Faculty Chair:
Leandrita Ortega, MD
Contacts:
Allan Rickman, MD
Charles Race, MD
Denise Race, RN
Required Experiences:
Outpatient clinics at Champion Orthopedics, 2539 Medical Drive, Suite 110, Alamogordo, NM 88310
GCRMC Operating Room, 2669 N. Scenic Drive, Alamogordo, NM 88310
Optional Experience:
Attend sessions at Southwest Sport and Spine Center, 1181 Mall Drive, Las Cruces, NM 88011
Weekly Schedule PGY2 or 3:
| Sunday | Monday | Tuesday | Wednesday | Thursday | Friday | Saturday |
| Ortho | Clinic | Ortho | Ortho | Clinic | ||
| Ortho | Clinic | Didactics | Clinic |
Requirements:
AOA
Surgery
The program must provide at least twenty weeks of training in surgical disciplines, including at least four weeks of general surgery training during the OGME-1 year.
At a minimum this shall include:
- Preoperative and post-operative care.
- Training in the following sub-specialties, which may be ambulatory or inpatient.
- Ophthalmology.
- Orthopedics.
- Urology.
- ENT.
Sports Medicine
- The program must provide at least 50 hours or two weeks of training in Sports Medicine. This is in addition to time spent in the continuity of care ambulatory site. At a minimum this must include:
- Pre-participation assessment.
- Didactic and clinical experiences.
- Management of uncomplicated sports related injuries.
- Rehabilitation of athletic related injuries.
- Injury prevention/training.
ACGME
Residents must have at least 200 hours (or two months) dedicated to the care of patients with a breadth of musculoskeletal problems. (Core)
This experience must include a structured sports medicine experience. (Detail)
Description of Rotation or Educational Experience:
The approach to diseases and disorders of the musculoskeletal system requires specific attitudes, knowledge and skills. Residency education is designed to provide experiences in a variety of settings that will give residents expertise in the diagnosis, prevention, treatment and rehabilitation of musculoskeletal diseases. These experiences should include patients of all ages and conditions of congenital, traumatic and degenerative causes.
The combined burden of medical conditions affecting the musculoskeletal system and preventable chronic diseases that are related to improper nutrition and inactivity in the United States is staggering. Musculoskeletal complaints rank second only to upper respiratory infections as the reason for seeking medical attention (Woodwell 2004). Yet, studies indicate musculoskeletal and sports medicine education in U.S. medical schools and primary care residencies may be inadequate (Freedman 1998). Training programs in family medicine that will lead to optimal care of patients who have musculoskeletal complaints, including those related to sports medicine, should encompass the outline of the attitudes, knowledge and skills provided in this curriculum guideline. This training will be obtained during block months of orthopedics during the second and third year of residency as well as longitudinally during the family medicine experience
Expectations:
Residents are expected to arrive to orthopedic and continuity clinics on time and to dress and act in a professional manner. The resident will contact preceptors’ office prior to their first day on the rotation in order arrange the initial meeting time and location on day one of the rotation. It is expected that while at the preceptors’ office the residents will be respectful of the office space and personnel. The resident is responsible for maintaining a procedure log as well as completing assigned readings. When possible, residents should accompany orthopedic preceptor to the operating room and perform musculoskeletal exams under anesthesia and observe common orthopedic procedures.
At the completion of residency training, a family medicine resident should:
- Perform an appropriate musculoskeletal history and physical examination, and formulate an appropriate diagnosis and recommend treatment, including requisite subspecialty referrals (Patient Care, Medical Knowledge, Systems-Based Practice)
- Perform an evidence-based, age-appropriate and activity-specific preparticipation physical evaluation, and provide guidance for an appropriate exercise prescription (Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism)
- Communicate effectively with a wide range of individuals regarding musculoskeletal health care, including patients, their families, coaches, school administrators and employers (Interpersonal and Communication Skills)
Faculty:
Family medicine faculty will provide precepting of orthopedic exams and procedures as seen in resident continuity clinics. Dr. Race and Dr. Rickman, will provide precepting during the focused orthopedic rotation. The faculty and community preceptors are expected to allow the resident to participate in active patient care and procedures when appropriate. The preceptors should also provide time and allowance for explanation and teaching of musculoskeletal conditions and their treatments. The continuing patient care experience in the family medicine center provides the principle site for training in ambulatory musculoskeletal care. Residents should have at least minimal experience in inpatient orthopedics. Preceptors who are competently trained must be available to work individually with residents, and to teach and assess performance of residents’ desired skills. The teaching of musculoskeletal care lends itself well to hands-on training in core conferences and workshops, using films, patient demonstrations and models. Experience can be provided in bone, muscle and joint examination, splinting, taping, casting, arthrocentesis and rehabilitative measures.
