Outcomes of a health coaching intervention delivered by medical students for older adults with uncontrolled type 2 diabetes.

Effective strategies are needed to address the health behaviors of older patients with diabetes. One approach is health coaching, the practice of health education and health promotion through a structured partnership designed to enhance well-being and facilitate the achievement of individuals' health-related goals. The aim of this study was to describe the development of a pilot health coaching curriculum, investigate its effects on geriatric patient outcomes, and examine qualitative feedback by older patients and medical students to the curriculum. This mixed-methods study involved 29 first-year medical students randomly paired with 29 older adults with uncontrolled Type 2 diabetes. Health-related quality of life (HRQoL), stage of change movement, diabetes knowledge, locus of control, Body Mass Index (BMI), and glycosylated hemoglobin (HbA1c) were assessed. Focus groups were used to evaluate patients' and medical students' experiences. Results showed significant increases in patients' HRQoL and stage of change for exercise improved significantly over time. There were no significant changes in stage of change for healthy diet and medication, diabetes knowledge, BMI, and HbA1c from baseline to end of study. Focus group data indicated positive responses by older patients and the medical students. A health coaching curriculum may improve patient outcomes and can provide medical students the skills needed to provide compassionate care for geriatric patients.

Best practices in teaching echocardiography to cardiology fellows: a review of the evidence.

BACKGROUND: Best practices in the teaching of performance and interpretation of echocardiography to cardiology fellows are unknown, and thus, it has traditionally been performed through an apprenticeship model. This review summarizes the existing literature describing evidence-based teaching of echocardiography. METHODS: A comprehensive search of multiple scientific and educational databases included prospective studies describing an educational intervention for teaching echocardiography to physicians. A total of 288 articles were retrieved, and 10 articles were included in our review. The Medical Education Research Study Quality Instrument (MERSQI), a validated rubric designed to measure the methodological quality of educational research, was used to assign a comprehensive score to each paper. RESULTS: The articles were categorized by educational themes as follows: focused curriculum-based training, simulation, and assessment of competency. Individual study MERSQI scores varied from 8 to 13 (mean 10.55) on a scale of 18 points. The distribution of each group's median score (focused curriculum-based training 11.64; simulation 12.92; assessment of competency 9.39) was analyzed using boxplots with a 95% confidence interval. The median MERSQI score for the assessment of competency group was significantly lower than the others. CONCLUSIONS: A review of the data exploring best practices in teaching echocardiography shows only limited effects describing the curricular and assessment components of an overall educational system, rather than one-on-one clinical teaching. Future papers should explore application of point-of-care teaching and the impact of interventions on patient outcomes.

Pediatric trainees' engagement in the online nutrition curriculum: preliminary results.

BACKGROUND: The Pediatric Nutrition Series (PNS) consists of ten online, interactive modules and supplementary educational materials that have utilized web-based multimedia technologies to offer nutrition education for pediatric trainees and practicing physicians. The purpose of the study was to evaluate pediatric trainees' engagement, knowledge acquisition, and satisfaction with nutrition modules delivered online in interactive and non-interactive formats. METHODS: From December 2010 through August 2011, pediatric trainees from seventy-three (73) different U.S. programs completed online nutrition modules designed to develop residents' knowledge of counseling around and management of nutritional issues in children. Data were analyzed using SPSS version 19. Both descriptive and inferential statistics were used in comparing interactive versus non-interactive modules. Pretest/posttest and module evaluations measured knowledge acquisition and satisfaction. RESULTS: Three hundred and twenty-two (322) pediatric trainees completed one or more of six modules for a total of four hundred and forty-two (442) accessions. All trainees who completed at least one module were included in the study. Two-way analyses of variance (ANOVA) with repeated measures (pre/posttest by interactive/non-interactive format) indicated significant knowledge gains from pretest to posttest (p < 0.002 for all six modules). Comparisons between interactive and non-interactive formats for Module 1 (N = 85 interactive, N = 95 non-interactive) and Module 5 (N = 5 interactive, N = 16 non-interactive) indicated a parallel improvement from the pretest to posttest, with the interactive format significantly higher than the non-interactive modules (p < .05). Both qualitative and quantitative data from module evaluations demonstrated that satisfaction with modules was high. However, there were lower ratings for whether learning objectives were met with Module 6 (p < 0.03) and lecturer rating (p < 0.004) compared to Module 1. Qualitative data also showed that completion of the interactive modules resulted in higher resident satisfaction. CONCLUSIONS: This initial assessment of the PNS modules shows that technology-mediated delivery of a nutrition curriculum in residency programs has great potential for providing rich learning environments for trainees while maintaining a high level of participant satisfaction.

