A Comprehensive and Modality Diverse Cervical Spine and Back Musculoskeletal Physical Exam Curriculum for Medical Students.

AUDIENCE

The target audience for this small group session focused on the cervical spine and back musculoskeletal physical exam is medical students of all levels, although it is most useful for those early in their career such as first- and second-year medical students. These videos can also be used for other health care professionals such as physicians, physician associates, nurses, or nurse practitioners learning or refreshing their physical exam skills.

INTRODUCTION

The physical exam (PE) is one of the core components of a physician's toolkit and learning to perform the neck and back exam is important. When done correctly, physical exams are a useful tool in evaluating patients and in creating a differential diagnosis. This is especially true for many patient concerns such as neck and back pain and in specialties such as neurology where diagnoses may be established using empiric observation by trained clinicians.1Beginning in 2019, the University of California, Irvine, School of Medicine (UCISOM) revised the physical exam portion of the Clinical Foundations (CF; "doctoring" course) which serves as a four-year longitudinal course for UCISOM students to learn, practice, and improve their history-taking, physical exam, differential diagnosis, and physicianship skills. Focusing on the PE component of the curriculum, a team of physicians reviewed the materials utilized to teach all PE sessions, and these videos specifically, the cervical spine and back musculoskeletal PE for the first- and second-year students. These materials included book chapters and third-party videos; additionally, student and physician feedback were reviewed. Previous student feedback felt that the third-party videos were not engaging and too long (run length per video was upwards of 60 minutes), and students requested videos with slightly more detail for future clinical exams. Utilizing the UCISOM clinical faculty and standardized patients (SP), a team of physician educators and students researched PE best practices for the cervical spine and back musculoskeletal physical exam and developed new video scripts and slides, and ultimately filmed, edited, and produced a series of eight videos demonstrating the cervical and back musculoskeletal PE maneuvers. These videos were one part of a series of fifty-six PE videos developed for learners of a comprehensive physical exam. Other portions of the series focus on vital signs, the cardiovascular exam, pulmonary exam, gastrointestinal exam, neurological exam, head, eyes, ears, nose and throat, and upper and lower extremity exams.

EDUCATIONAL OBJECTIVES

By the end of this session, students will be able to: 1) demonstrate how to properly perform a cervical spine and back physical exam, 2) understand the reasoning behind cervical spine and back PE maneuvers, 3) identify the proper technique and equipment to use for the cervical spine and back PE, 4) understand normal and abnormal findings in the cervical spine and back PE, 5) accurately record and report exam findings for the cervical spine and back PE.

EDUCATIONAL METHODS

The first-year medical student physical exam small group sessions used a flipped classroom model with the videos serving as a learning resource center (LRC) followed by an in-person, hands-on PE session with standardized patients (SP) led by a Dean's Scholar.Prior to the in-person session, the students were required to watch, at minimum, the English cervical spine and back "Full Video" physical exam. Bilingual Spanish speaking students in the UCISOM PRIME-LC (Program in Medical Education for the Latino Community) cohort were also encouraged to watch the Spanish "Full Videos" because their hands-on sessions are completed in Spanish. Learners were also given the option to read about the physical exam, its purpose and steps to perform each maneuver via the Bates Guide to Physical Examination and History Taking which is available via the UCISOM Library.The in-person, hands-on cervical spine and back musculoskeletal PE sessions occurred in a large group setting with approximately fifty students and four to six faculty members present; students were separated into groups of three to six students at a table with a standardized patient, and the session occurred over the span of two hours. When students arrived at the PE didactic session, the cervical spine and back musculoskeletal exam was discussed, and then groups would practice the PE with the facilitator and standardized patient using the video to guide the examination.

RESEARCH METHODS

After completion of the small group session, learners from the first- and second-year medical school classes were encouraged to complete a Qualtrics survey regarding the videos and small group sessions. The survey asked students if they felt the videos were helpful, whether they made them more confident at performing physical exams, and if they had high production quality.

RESULTS

As of January 2023, the musculoskeletal cervical spine and back videos received 372 views and downloads, 318 unique viewers, and delivered 1,776 minutes of content. Thirty-one learners (response rate of approximately 25%) responded to the survey. The educational quality of all the musculoskeletal videos, including cervical spine and back, averaged 4.71 out of 5, the usefulness averaged 4.63 out of 5, and the production quality averaged 4.56 out of 5.

DISCUSSION

Based on the results from our survey as well as end-of-course feedback and verbal feedback sessions with leaners, we deem this educational content efficacious. The videos and all content related to them (eg, scripts, graphics, voice over) were assessed by a team of seven physicians. We feel the efficacy of the videos increases when implemented with other modalities of LRC such as written material or podcasts. Using multiple other modalities allows learners to experiment and utilize the modality that will aid their learning the best. Importantly, we also learned from the implementation of the videos that auto-generated subtitles for the videos in Spanish were often incorrect. This was in part due to the learning management system used to maintain the videos, but also could have been alleviated by including subtitles within the videos themselves. Overall, video content demonstrating these maneuvers, both with and without additional graphics and voice-over, and in two languages, was highly efficacious for UCISOM students in the CF course.

TOPICS

Physical exam, cervical spine, neck, back, low back, musculoskeletal, video, voice-over, medical student education.