Department of Medical Education, University of Sheffield, Coleridge House and
1 Institute of General Practice and Primary Care, Community Sciences Building, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
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Abstract |
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Methods. GPs (n=446) on the Sheffield and Barnsley principal lists were sent a questionnaire (53.8% response rate). Semistructured interviews of a purposive sample of 10 GPs were analysed qualitatively to increase understanding of the research objectives.
Results. GPs were self-confident in managing common musculoskeletal conditions such as gout (86% of GPs who replied), back pain (69%), osteoarthritis (62%) and sporting injuries (58%) entirely within the surgery. Despite high levels of confidence in diagnosing non-specific pain syndromes, 68% of GPs would refer to a rheumatologist. Most GPs (68%) were happy with their current referral rates to physiotherapists and 65% of GPs in this sample provided a personal injection service. Reduction of inappropriate prescribing of non-steroidal anti-inflammatory drugs would be helped by better patient education materials on treatments (90%) and more resources for the primary care physiotherapy service (85%). Half of the GPs had had specific musculoskeletal training within the last 5 yr. Half of the GPs planned to update their knowledge and skills in the next year, 64% of these preferring a taught interactive course, 50% wanting to sit in with a consultant in clinic and 46% preferring to learn as part of a personal learning plan.
Conclusions. GPs feel confident managing the majority of musculoskeletal conditions within the surgery provided they have adequate support in terms of opportunities for appropriate education, particularly joint injection techniques, ongoing consultant support for complex cases with poor outcomes, particularly non-specific pain syndromes, adequate access to physiotherapy, and a multidisciplinary approach to pain control and inappropriate prescribing.
KEY WORDS: Musculoskeletal, Continuing professional development, Rheumatology, General practitioners.
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Introduction |
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The education and training of GPs may not match demand from patients with musculoskeletal disorders, and this may stem from inadequate teaching at medical school, particularly in clinical skills [8], evidenced by a low awareness of musculoskeletal disorders amongst junior medical staff [9]. At the vocational training level [10], a lack of confidence in managing rheumatological conditions is related to a lack of experience and poor teaching, although a third of UK GP registrars had injected a shoulder joint and over three-quarters had aspirated knees during their training. As a consequence, GPs may well manage patients suboptimally; in particular [11], they are not referring enough patients for physiotherapy, they are prescribing too many non-steroidal anti-inflammatory drugs (NSAIDS) and are reluctant to use intra- and peri-articular steroid injections. In addition, there is concern by consultant rheumatologists that GPs may be failing to address the importance of disease-modifying drugs (DMARDs) in early rheumatoid arthritis [12].
Whilst there may be agreement about the education needed for the optimal management of individual patients [3], there is conflicting evidence to guide the optimal performance of GPs over a range of musculoskeletal conditions and still less as to which educational interventions may improve performance. Consequently, service provision remains diverse rather than integrated. For example, both physiotherapy and chiropractic have been shown to reduce symptoms [13] in low back pain, whereas there is inadequate evidence that NSAIDs are superior to simple analgesics such as paracetamol [14]. Nevertheless, in back pain, GPs tend to use NSAIDs in 22% of patients, referring 16% to physiotherapy [15]. Evidence-based guidelines have emerged for managing low back pain, but there is variable adherence by GPs [16]. The evidence on the use of corticosteroid injections administered by the GP may be incomplete. Injections are said to be more effective than physiotherapy for treating a painful stiff shoulder [17], but the effect only lasts 23 months and the injection may need repeating.
Whilst the majority of consultant rheumatologists have been involved in teaching GPs [18], arthritides have made up nearly half of the teaching topics and little attention has been paid to common problems, such as vague soft-tissue pain, back pain, minor injuries and the examination and injection of joints. The present research had three objectives: (i) to identify the learning needs and preferred learning methods of GPs in musculoskeletal medicine in relation to their current ways of working; (ii) to identify innovations which may support primary care management of common musculoskeletal problems; and (iii) to identify ways in which GPs' perceived barriers to good practice in musculoskeletal medicine might be overcome.