Porcine wet lab improves surgical skills in third year medical students.

BACKGROUND: Medical students desire to become proficient in surgical techniques and believe their acquisition is important. However, the operating room is a challenging learning environment. Small group procedural workshops can improve confidence, participation, and performance. The use of fresh animal tissues has been rated highly among students and improves their surgical technique. Greater exposure to surgical procedures and staff could positively influence students' interest in surgical careers. We hypothesized that a porcine "wet lab" course for third year medical students would improve their surgical skills. METHODS: Two skills labs were conducted for third year medical students during surgery clerkships in the fall of 2011. The students' surgical skills were first evaluated in the operating room across nine dimensions. Next, the students performed the following procedures during the skills lab: (1) laparotomy; (2) small bowel resection; (3) splenectomy; (4) partial hepatectomy; (5) cholecystectomy; (6) interrupted abdominal wall closure; (7) running abdominal wall closure; and (8) skin closure. After the skills lab, the students were re-evaluated in the operating room across the same nine dimensions. Student feedback was also recorded. Fifty-one participants provided pre- and post-lab data for use in the final analysis. RESULTS: The mean scores for all nine surgical skills improved significantly after participation in the skills lab (P ≤ 0.002). Cumulative post-test scores also showed significant improvement (P = 0.002). Finally, the student feedback was largely positive. CONCLUSIONS: The surgical skills of third year medical students improved significantly after participation in a porcine wet lab, and the students rated the experience as highly educational. Integration into the surgery clerkship curriculum would promote surgical skill proficiency and could elicit interest in surgical careers.

A tiered mentorship program improves number of students with an identified mentor.

BACKGROUND: Mentorship is critical to professional development and academic success. Unfortunately, only about 40% of medical students can identify a mentor. While group mentorship has been evaluated - the concept of a specialty specific, tiered group mentorship program (TGMP) has not. In the latter, each member of the group represents a unique education or professional level. PURPOSE: The purpose of this study was to investigate the ability of a specialty-specific, tiered group mentorship program to improve mentorship for students interested in emergency medicine. METHODS: Groups consisted of faculty members, residents, 4th-year students pursuing a career in Emergency Medicine, and junior (MS1, MS2, and MS3) medical students (13 total groups). Students completed confidential electronic surveys before and after completion of the program. RESULTS: Of 126 students, 85 completed the Course Evaluation Survey. At program onset, 11.4% of 1st-year students, 41.7% of 2nd-year students, 50% of 3rd-year students, and 28% of the total students could identify a mentor. After completion, 68.6% of 1st years, 83.3% of 2nd years, 90% of 3rd years, and 77.6% of the total reported they could identify a mentor. Faculty were rated most important members followed by the 4th-year student. CONCLUSION: A tiered group mentorship program improved the ability of students to identify a mentor. Students identified mentoring relationships from individuals at various professional levels.

How we use social media to supplement a novel curriculum in medical education.

BACKGROUND: The millennial learner is reliant on technology to gain knowledge. Social media in the form of Twitter and Facebook provide a unique way to reach these learners. AIMS: To demonstrate a supplement to a curriculum using "push technology" via Twitter and Facebook to deliver educational content to mobile devices. METHODS: A curriculum consisting of high-yield ultrasound concepts was developed and posted to Twitter @EDUltrasound daily. Followers received tweets "pushed" directly to their mobile devices. Following the year-long program, followers were surveyed regarding the program's effectiveness. To determine the ways in which tweets were reaching users, followers were categorized demographically. RESULTS: Daily "tweets" were posted each morning beginning on July 1, 2010. By the end of the year, there were 87 followers on Twitter and 78 on Facebook. The majority of followers (55.6%) had not previously used Twitter. The majority of followers (88.9%) found Twitter user-friendly, while most (81.5%) found the information useful. CONCLUSIONS: Due to ease of use and widespread applicability, Twitter and Facebook are excellent applications of "push technology" as a means to deliver educational content. This pilot project demonstrates the potential of social media to both supplement and enhance traditional educational methods.

The cognitive behavior survey: testing for factorial validity and time invariance across two years of medical school.

