Clin Rheumatol DOI 10.1007/s10067-013-2479-9
ORIGINAL ARTICLE
Musculoskeletal education in general practice: a questionnaire survey E M Wise & D J Walker & D A Coady
Received: 15 July 2013 / Revised: 16 December 2013 / Accepted: 24 December 2013 # Clinical Rheumatology 2014
Abstract Musculoskeletal education in primary care has previously been shown, in 1995, to be inadequate [1]. The aims of this study were to evaluate the current musculoskeletal education and skills during vocational training for general practice and to see if progress has been made. Questionnaires were sent to General Practice Registrars, in general practice attachments in June 2004. Four UK General Practice Deaneries participated (Northern, Mersey, Yorkshire and Wessex). Questionnaires were received from 251 (44 %) registrars. Of the responders, only 77 % reported receiving specific clinical rheumatology teaching at medical school and 30 % had not received any tutorials on musculoskeletal conditions during their vocational training. Of the registrars, 16 % reported having completed a rheumatology post, and an additional 19 % had been able to attend rheumatology outpatient clinics; 70 % of the registrars had injected or aspirated the knee although less than half of these (22 %) had done this in a primary care setting. Lack of experience was associated with low confidence at knowing when to perform the injection and with performing the injection itself. A significant proportion of registrars reported being pre-dominantly self-taught for performing injections (soft tissue=10.7 %, joint injections= 8.7 %) and for the management of shoulder pain (20.1 %). Registrars rated their overall musculoskeletal training as inadequate. Primary care musculoskeletal education remains inadequate and needs to be improved to enable registrars to be E. M. Wise City Hospitals Sunderland, Sunderland, UK D. J. Walker Department of Rheumatology, The Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK D. A. Coady (*) Department of Rheumatology, City Hospitals Sunderland, Kayll Road, Sunderland SR4 7TP, UK e-mail: [email protected]
confident in managing a significant proportion of their workload. Identifying learning needs for primary care would inform future educational interventions. Keywords Education . Family Practice . Musculoskeletal diseases
Introduction Musculoskeletal disorders are common, accounting for up to one third of general practitioner (GP) consultations [2, 3], cause a significant amount of disability [4] and have huge resource implications for the National Health Service (NHS). It is predicted that, in the future, as the proportion of older people in the population increases then the amount of musculoskeletal conditions will also increase [5] (Table 1). As GPs are the first point of contact for patients in the UK, it is important that they are adequately equipped to manage musculoskeletal disorders [6]. Studies looking at undergraduate teaching have highlighted concerns that future doctors may not be receiving adequate training in musculoskeletal medicine. A questionnaire study in 1997 showed that in five medical schools up to half of all students may receive no clinical rheumatological teaching at all [7]. It was also noted that little emphasis was placed on primary care musculoskeletal disorders. Primary care attachments in medical school may also be limited, students often spending only 2–4 weeks in general practice with their time also being taken up by lectures and tutorials [8]. This is insufficient time for the medical student to gain an appreciation of the importance of musculoskeletal disorders in primary care or to gain clinical skills. This pattern appears to be continued into postgraduate education where studies looking at medical and paediatric hospital admissions have shown that musculoskeletal
Clin Rheumatol Table 1 Musculoskeletal disease prevalence rates (per 100,000 person years at risk), GPRD 2001 [3] Disease
All ages (>16) (95 % CI)
All musculoskeletal events Soft tissue rheumatism and CWP Back pain Osteoarthritis
13,275 (13,215, 13,336) 4,068 (4,034, 4,104) 3,747 (3,715, 3,779) 1,724 (1,702, 1,746)
Rheumatoid arthritis Polymyalgia rheumatica Osteoporosis Ankylosing spondylitis SLE Scleroderma Gout
215 (207, 223) 165 (159, 172) 135 (129, 141) 37 (34, 40) 13 (12, 15) 6 (5, 7) 6 (4, 7)
assessments are rarely documented and when present are very limited, contrasting markedly with other systems. Self-rated confidence in assessment of musculoskeletal disorders is low compared to other systems [9, 10]. In 1995, Lanyon et al. published the results of a national questionnaire looking specifically at GP trainees/GP registrars’ (GPRs) rheumatology education [1]. This showed that by the end of their trainee year 35 % of the responding registrars had not received any tutorials on rheumatology topics from their trainers and only 43 % had had any rheumatology teaching on their central teaching sessions from the vocational training scheme. Trainees reported that they were under-confident at managing musculoskeletal disorders, and when asked to rate the amount of their rheumatology education, responded with inadequate. The authors suggested that a standardised rheumatology curriculum be developed and incorporated into all GP schemes. Following on from this, in January 2000, Arthritis Research UK published a Learning guide for general practitioners and general practice registrars on musculoskeletal problems, the content of which was decided by a multidisciplinary group representing Arthritis Research UK, the RCGP and the Primary Care Rheumatology (PCR) society [11]. The guide was distributed to general practice trainers throughout the country although what its uptake has been is unknown. The aims of this study were to repeat the questionnaire survey used by Lanyon et al. in a sample of four deaneries to see if, 10 years on, GPR teaching has changed and to see if the Arthritis Research UK Learning Guide has made any impact on GPR education.
