as one of the most important skills in rheumatology.⁹ Several curricula for the musculoskeletal exam exist, but the few that have incorporated the hand examination are inadequate. One curriculum, which included spaced repetition and clinician coaching, showed significantly improved OSCE scores in all musculoskeletal regions except for the hand exam.¹⁰ Another curriculum for the hand exam included informational booklets, expert demonstration, and hands-on practice but did not report outcomes or feedback from learners after the intervention.¹¹ Brief exposure to rheumatology through clinical rotations is insufficient for developing musculoskeletal examination skills and gaining confidence in performing this exam. Although exposure during rheumatology clinical rotations was shown to increase IM residents’ confidence in performing the musculoskeletal physical exam, confidence levels were still persistently below 70 (out of 100) on a visual analog scale.¹² And although numerous approaches to teaching the hand physical exam exist, no single optimal method has been found.¹³

Simulation training may be particularly promising for teaching the hand musculoskeletal exam, as it provides a safe environment for learners to practice skills within a realistic clinical situation.¹⁴ One notable benefit of using 3-dimensional anatomic models and simulators is that this approach allows for deliberate, repeated, and targeted practice with immediate feedback from an instructor. Although a simulation approach for teaching the musculoskeletal exam and injection procedures has been proposed, the anatomic areas of interest included the knee and shoulder but not the hand.¹⁵ Simulation-based education has been shown to improve skills, and in some instances clinical outcomes, making it a good pedagogical framework for the hand exam.¹⁶

Currently, there are no published curricula for the hand examination that demonstrate an effective learning outcome. Therefore, we designed a curriculum for residents in IM to learn the hand musculoskeletal examination with a 3-dimensional model of the hand that had been previously developed and validated by our team as a proof of concept.¹⁷ Our aim was to create an innovative workshop, inclusive of all educational materials, to teach the hand exam that integrates didactic instruction with simulation. We hypothesized that the workshop would help learners perform the hand examination and improve their self-reported confidence in the skill.

Methods

We developed a workshop based in experiential learning theory to teach residents the hand exam. The workshop was for IM residents who were participating in a rheumatology rotation between April 2023 and April 2024 at 2 large midwestern academic institutions: Washington University and Henry Ford Health. Learners completed the workshop during their rheumatology rotation, and learners had approximately 2–5 days of rheumatology clinic exposure prior to this workshop. At Henry Ford Health, rheumatology was a required rotation, and at Washington University, it was optional. The workshop included a didactic portion with a hands-on practice session and an OSCE. To incorporate simulation-based education, we utilized an inexpensive and easily constructed hand model that had been previously developed and validated.¹⁷ Two to 4 IM residents completed the workshop at a time. Learners were expected to have some prerequisite knowledge of basic hand anatomy and general concepts related to inflammatory arthritis. Workshop facilitators were either faculty or fellows experienced in rheumatology who understood the workshop structure and were able to adequately demonstrate hand exam technique. To standardize all components of the workshop, all facilitators attended virtual training, which included instructions for completing the global ratings. The Henry Ford Health (approval No. 16358, April 19, 2023) and Washington University Institutional Review Boards deemed this educational study exempt from full review (approval No. 20230609, April 13, 2023). All residents were made aware that their participation was part of a research study, and a risk and benefit of participation and consent form was provided.

The materials and evaluations developed for this streamlined workshop were reviewed by 4 experienced rheumatologists. Four pairs of 3-dimensional hand models were created with materials easily bought from craft or online stores, including human-scale plastic skeleton hands, foam dough (Playfoam), liquid sealant (Mod Podge), a paintbrush, nitrile craft gloves in multiple colors, and knit gloves (Appendix A).¹⁷ Considering that assembly of all the hand models required for this workshop would take approximately 1 hour, not including drying time, this step was completed before the workshop.

For this curriculum, 4 pairs of hand models were created: 1 pair used for demonstration and hands-on practice of palpation techniques and 3 pairs used for the OSCEs (complete directions for assembly are presented in Appendix A). The demonstration model was constructed to include a right hand with inflammation and a left hand with no simulated swelling to allow comparison between healthy and affected joints. The right hand of the demonstration model included inflammation in the wrist, the second metacarpophalangeal, and the fourth proximal interphalangeal, as the technique for examining the wrist and metacarpophalangeal joint differs from the technique for evaluating the proximal interphalangeal and distal interphalangeal joints. The 3 pairs of models used for the OSCE represented hand swelling associated with 3 different types of inflammatory arthritis: rheumatoid arthritis, systemic lupus erythematosus, and psoriatic arthritis. The hand models for the OSCEs were set out at stations with a short fictional scenario describing patient symptoms and were made with different-colored latex gloves. The OSCE was a formative assessment that included real-time expert feedback on technique while performing hands-on simulated practice. We did not provide the learners with the answers to the OSCE to protect the integrity of the project.

The workshop had 4 major components: a 3-minute instructional video, a 10-minute section that included a demonstration of the hand exam by the facilitator and time for hands-on practice with a hand model, a 3-station OSCE, and a workshop evaluation survey. Workshop facilitators used a facilitator guide (Appendix B).