BACKGROUND: The Cognitive Behavior Survey (CBS) assesses learner behavior in healthcare-related fields. PURPOSE: The study aims were to evaluate the factorial validity of the CBS, which purports to measure three dimensions of learner behavior--conceptualization, reflection, and memorization--and propose and test an alternative model including its time invariance. METHODS: The CBS was administered to 3 cohorts of medical students upon matriculation and at the end of their 1st and 2nd year. RESULTS: Confirmatory factor analysis (CFA) did not support the original CBS model. Exploratory factor analysis (EFA) with an independent sample provided a new model. Retesting the EFA model using CFA with the original sample yielded a model with improved fit and time invariance. CONCLUSIONS: This study provides evidence for the original CBS 3-factor structure but requires alternative scoring for a time-invariant model.

Brightness mode quality ultrasound imaging examination technique (B-QUIET): quantifying quality in ultrasound imaging.

OBJECTIVES: Ultrasound image interpretation and education relies on obtaining a high-quality ultrasound image; however, no literature exists to date attempting to define a high-quality ultrasound image. The purpose of this study was to design and perform a pilot reliability study of the Brightness Mode Quality Ultrasound Imaging Examination Technique (B-QUIET) method for ultrasound quality image assessment. METHODS: A single sonologist performed a Trinity hypotensive ultrasound protocol on 3 participants of varying body types. Each participant's ultrasound examination was repeated in 4 locations; static clinic location, mobile ambulance, airplane, and helicopter. Images were reviewed by a sonographer, radiologist, and emergency medicine physician using the B-QUIET method and underwent statistical analysis using generalizability theory for reliability of the assessments using the tool. RESULTS: The B-QUIET method showed high reliability of most subscale items. Approximately two-thirds of the reviewed images had complete inter-rater reliability on 90% of the items. There was relatively low inter-rater reliability for the Identification/ Orientation subscale items. The inter-rater reliability κ value was calculated as 0.676 overall for the method. CONCLUSIONS: The need for a standardized method to evaluate the quality of an ultrasound image is well documented. The B-QUIET method represents the first attempt to quantify the sonographer component of ultrasound images. Further reliability and validation studies of this method will be needed; however, it represents a tool for standardized ultrasound interpretation, ultrasound training, and institutional quality assessment.

Managing antidepressants in primary care: physicians' treatment modifications.

To examine antidepressant management practices in primary care, patients (N = 148) given an antidepressant for at least one month completed the Beck Depression Inventory (BDI-II), the Patient Health Questionnaire-9 (PHQ-9), and a demographic survey. Participants' mean age was 50.7 yr. and 80% were women. Patients' charts indicated whether physicians had made changes to prescribed antidepressants or dose either 6 wk. before or 6 wk. after study entry. For the 87% of participants whose depression status could be determined, 10% met dysthymic disorder criteria and only 33% had had a medication change in the previous month. Major depressive disorder occurred in 37% but only 18% had had a medication change. Co-existing dysthymic disorder and major depressive disorder were diagnosed in 34%, with 24% receiving a medication change. Participants not receiving a medication change had mean BDI-II scores indicating moderate depression. Lack of antidepressant adjustment suggests physicians may need to monitor depressive symptoms closely using protocols and prompts.

Impact of clinical pathway on quality of care in sickle cell patients.

Clinical pathways are disease specific and are designed to standardize care. They are intended to serve the purpose of improving quality of care and decreasing healthcare and societal costs. A retrospective cross-sectional study was conducted comparing sickle cell patients admitted to Mercy Children's Hospital (MCH) from June 1999 to November 2001 before the implementation of the clinical care pathway (n=66), to a similar group of patients admitted from December 2001 to July 2004 after pathway (n=121) implementation. The χ2 tests were used to compare categoric variables and independent t-tests for continuous variables. The results indicate improvement in compliance postpathway with specific care elements: incentive spirometry, pulse oximetry, ordering comfort measures, right dosage of pain medications, and achieving excellent nursing compliance in documenting pain scores. There was a significant decrease in the number of blood transfusions in postpathway patients. Though limited by sample size, the results suggest that clinical pathways are good tools for standardization of care in certain care elements and help to improve quality of care in sickle cell patients.

Coherence between physician diagnosis and patient self reports of anxiety and depression in primary care.