Methods The previously validated questionnaire looking at musculoskeletal education and management skills was reviewed, and
three questions were added [1]. Two of these were to investigate further the GPR’s experience of injecting soft tissue lesions and joints. It was noted that in the original study 84 % of registrars reported that they had injected or aspirated the knee. This seemed a large number from the authors’ own experience and from the prevalence of knee disorders in primary care. We therefore asked that if they had answered yes to injecting/aspirating a joint/soft tissue lesion, had they performed the injection in general practice? The third question was added at the end of the questionnaire asking if the registrars were aware of the learning guide, and if they were, had it been used in their training/teaching? This was to try to assess the effect that the production and dissemination of the guide has had on general practice education. The new four-page questionnaire was disseminated to registrars in general practice posts (including innovative posts with a general practice component) in June 2004 in four deaneries. The deaneries (Northern, Mersey, Yorkshire and Wessex) were chosen for their ease of access, and each used their preferred method of distribution.
Results Questionnaires were sent to 571 registrars in the four deaneries, and responses were received from 251 (44 %). Response rates were similar across the deaneries. There was a range of years of qualification and representation from the majority of medical schools within the country. Due to changes in GP training, we are reporting results from registrars at different points in their training, unlike the 1995 study which reported results from GPRs in their final months of training. Undergraduate teaching Of the registrars, 77 % reported receiving specific clinical rheumatology teaching at medical school. They rated the teaching in terms of its relevance to general practice as 5 (median, range 1–10) on a scale of 1 to 10 with 1 being not relevant at all and 10 being very relevant. Postgraduate teaching General practice registrars may receive musculoskeletal teaching from different sources and at different times: from the scheme, from hospital posts or from their trainer. Thirty-nine registrars (15.7 %) had a rheumatology post in their vocational training, and an additional 45 (19 %) were able to attend rheumatology outpatient clinics. Only 104 (42 %) registrars had received teaching on musculoskeletal conditions on vocational training scheme day release courses. Seventy-seven (32.1 %) had attended additional teaching in the form of
Clin Rheumatol
regional study days on the topic. On average, registrars estimated that they had spent an average of one half day on rheumatological topics. There was some variation across the deaneries with trainees in Yorkshire being more likely to have had rheumatology experience both as an SHO (26 % of GPRs compared to the average across all deaneries of 15.7 %) and as part of their day release sessions (70.7 % compared to the average of 41.8 %) although this may not be significant given the 44 % response rate. Most registrars recalled having tutorials on musculoskeletal conditions (173 (70 %)) with a median of only 2 h of teaching (Table 2). Back pain was the most commonly reported tutorial topic. Conditions such as childhood locomotor disorders and the management of musculoskeletal disability were less frequently discussed. Acquisition of injection skills Joint injection techniques were mainly taught by rheumatologists, whereas soft tissue injections were taught by the trainers (Table 3). A significant number of registrars claimed to be self-taught in both areas (10.7 % soft tissue, 8.7 % joint injections). Other sources of teaching included the following: A&E registrars/consultants; GPs other than the trainer; courses, e.g. minor surgery courses; and other medical staff. Most registrars (174, 70 %) had injected/aspirated the knee joint during their training although less than half of these had injected/aspirated the joint in a primary care setting. The most common soft tissue injection performed was for tennis elbow. Registrars were most confident at knowing when to inject the knee and at performing knee injections which corresponds with the knee being the most commonly injected site (Table 4). At each injection site, confidence scores were lower in those who had never injected compared to those who had injected. Registrars who had completed an SHO post in rheumatology were, on average, more confident about both knowing when to inject and at performing injections. Table 2 Tutorial topics reported by respondents (% of registrars who reported teaching, n=173) comparing 1995 data with 2004