First, a 3-minute instructional video was shown that demonstrated basic hand anatomy, the steps of the hand exam, and appropriate technique for assessing small joint swelling of the hands (Appendix C). A 10-minute demonstration with hands-on practice was done next. Facilitators provided a live demonstration on how to perform the hand exam, and learners then applied what they learned by practicing on the demonstration hand model. The facilitator provided real-time feedback on technique and learners’ accuracy of identifying small joint swelling during the practice sections. Questions were answered during this period, and learning points from the video were re-emphasized. Next, learners participated in a 15-minute 3-station OSCE, which included 3 descriptive clinical vignettes alongside pairs of hand models with simulated joint swelling representative of the pattern or distribution in 3 types of inflammatory arthritis (Appendix D; see Appendix B). Clinical vignettes were developed by curriculum creators to describe symptoms specific to rheumatoid arthritis, systemic lupus erythematosus, and psoriatic arthritis. Learners used worksheets (Appendix E) to mark areas of small joint swelling at each of the 3 stations.¹⁷ Residents were not timed at the stations, but learners generally took less than 5 minutes at each station. As learners were examining the models in the OSCE, facilitators used a 5-point global rating scale (Appendix F) to grade the learners on their hand exam performance. After learners were finished with all 3 stations, they were asked to complete a short electronic survey regarding their confidence levels in performing the hand exam, in assessing joint swelling, and on the effectiveness and relevance of the workshop to clinical practice (Appendix G). Facilitators then graded the learners’ performance using a key and scorecard (Appendix H).

Following the workshop and evaluation survey, learners applied these physical examination skills during their rheumatology electives, assessing for swelling in the small joints of the hands of patients seen in clinical encounters. Learners’ performance in the OSCE as evaluated by facilitators via the global rating scale was described as the mean and standard deviation. Survey results were described as counts and percentages, and results from survey items querying confidence before and after the workshop were analyzed with the Wilcoxon signed rank test. All analyses were performed in SAS 9.4 (SAS Institute Inc., Cary, NC, USA).

Results

All 36 IM residents in the rheumatology rotation completed the workshop and survey (100% response rate). Facilitators’ evaluations of the participants’ performance in the OSCE revealed a mean global rating score of 4.67 (SD = 0.65), indicating a high level of competence with few errors.

Results from the postworkshop survey revealed that residents’ self-reported confidence in both performing the hand exam and assessing joint swelling increased after taking the workshop (Table 1; P < .001).

Table 1. Postworkshop Survey Results Exploring Learner Confidence in Performing the Hand Examination and Assessment of Small Joint Swelling (N = 36).

Whereas 28 learners (77.7%) reported lacking confidence in both skills before the workshop, almost all learners reported being confident or very confident in performing the hand exam (n = 35 [97.2%]) and in assessing joint swelling (n = 34 [94.4%]) after the workshop. In addition, all learners (100%) reported that they would likely or very likely incorporate skills learned during the workshop to evaluate a patient with hand pain (Table 2).

Table 2. Postworkshop Survey Results Exploring Learner Evaluation of the Hand Examination Workshop (N = 36).

In addition, 97.2% reported that the workshop was effective or very effective for learning how to perform the hand examination. Subjective feedback in the survey included comments about how participants enjoyed the workshop. Notably, individuals specifically commented that the instructional video and use of the hand model together were very effective. One participant noted: “[It was a] very good workshop. [I] thought the progression from video to model to patient was fantastic and all done in a very timely manner.” Constructive comments were also provided, including a suggestion that discussing the physical exam patterns in specific rheumatic conditions during the workshop would be beneficial and that the audio during the video could be improved.

Discussion

Our streamlined workshop for learning the hand examination, which included easy-to-make 3-dimensional simulated hand models of inflammatory arthritis, was well received by residents completing a rheumatology rotation. Evaluation by experienced rheumatologists revealed that residents performed with high quality during an OSCE, in which they performed the hand exam on hand models simulating 3 forms of inflammatory arthritis. Importantly, learners reported that their confidence in performing the hand exam and identifying swollen joints was substantially higher after taking the workshop. In addition, participants reported that they would apply their new skills within their clinical practice. Overall, our curriculum is a rapid, low-cost, and feasible training program that can be easily modified and adapted to meet different educational needs.

Physical examination skills are included in the Accreditation Council of Graduate Medical Education milestones because effective physical exams are crucial for accurate, timely diagnoses and optimal patient outcomes.¹⁸ Our workshop provides essential training in a physical exam technique that is rarely taught, offering instruction that complements traditional cardiac and pulmonary exam skills. In particular, there is a great need for generalists to be highly skilled in performing musculoskeletal physical exams, as most patients with hand pain are initially evaluated by primary care providers and internists, especially in the setting of the anticipated rheumatology workforce shortage.¹⁹ Therefore, avoiding misdiagnoses and preventing delays in treatment greatly depend on the ability of the generalist to differentiate inflammatory from noninflammatory arthritis. The trainees who participated in our workshop will serve as future internists and primary care providers, and refining hand exam skills during early career training may be a particularly effective strategy because skills obtained during residency are often retained many years after training.²⁰