Call:
There is no call specific to this rotation.
Patient Care
Goal
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:
Competencies
- Understand the importance of diagnosing and treating musculoskeletal injuries in Family Medicine
- Understand exercise as an important and beneficial part of patients’ lives
- Perform appropriate pre-participation physical evaluation of athletes
- Be aware of the special needs of patients who have acute injuries
- Have knowledge of proper rehabilitation of acute musculoskeletal injuries to help speed recovery, maximize function and minimize the risks of re-injury, chronic pain and chronic disability
- Understand prevention strategies as an important part of the care of the musculoskeletal system
Objectives
- Perform an appropriate musculoskeletal history and physical examination, and formulate an appropriate diagnosis and recommend treatment, including requisite subspecialty referral
Skills
In the appropriate setting, the resident should demonstrate the ability to independently perform or appropriately refer:
1. Basic management of:
- Fractures (simple, stable, closed and non-displaced that do not require surgical correction).
- Ligament sprains
- Finger
- Toe
- Ankle
- Knee
- Vertebral column
- Wrist
- Elbow
- Shoulder
- Muscular strains (e.g., hamstring, trapezius)
- Other problems
- Costochondritis
- Bursitis, tendinopathy, tenosynovitis
- Common fibrocartilage injuries such as labral and meniscal tears
- Dislocations (e.g., nursemaid’s elbow)
- Nerve entrapment syndromes
- Baker’s cyst
- Chondromalacia patellae
- Apophysitis (e.g., Osgood-Schlatter disease)
- Osteochondroses/aseptic necrosis
- Osteoarthritis/crystalline-induced arthritis (e.g., gout, pseudo-gout)
- Metabolic bone disease (osteoporosis, Paget’s disease)
- Acute and chronic low back pain
- Foot conditions
- Hallux valgus (bunions)
- Pantar fasciitis
- Mortons neuroma
- Osteomyelitis
- Overuse syndromes
- Shoulder impingement
- Patellofemoral syndrome
- Rheumatologic Disorders
2. Additional skills
- Fractures
- Closed tarsal and carpal bones, particularly navicular
- Smith’s and Colles’ fractures
- Non-displaced medial or lateral epicondyle of humerus
- Non-displaced Salter-Harris Type I or Type II epiphyseal injuries in children
- Dancer’s and Jones’ fractures (proximal 5th metatarsal)
- Meniscal tears
- Recurrent dislocations (e.g., patella, shoulder)
3. Orthopedic emergency recognition and stabilization
- Acute compartment syndrome
- Hip dislocation
- Knee dislocation
- Unstable pelvis fracture
- Cervical spine fracture
- Spinal cord injury
- Cauda equine syndrome
- Neuro-vascular compromise
4. Functional rehabilitation
- Prescription of home exercise programs
- Prescription of physical therapy
5. Surgical Assistance
Medical Knowledge
Goal
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:
Competencies
In the appropriate setting, the resident should demonstrate the ability to apply knowledge of:
1. Normal anatomy and physiology of the musculoskeletal system
2. Normal growth and development of the musculoskeletal system
3. Musculoskeletal history taking
4. Principles of musculoskeletal physical examination
5. Indications, contraindications and interpretation of joint fluid
6. Indications, limitations, contraindications and informed consent for office-based musculoskeletal procedures such as:
- Common joint aspirations
- Common joint injections
- Common injections for bursitis
- Common injections for tendinopathy
7. Testing
- Interpretation of radiographs
- Use of magnetic resonance imaging, computed tomographic scanning and bone scanning
- Indications for arthrogram, myelogram and arthroscopy
- Application of electromyography(EMG) and nerve conduction studies
8. Pathogenesis/pathophysiology and recognition of:
- Joint pain, swelling and erythema
- Muscular pain, swelling and injury
- Musculoskeletal trauma
- Fractures
- Dislocations
- Tendinopathy spectrum (tendinitis to tendinosis)
- T endon ruptures (partial and complete)
- Nerve injuries
- Bone and joint deformities
- Bone and joint infections
- Musculoskeletal congenital anomalies
- Musculoskeletal birth injuries
- Compartment syndrome
- Avascular necrosis
- Osteoporosis
- Overuse syndromes
- Back pain syndromes
9. Pediatric problems
- Hip dislocation
- Congenital hip dysplasia
- Legg-Calvé-Perthes disease
- Osgood-Schlatter disease
- Slipped capital femoral epiphysis
- “Clubfoot” (talipes equino varus)
- In-toeing (metatarsus adductus, tibial torsion, femoral anteversion)
- “Bowleg” (genu varum) and “knock knee” (genu valgum)
- Epiphyseal injuries (Salter-Harris classification)
- Transient synovitis
- Dislocation of the radial head (Nursemaid’s elbow)
- Blount disease
- Rickets
- Osteogenesis imperfecta
- Thoracolumbar scoliosis
Objectives
- Resident will describe basic anatomy of the knee, shoulder, hip, elbow, wrist and ankle
- Resident will list joint-specific history questions for pt’s with acute joint injuries
