Faculty and resident Perceptions about Teaching and Learning the Pediatric Musculoskeletal Examination

Background: The purpose of this research project is to explore how we currently teach the musculoskeletal exam to Pediatric residents and how they experience the acquisition of this set of skills. Many diseases in Pediatric Rheumatology are diagnosed based on the clinical exam, and we rely on these future Pediatricians to identify children who require the assessment of a subspecialist. Unfortunately, despite our efforts in teaching the musculoskeletal exam, many Pediatric patients will have significant functional limitations identified on their first visit to a Pediatric Rheumatologist due to delays in recognition of their inflammatory joint disease. The manner in which the Pediatric musculoskeletal is taught and learned may be at the root of the problem. Method: A qualitative study designed to investigate and describe the experiences of teachers and learners of the Pediatric musculoskeletal exam in a single tertiary care centre was conducted. The study population consisted of a purposeful sample of Pediatric Rheumatology teaching faculty and General Pediatric residents at the Hospital for Sick Children who have completed their Pediatric Rheumatology rotation. Semi-structured individual interviews of approximately one-hour duration were conducted in-person with each participant. Interviews were transcribed verbatim, and were analyzed on a rolling basis, using a constant comparative method of analysis associated with grounded theory. Results: Twenty two (22) interviews were conducted, with 7 General Pediatric junior residents, 7 senior residents, and 8 Pediatric Rheumatology faculty. As themes were formulated, Bandura’s social cognitive learning theory served as a framework to illuminate and interpret our findings. In particular, Bandura’s description of the process of self-regulated learning provided deeper understanding of issues raised by participants including the onus for successful learning falling to the learner; self-monitoring behavior and the disconnect between motor skills and clinical interpretation; the role of the joint count and hidden curriculum surrounding this issue; and diminishing skill and confidence with lack of practice in subsequent rotations. Conclusions: Themes identified illustrate multiple perceived strengths and weaknesses in how the musculoskeletal examination is taught to General Pediatric residents. The factors that facilitate learning the musculoskeletal examination may be used to inform future curriculum development.