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Setting and subjects |
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Methods
Our review of the literature had identified a number of themes pertinent to the research objectives. Open-ended interviews were conducted with a sample of four GPs, two consultant rheumatologists and a sports physician, and were structured so that questions were asked that were relevant to the refining of the developing questionnaire and ensuring content validity. The draft questionnaire was piloted on 10 randomly selected GPs from an adjacent health authority. The final form requested information on referral patterns, perceived workload and self-rating of the usefulness of a range of educational interventions designed to meet GPs' possible education needs with regard to musculoskeletal disorders. In addition, five-response Likert-type items were used to explore the self-assessment of confidence in managing common musculoskeletal problems, barriers to accessing physiotherapy services, prescribing non-steroidals by GPs, and the provision of intra-articular injections.
Non-responders were sent one postal reminder after 2 weeks. Responses received after the closing date were not analysed. Statistical analysis was undertaken with SPSS version 10 (SPSS, Chicago, IL, USA).
In-depth semistructured interviews were conducted in their places of work with a purposive sample of GPs selected on the basis of the free text in the questionnaires returned by the GPs. All interviews were audio-recorded in full with the subjects' consent, tapes were transcribed, and thematic analysis was carried out using standard qualitative methods [19].
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Results |
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Workload
In this survey musculoskeletal disorders made up 18.0% (S.D. 8.4%) (n=217) of the GPs' perceived workload.
Referrals
Although many patients presented without a clear distinct diagnosis (GP: W), GPs perceived that musculoskeletal medicine should be based largely within primary care, but that more support was needed.
"90% [of the musculoskeletal service] is going to stay in primary care and doesn't need secondary service, but we do need more support, more access to investigations and treatment, and colleagues to work with us. (GP: B)"GPs were generally self-confident about managing common musculoskeletal conditions (Table 1
"... common conditions such as fibromyalgia, pain syndromes, which I don't think rheumatologists are terribly interested in the management of ... tend to be sent back to the GP; the message is we can't do any more, get on with it ... people deserve more than that, because these are common conditions which cause lots of distress and disability. (GP: W)"In early rheumatoid arthritis, for which GPs' confidence to manage with their own skills was low (16.7%), the availability of advice to the GP from a consultant may increase self-confidence to manage patients with early rheumatoid disease at the GP practice (34.7%).
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TABLE 1. Levels of self-confidence (%) of GPs in managing common musculoskeletal problems presenting in the surgery
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TABLE 2. Patterns of referral to specialties from general practice (%) for common musculoskeletal conditions
Physiotherapy
Most GPs (67.5%) were happy with their own current referral rates to physiotherapists, 73% feeling confident about their own diagnostic skills and 68% of GPs reporting that their physiotherapy waiting list was too long.
"It's not relevant by the time they actually are offered an appointment; they've forgotten about it or they prefer to live with it. (GP: P)"
Giving steroid injections
Of the GPs in this sample, 64.6% provided a personal injection service, with 28.8% prepared to update or enhance their injection skills in the following year. Suggestions for improving the quality of a primary care injection service included regular drop-in clinics for teaching injection skills at the local hospital (52.9%), good access to evidence-based research findings on steroid injections (52.5%), fast-track service to consultants when injection treatment had been tried (51.7%), and locally produced guidelines on the practice of injections (51.1%).
Those who did not give injections offered several reasons: little opportunity to learn (64.3%); not enough opportunity for regular practice to keep up skills (60.7%); medicolegal worries (45.3%); and lack of time (42.9%).
Reducing the prescribing of NSAIDs
GPs recognized that NSAIDs were frequently implicated in ill health (GP: W) and do not cure a lot of things (GP: S), but the reasons for prescribing NSAIDS were complex. For example, one doctor saw it as part of a gate-keeping role because of lack of other resources, such as physiotherapy.