- Resident will describe lab interpretation of joint fluid (ie transudative vs exudative process)
- Resident will identify the indications and contraindications of joint aspiration and injection
- Resident will identify major bony structures of the shoulder, knee, hip, upper extremity and lower extremity
- Resident can summarize injuries which require MRI, CT, and/or bone scan
- Resident will identify the common causes of joint swelling, pain and erythema
- Resident will describe mechanism and pathophysiology of compartment syndrome
- Resident will summarize the identification of osteoporosis and the appropriate evidence-based screening
- Resident will list the classification of Salter-Harris classification
- Resident will explain the importance of epiphyseal injury in the pediatric patient
- Resident can explain the pathophysiology and treatment of Osgood-Schlatter disease
- Resident will list the treatment options for thoracolumbar scoliosis
Practice Based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Residents are expected to develop skills and habits to be able to:
Competencies
- Identify strengths, deficiencies and limits in one’s knowledge and expertise
- Identify and perform appropriate learning activities
- Participate in the education of patients, families, students, residents and other health professionals, as documented by evaluations of a resident’s teaching abilities by faculty and/or learners
Objectives
- Resident will list areas of weakness in musculoskeletal medicine at the beginning of rotation and reevaluate at end of rotation to improve on knowledge base
- Resident will participate in education of patient and family with musculoskeletal disease as demonstrated by direct observation by the community and family medicine preceptor
- Resident will prepare musculoskeletal specific lectures and present in didactics using evidence-based articles and guidelines
System Based Practice
Goal
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:
Competencies
- Coordinate patient care within the health care system relevant to their clinical specialty
- Incorporate considerations of cost awareness and risk-benefit analysis in patient care
- Advocate for quality patient care and optimal patient care systems
Objectives
- Demonstrate ability to coordinate patient referral to orthopedic specialty when appropriate
- Demonstrate ability to practice cost-effective medicine in the setting of orthopedics, especially in diagnostic testing
- Work collaboratively with financial counsellors, orthopedics and physical therapy to provide optimal healthcare to the patient
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:
Competencies
- Compassion, integrity, and respect for others
- Accountability to patients, society, and the profession
- Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation
Objectives
- Arrive to appropriate clinic/office on time
- Demonstrate respect to specialty physicians and their staff while in the office setting or in the operating room
Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to:
Competencies
- Communicate effectively with patients and families across a broad range of socioeconomic and cultural backgrounds
- Communicate effectively with physicians, other health professionals, and health related agencies
- Work effectively as a member of leader of a health care team or other professional group
Objectives
- Provide appropriate education to patient and families related to orthopedic injuries
- Discuss pertinent and focused patient information with specialty physician or physical therapy as appropriate when making referrals
Teaching Methods
Residents will provide medical care to patients under the direct supervision of the attending physician both in the FMS clinic and the orthopedic clinic. They will be directly supervised on all procedures performed in the FMS clinic, orthopedic clinic and in the operating room. Residents will receive orthopedic-specific didactic lectures during didactic sessions. Residents will be assigned specific reading topics to be completed by the end of the orthopedic rotations.
Assessment Method (Residents)
Residents will be assessed on their orthopedic rotation using global 360 evaluations. The REDI system will also be used in evaluation during FMS clinic by the attending FMS faculty. Direct observation of procedures with procedure checklists will be completed by the evaluating faculty.
Assessment Method (Program Evaluation)
Residents will be provided with an evaluation tool of the rotation to be completed at the end of the rotation to improve upon the rotation. This will also be assessed during quarterly IEPs with the resident and advisor to determine if changes needs to be made
Level of Supervision
Residents will be directly supervised by orthopedic faculty and by FM faculty for any orthopedic patients and/or procedures
Educational Resources
Books
Orthopedic Physical Assessment- Magee
Essentials of Musculoskeletal Care-Snider
Practical Orthopedics-Mercier
Videos:
Readings:
SNMFMRP Curriculum 