We selected 3 different forms of inflammatory arthritis for our workshop because they are common causes of hand pain that share some key physical features; however, the curriculum is easily adaptable to different disease processes and educational objectives by increasing vignette complexity—for example, incorporating vital signs, laboratory results, or other clinical details. Our video for the hand exam was concise, with a length of under 3 minutes, which improves learner engagment.²¹ The learning goals of our workshop aligned with the capacity of the hand models; therefore, this curriculum did not discuss other topics related to inflammatory arthritis, including distribution of joint involvement for other types of inflammatory arthritis. To augment our curriculum, we have included some foundational rheumatology concepts in the appendices for facilitators who may not have rheumatology expertise. The curriculum is best utilized as an introduction to the rheumatologic hand physical examination with opportunities to scaffold the material in the clinical environment.

Our curriculum leveraged experiential learning theory by first introducing the hand exam with an instructional video, then providing a live demonstration with time for hands-on simulation practice and finally assessing learners through a 3-station OSCE. A key benefit of the hand model simulation approach is that it provides a safe space for trainees to repeatedly practice palpation on simulated hand models, which avoids the hesitancy that trainees may experience in the clinic with patients who can feel pain during the exam. Additionally, our workshop included an opportunity for learners to reflect on their performance.

We conducted our workshop during IM residents’ rheumatology rotation with the aim of helping trainees learn skills that they could apply with more confidence during patient encounters after having practiced in a safe environment and having received immediate formative feedback. Although there were no patient encounters during the workshop, learners appreciated the placement of the workshop during a rheumatology rotation for which they could apply the learned skills immediately during patient encounters and receive formative feedback. Overall, the timing of the workshop within the rheumatology rotation allowed for scaffolding of the hand examination skill.

Our simulation workshop involved a combination of traditional didactics and a hands-on OSCE, but most importantly, it focused on identifying inflammation in the hand. Programs for teaching musculoskeletal exam techniques typically cover a range of anatomic sites, which may not provide enough depth or nuance for students to learn the more subtle aspects unique to assessing different joints. To the best of our knowledge, our workshop is the first to focus specifically on the hand examination, and, considering the serious impact of hand pain on quality of life and the complex anatomy of the hand, we recommend that courses designed to teach musculoskeletal exam skills include targeted content on the hand. Many early learners could benefit from this curriculum, including medical students, IM residents, and rheumatology fellows who are early in their training, with the goal of learning the mechanics and rudimentary interpretation of the swollen hand joint examination. This workshop can also be used to teach residents in specialties beyond IM, such as family medicine, physical medicine and rehabilitation, hand plastic surgery, and orthopedics. Moreover, our curriculum is accessible to programs with limited resources, given the low cost of the model and the accessibility of the curriculum.

We chose to use the low-fidelity hand model featured in our curriculum because it is inexpensive, easy to create, and the only published model with sufficient validity evidence. However, the model's limitations had some effects on our curriculum. For instance, the Playfoam hardens over time and may require replacement. The hand models do not have external anatomic landmarks to help locate the joint spaces, and we have included possible adaptations to add joint space markings (see Appendix B). The model does not convey advanced features, such as joints with range of motion, simulation of warmth or skin changes, or feedback mechanisms for identifying the anatomic locations of joint lines or applying the right amount of pressure during the examination. As a result, our curriculum is limited to assessing swelling without these other features that coexist in inflammatory arthritis; therefore, our outcome measures should be interpreted in that context. The models are best suited for novice learners who are beginning to develop their skills rather than advanced learners practicing nuanced physical examinations. The models are not ideal for advanced learners given the model's lower predictive validity; its simplicity does not allow for advanced skill transfer.¹⁷

Limitations of our study include a modest number of participants at 2 sites, which limits generalizability. We did not include a traditional cohort to compare outcomes, nor did we measure confidence or global rating scales months after the curriculum to measure retention of confidence and skills in the clinical environment, which should be investigated. It is possible that learners experienced a perceived increase in confidence, as we surveyed them before they had the opportunity to examine patients in the clinical environment after the workshop. Although we evaluated changes in learner confidence, we did not evaluate changes in clinical decision-making or clinical outcomes, which should be explored to determine whether skills acquired in the classroom translate into meaningful effectiveness in real-world clinical practice. In the future, we plan to review medical documentation, time to diagnosis, and time to a rheumatology referral. Lastly, our workshop did not evaluate participants’ diagnostic skills in differentiating the 3 types of inflammatory arthritis; however, this was not the objective of this specific study, and we may create simulation models to explore diagnostic skills in the future.

In the future, we will adapt the educational content to include models representing findings in osteoarthritis, such as Heberden's or Bouchard's nodes. Other possible rheumatological conditions with unique physical characteristics, such swan neck deformities, tophaceous gout, and dactylitis, may also be taught with simulated hand models with their complementary curricula. Teaching hand examination skills with simulation models allows experiential learning in a safe environment, and it is our hope that our targeted approach can be adapted for other important physical exam concepts in rheumatology.

Funding Statement

None to report.