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App Refines the Art of Diagnosing Pediatric Musculoskeletal Pain

Use of simulation helps students reach a diagnosis faster and more cost-effectively


Simulation and case-based learning approaches for medical education are garnering attention for their ability to directly assess learners and provide immediate, personalized feedback for improvement.


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Cleveland Clinic Children’s Associate Professor of Pediatrics and pediatric rheumatologist Angela Robinson, MD, MPH, decided to take advantage of this trend by designing an online simulation game to teach high-value care and proper musculoskeletal evaluation to medical students and pediatric residents.

“Our goal is to facilitate the correct and timely diagnosis of pediatric musculoskeletal conditions causing joint pain using a method that students raised in the digital age find more appealing than traditional instruction,” she explains.

Her project, initially developed for use on iPads and tablets, was recently awarded a three-year grant from the Rheumatology Research Foundation. The funds will be used to further refine the game and reformat it for smartphone access.

A new style of learning how to diagnose pediatric musculoskeletal pain

General pediatricians need to know how to properly evaluate a variety of musculoskeletal complaints; put forth a reasonable differential diagnosis using standard evaluation techniques, laboratory and imaging workups; and understand when to refer to a subspecialist. New thinking suggests that students develop these skills more effectively through learner-centered, self-directed curricula.

“We feel an asynchronous, multimedia, choose-your-own-adventure platform is an exciting way to learn. Using virtual pediatric patients allows learners to gain knowledge of the consequences of inefficient or inappropriate decisions without harming any real patients,” Dr. Robinson explains.

How the game works

The recently funded project is based on the success of two pilot projects that began in 2016. This iteration includes case studies in five scenarios associated with pediatric musculoskeletal pain: Lyme arthritis, transient synovitis, Osgood-Schlatter disease, juvenile ankylosing spondylitis and benign growing pain.

Learners will take a history and physical on a virtual patient before deciding which tests to order.

“We plan to evaluate whether there are differences in the tests that are ordered if the costs are known up front or hidden, and whether their selections change as training progresses,” she explains. “We will also test whether pre-module lectures on the causes of musculoskeletal pain and high-value care influence the cost of the workup.”

There are no multiple-choice questions. “Multiple choice doesn’t get at how the learner arrived at their decision,” she says.

Instead, a branched storyboard approach will be used to track clinical reasoning and diagnostic skills. Each decision the learner makes prompts a question as to whether the learner has determined the diagnosis, and if not, what test do they want to order next. Scoring metrics are based on utilization of necessary and unnecessary testing.

Teaching high-value care

The content of the game has been aligned with the American College of Physician’s curriculum for high-value care.

“Physicians order too many tests out of fear we might miss something and a desire to reassure patients we know the diagnosis,” says Dr. Robinson. “I am confident this new approach to learning will improve a pediatrician’s ability to order the most appropriate tests to reach a correct diagnosis quickly, while reducing unnecessary testing.”


A work in progress

The game will be tested by medical students and residents in three children’s hospitals. The feedback they provide will be incorporated into the final product, which is expected by mid-2023.

“Ultimately, we would like this module to be available on the American College of Rheumatology website or MedEdPortal,” says Dr. Robinson.

Although the creation of a simulation game takes time, resources and expertise that is currently in short supply, Dr. Robinson is excited about the potential impact of this learning style on medical education.

“If it makes a difference in how tests are ordered and diagnoses are made, the game could be expanded to all areas of pediatrics,” she says.


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