"... a lot of these things [NSAIDS] are given to give a bit of time and hope things settle down, because a lot of these things do settle down with time and rest. (GP: S)"In order to reduce the prescribing of NSAIDs, GPs thought some effective strategies might include better patient education materials about treatments (90%), more resources for the physiotherapy service (80.5%), easier access to a chronic pain service (79.3%) and better provision of educational courses on musculoskeletal medicine (77.9%).
GP education
GPs were happy to identify their learning needs to develop a better service but there was an emphasis on education being multidisciplinary, interactive and centred on primary care. GPs did not want a standard lecture with a secondary care perspective ... where the opportunities for feedback and discussion are very limited (GP: B). Those areas in which GPs were less confident in managing themselves but are nevertheless common would provide the basis of GPs' future learning needs. These include the management of early rheumatoid arthritis, for which only 16.7% were prepared to manage with their own skill and knowledge, osteoporosis (28.8%), the management of the patient with widespread aches and pains (29.6%), and polymyalgia rheumatica (39.2%).
Half of the GPs in this sample had had specific training on musculoskeletal medicine over the last 5 yr and 50% of the GPs planned to update their skills in the following year (Table 3), preferring a taught interactive musculoskeletal course (64.2%), to sit in with a consultant in clinic (49.2%), to do it as part of a personal learning plan (45.9%) or a Primary Care Group study day (31.2%).
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Discussion |
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The specific learning needs of GPs identified in this research need to be addressed by course organizers within short, interactive courses for small groups, aimed at maintaining and developing new knowledge and skills in musculoskeletal medicine. However, GPs need access to a range of learning material according to their personal learning style and preferred format. For example, GPs in this study recognized the need for access to up-to-date research-based evidence on good practice in musculoskeletal medicine. GPs could be encouraged to use such learning material as part of their own continuing professional development through personal learning plans. In addition, GPs may need to gain more awareness of the extensive range of patient educational material [21] and incorporate this into their consultations. GPs consider consultant colleagues to be an important resource for meeting their learning needs, but there is perhaps a disparity between what GPs need to learn about, i.e. managing common conditions well, and what rheumatologists may think is a priority, i.e. managing inflammatory disease and connective tissue disease [3]. Consultant rheumatologists may need to reassess the degree of their speciality interest in inflammatory disease, and place more emphasis on osteoarthritis, metabolic bone disease, low back pain and osteoporosis [22]. In the longer term, there may be more integrated working between primary and secondary care, driven by moves to provide teaching on the locomotor system in a multidisciplinary, community-based way, starting at medical school [23, 24].
Consultants, in conjunction with their units within the hospital trusts, may consider becoming more innovative in providing educational support for GPs who are happy in the management of common musculoskeletal problems in primary care. In particular, GP specialists who provide an injection service will benefit from local guidelines/protocols and access to local drop-in injection clinics where they can update their skills. A service providing rapid access to consultants for patients in whom injection treatment has been tried appropriately but unsuccessfully may reduce the overall waiting time of patients from their initial presentation in primary care.
For those primary care teams that do not offer an injection service, consideration needs to be given to mentorship by local multidisciplinary experts to promote uptake of the necessary training. There may be a place for clinical skills centres where novices can use simulation models to practice injection techniques.
There may well be some learning needs for consultants to address for their own professional development. These would include being aware of the range and quantity of common conditions that GPs treat in their surgeries, the management of patients with non-specific musculoskeletal pain syndromes where there are traditionally poor outcomes, and a recognition that many GPs are happy to manage inflammatory rheumatological conditions with advice and support. Innovative ways of providing support have been tried elsewhere, for example telephone helplines [25]. Finally, it is necessary to recognize the need for a multidisciplinary pain relief service in chronic conditions.
This research suggests that the barriers to providing a musculoskeletal service in primary care are complex. Primary care trusts will need to consider the most effective configuration of services that meets their patients' needs and is deliverable in an integrated way. This may cut across the traditional boundaries of orthopaedic surgery, rheumatology and the emerging specialties of orthopaedic medicine and sports medicine. GPs by and large seem willing to support this change and to adapt their own educational priorities to meet the challenge, but will need some direction from education providers.
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Acknowledgments |
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Notes |
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References |
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