Mood and anxiety disorders complicate the care of patients with physical illness and pose challenges for primary care physicians. This study explored the coherence between a screening tool (PRIME-MD), a standardized questionnaire (Eysenck Personality Inventory), and physician diagnoses of anxiety and depression. Of 165 patients, 29% had diagnoses of depression, 21% had anxiety, and 59% had no mental health diagnosis. Patients who were younger, female, divorced/widowed, or unemployed with minimal education had highest prevalence of anxiety or depression. Scores on the self-report inventories were significantly higher in patients with physician-diagnosed anxiety or depression compared with those without these diagnoses. Medical use and chronic illness were highest in patients with anxiety or depression diagnoses. Despite the statistical agreement between the self-report inventories and physician diagnosis, the coherence among these measures was less than optimal. Use of self report tools is recommended to complement physician understanding of patient symptom description and management of anxiety and depression in primary care.

Methods of teaching and evaluating electrocardiogram interpretation skills among cardiology fellowship programs in the United States.

BACKGROUND: This study examines the methods used by cardiology training programs within the United States to teach electrocardiogram (ECG) interpretation and prepare fellows for the American Board of Internal Medicine board examination. METHODS: A link to an 18-question Web-based survey was electronically mailed to 198 fellowship directors in the United States. RESULTS: The response rate was 45%. Most participating programs were university hospitals or affiliates (77%) and of moderate size (at least 11 total fellows [72%]). Programs were coordinated by senior (68%) general (60%) cardiologists. Only 42% of the programs performed formal testing. The American Board of Internal Medicine answer sheet was used by most faculty (92%) when teaching ECG interpretation. CONCLUSIONS: Teaching of ECG interpretation varies among US fellowship programs. Coordination of curricula is performed by senior faculty, likely reflecting a trend toward subspecialization and dilution of ECG expertise among younger faculty. Future endeavors should focus on curriculum standardization with regular competency assessment.

The patient-physician relationship and medical utilization.

OBJECTIVE: The goal of this study was to (1) explore the relationship between medical utilization and characteristics of the patient-physician relationship and (2) evaluate the relationship between physician perception of patient difficulty, chronic medical problems, and patient somatizing tendencies. METHOD: Patients in an academic family practice center were asked to complete a demographic data sheet, the PRIME-MD Patient Questionnaire, and the Barrett-Lennard Relationship Inventory regarding their relationship with their physicians. Their physicians completed the Difficult Doctor-Patient Relationship Questionnaire. Patient charts were examined for number of office visits and phone calls in the previous year, as well as number of chronic problems and medications. The study was conducted from September 2000 to November 2001. RESULTS: Forms were completed by 165 patients and 20 physicians. Forty-three patients who were approached refused to participate. Patient ratings on the Barrett-Lennard Relationship Inventory were not related to utilization measures. Physician ratings of difficulty were significantly related to phone calls and visits (p < .05), as well as PRIME-MD Patient Questionnaire somatization tendencies (p < .05) but not to number of chronic problems. Patient and physician ratings were not significantly correlated. Gender (p < .001), marital status (p < .04), education (p < .03), and employment status (p < .002) were all related to utilization measures. CONCLUSION: Medical utilization was associated with somatizing tendencies of patients and the physicians' perception of patient difficulty. Physicians rated patients as difficult if they tended to somatize but not if they had a number of chronic problems.

Does emotional intelligence predict breaking bad news skills in pediatric interns? A pilot study.

BACKGROUND: While both patients and physicians identify communication of bad news as an area of great challenge, the factors underlying this often complex task remain largely unknown. Emotional intelligence (EI) has been positively correlated with good general communication skills and successful leadership, but there is no literature relating EI to the delivery of bad news. PURPOSE: Our objectives were to determine: 1) performance of first-year pediatric residents in the delivery of bad news in a standardized patient (SP) setting; and 2) the role of EI in these assessments. Our hypothesis was that pediatric trainees with higher EI would demonstrate more advanced skills in this communication task. METHODS: Forty first-year residents participated. Skill in bad news delivery was assessed via SP encounters using a previously published assessment tool (GRIEV_ING Death Notification Protocol). Residents completed the Emotional and Social Competency Inventory (ESCI) as a measure of EI. RESULTS: Residents scored poorly on bad news delivery skills but scored well on EI. Intraclass correlation coefficients indicated moderate to substantial inter-rater reliability among raters using the delivering bad news assessment tool. However, no correlation was found between bad news delivery performance and EI. CONCLUSIONS: We concluded that first-year pediatric residents have inadequate skills in the delivery of bad news. In addition, our data suggest that higher EI alone is not sufficient to effectively deliver death news and more robust skill training is necessary for residents to gain competence and acquire mastery in this important communication domain.

Breaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention.

OBJECTIVE: Patients and physicians identify communication of bad news as a skill in need of improvement. Our objectives were to measure change in performance of first-year pediatric residents in the delivery of bad news after an educational intervention and to measure if changes in performance were sustained over time. METHODS: Communication skills of 29 residents were assessed via videotaped standardized patient (SP) encounters at 3 time points: baseline, immediately post-intervention, and 3 months post-intervention. Educational intervention used was the previously published "GRIEV_ING Death Notification Protocol." RESULTS: The intraclass correlation coefficient demonstrated substantial inter-rater agreement with the assessment tool. Performance scores significantly improved from baseline to immediate post-intervention. Performance at 3 months post-intervention showed no change in two subscales and small improvement in one subscale. CONCLUSIONS: We concluded that breaking bad news is a complex and teachable skill that can be developed in pediatric residents. Improvement was sustained over time, indicating the utility of this educational intervention. PRACTICE IMPLICATIONS: This study brings attention to the need for improved communication training, and the feasibility of an education intervention in a large training program. Further work in development of comprehensive communication curricula is necessary in pediatric graduate medical education programs.

Virtual alternative to the oral examination for emergency medicine residents.

INTRODUCTION: The oral examination is a traditional method for assessing the developing physician's medical knowledge, clinical reasoning and interpersonal skills. The typical oral examination is a face-to-face encounter in which examiners quiz examinees on how they would confront a patient case. The advantage of the oral exam is that the examiner can adapt questions to the examinee's response. The disadvantage is the potential for examiner bias and intimidation. Computer-based virtual simulation technology has been widely used in the gaming industry. We wondered whether virtual simulation could serve as a practical format for delivery of an oral examination. For this project, we compared the attitudes and performance of emergency medicine (EM) residents who took our traditional oral exam to those who took the exam using virtual simulation. METHODS: EM residents (n=35) were randomized to a traditional oral examination format (n=17) or a simulated virtual examination format (n=18) conducted within an immersive learning environment, Second Life (SL). Proctors scored residents using the American Board of Emergency Medicine oral examination assessment instruments, which included execution of critical actions and ratings on eight competency categories (1-8 scale). Study participants were also surveyed about their oral examination experience. RESULTS: We observed no differences between virtual and traditional groups on critical action scores or scores on eight competency categories. However, we noted moderate effect sizes favoring the Second Life group on the clinical competence score. Examinees from both groups thought that their assessment was realistic, fair, objective, and efficient. Examinees from the virtual group reported a preference for the virtual format and felt that the format was less intimidating. CONCLUSION: The virtual simulated oral examination was shown to be a feasible alternative to the traditional oral examination format for assessing EM residents. Virtual environments for oral examinations should continue to be explored, particularly since they offer an inexpensive, more comfortable, yet equally rigorous alternative.

Somatization in Family Practice: Comparing 5 Methods of Classification.

BACKGROUND: It has been suggested that patients with somatoform disorders are high utilizers of medical care, yet interpretation of studies has been difficult because of variant methods of diagnosis. The goal of this study was to compare 5 different methods of classification on the same group of subjects and to examine prevalence rates of somatoform disorders and medical utilization. METHOD: Subjects completed a demographic questionnaire in the physician's office and the somatization section of the Diagnostic Interview Schedule (DIS) by telephone. Subsequently, their medical charts were examined. Using the 5 methods of diagnosis, somatizers were compared with nonsomatizers for level of utilization of medical services. The setting was a medical school-based family practice residency training center. Participants were 119 patients waiting to see their family doctors. The main outcome measures were prevalence of somatization symptoms and chart information (utilization, number of health problems). RESULTS: One subject met the Diagnostic and Statistical Manual (DSM-IV)-based DIS criteria for somatization disorder. With the Bucholz modification for scoring the DIS, 10 subjects were diagnosed with somatization disorder. With the abridged Escobar criteria of 6 symptoms, 7 subjects met diagnostic criteria, while 28 met the criteria for multisomatoform disorder of 3 symptoms, as suggested by Kroenke. The diagnosis of undifferentiated somatoform disorder, requiring only 1 unexplained symptom, was obtained by 94 of the subjects. CONCLUSION: Findings from this study revealed widely divergent prevalence rates of somatoform disorders, depending on methods of diagnosis used. Correlation with rates of medical utilization is suggested as an external criterion for validating diagnostic methods.

Patient-Physician Relationship and Service Utilization: Preliminary Findings.

BACKGROUND: Difficult physician-patient encounters pose a challenge in all aspects of health care. Characteristics of both physicians and patients affect the office encounter and utilization of services. The objectives of this study were to explore the impact of patients' characteristics and the patient-physician relationship on service utilization. METHOD: A sample of 22 family practice patients and their physicians completed questionnaires prior to and/or after an office visit. Chart review yielded demographic information and history. The number of office visits and phone calls were obtained from billing records. RESULTS: The number of patient-reported physical problems was correlated with negative affect (r = 0.63, p <.002), the number of phone calls to the office (r = 0.52, p <.02), and the difficulty of the encounter as perceived by the physician (r = 0.58, p <.005). The number of phone calls also correlated with the number of life events (r = 0.43, p <.05) and the patient's perception of the physician's warmth (r = 0.48, p <.03) and understanding (r = 0.44, p <.04). CONCLUSION: Life stress, negative affect, physical complaints, and the patients' perception of their physician impact utilization. Armed with information about patient characteristics prior to the office visit, the physician can increase efficiency and facilitate a more productive encounter.

Telephone-based treatment for family practice patients with mild depression.

The need for treating milder forms of depression has recently been of increased interest. This was a randomized, controlled study to evaluate the effects of telephone-based problem-solving therapy for mild depression. Comparison groups were a treatment-as-usual group and another group receiving stress-management training by telephone. From 1,742 family practice patients screened for depression, 54 with mild depression entered the study. Treatment was provided by experienced family practice nurses, trained and supervised in the treatments. The Hamilton Rating Scale for Depression was administered before and after the intervention period, and the Beck Depression Inventory and Duke Health Profile were administered at the end of the intervention period. Of the 36 subjects assigned to the problem-solving and stress-management groups, half dropped out early in the study. Five from the treatment-as-usual group were lost to follow-up. In the remaining subjects, there was a significant decrease in depression scores. There were no significant differences in the amount of decrease between the groups on any scores. The small sample and high dropout rate limit the interpretation of the findings. However, since all subjects tended to improve, regardless of treatment received, mild levels of depression may generally remit even without focal intervention, and watchful waiting may be a reasonable alternative for management.

Development and validation of a musculoskeletal physical examination decision-making test for medical students.

OBJECTIVE: Despite a renewed emphasis among educators, musculoskeletal education is still lacking in medical school and residency training programs. We created a musculoskeletal multiple-choice physical examination decision-making test to assess competency and physical examination knowledge of our trainees. DESIGN: We developed a 20-question test in musculoskeletal physical examination decision-making test with content that most medical students and orthopedic residents should know. All questions were reviewed by ratings of US orthopedic chairmen. It was administered to postgraduate year 2 to 5 orthopedic residents and 2 groups of medical students: 1 group immediately after their 3-week musculoskeletal course and the other 1 year after the musculoskeletal course completion. We hypothesized that residents would score highest, medical students 1 year post-musculoskeletal training lowest, and students immediately post-musculoskeletal training midrange. We administered an established cognitive knowledge test to compare student knowledge base as we expected the scores to correlate. SETTING: Academic medical center in the Midwestern United States. PARTICIPANTS: Orthopedic residents, chairmen, and medical students. RESULTS: Fifty-four orthopedic chairmen (54 of 110 or 49%) responded to our survey, rating a mean overall question importance of 7.12 (0 = Not Important; 5 = Important; 10 = Very Important). Mean physical examination decision-making scores were 89% for residents, 77% for immediate post-musculoskeletal trained medical students, and 59% 1 year post-musculoskeletal trained medical students (F = 42.07, p<0.001). The physical examination decision-making test was found to be internally consistent (Kuder-Richardson Formula 20 = 0.69). The musculoskeletal cognitive knowledge test was 78% for immediate post-musculoskeletal trained students and 71% for the 1 year post-musculoskeletal trained students. The student physical examination and cognitive knowledge scores were correlated (r = 0.54, p<0.001), but were not significantly different for either class. CONCLUSIONS: The physical examination decision-making test was found to be internally consistent in exposing the deficiencies of musculoskeletal education skills of our medical students and differentiated between ability levels in musculoskeletal physical examination decision-making (residents vs recently instructed musculoskeletal students vs 1 year post-musculoskeletal instruction).