Regional musculoskeletal examination Registrars’ perceived self-confidence at the regional examinations was high, with median ratings of 8 for examination of the back and knee, 7 for the shoulder and hip and 6 for the foot (1=not confident at all/10=very confident) (Table 5). The trainer was reported as being the person who predominantly taught GPRs how to examine and treat shoulder pain (27.9 %) although a significant number were self-taught (20.1 %). Fewer registrars reported having been taught by hospital consultants: rheumatologist (11.7 %), orthopaedic surgeons (15.1 %) and general physicians (7.3 %). Management strategies Registrars’ perceived confidence at managing specific musculoskeletal conditions was generally high and equivalent to their confidence at managing asthma and hypertension. Educational methods Preferred educational methods were as follows: trainer tutorials, small group teaching, rheumatology outpatient clinics and SHO posts (Table 6). Distance learning and attending symposia were the least popular. General practice registrars rated their overall VTS training on musculoskeletal conditions as inadequate, with a median response of 4 (1=totally inadequate, 10=completely adequate). Only 10 % of respondents were aware of the Arthritis Research UK Learning guide for general practitioners and general practice registrars on musculoskeletal problems.
Discussion Lanyon’s study was a national evaluation of general practice rheumatology education, but this survey looking at training in four deaneries offers an interesting comparison. Whether these
Tutorial topics
1995 Percentage (no.)
2004 Percentage (no.)
Back pain Osteoarthritis Osteoporosis Gout Soft tissue/periarticular disorders Rheumatoid arthritis Sports injuries Management of musculoskeletal disability Locomotor disorders in childhood
52.4 (563) 26.1 (280) 21.9 (235) 25.8 (277) 26.2 (282) 28.8 (319) 20.1 (223) 13.7 (147) 8.5 (91)
87.3 (151) 43.9 (76) 42.8 (74) 39.3 (68) 38.2 (66) 33.5 (58) 20.2 (35) 11.6 (20) 10.4 (18)
Clin Rheumatol Table 3 Injection sites reported by trainees showing differences between 1995 and 2004
Injection site
Given injections 1995 (trainees=1,075)
Knee joint Shoulder: glenohumeral joint Tennis elbow Shoulder: subacromial Elbow joint Shoulder: acromio-clavicular joint Plantar fasciitis Golfers elbow De Quervain’s tenosynovitis Bicipital tendonitis
deaneries are representative of the current training situation throughout the UK is unknown although there is no evidence to suggest that they are not. A response rate of 44 % is comparable to response rates in other general practice questionnaire studies [12]. Although this does raise the question as to whether the responses are more likely to be from registrars interested in musculoskeletal conditions and so more likely to have requested teaching, or conversely from registrars who feel that their education is lacking. The majority of registrars had received specific clinical rheumatology education at medical school although this was not regarded as being particularly relevant to general practice. This is consistent with the results of studies specifically looking at undergraduate musculoskeletal education [6]. As current medical school and foundation programme education in musculoskeletal disorders is deemed insufficient [13], there is an opportunity for vocational training to make up this gap and produce competent doctors. Unfortunately, in 1995, GPRs reported their education as lacking [1], and from this survey in four deaneries, it appears that not enough has changed. Table 4 Confidence at knowing when to inject joints/soft tissue lesions and confidence at performing joint injections 2004 data (1=not confident at all/10= very confident)
Glenohumeral joint Acromio-clavicular joint Subacromial bursa joint Knee joint Elbow joint Tennis elbow Golfers elbow De Quervain’s tenosynovitis Bicipital tendonitis Plantar fasciitis
2004 (trainees=251)
No. (%)
Rank
No. (%)
Rank
897 (84) 416 (39) 596 (56) 361 (34) 292 (28) 251 (24) 277 (27) 236 (23) 123 (12) 142 (14)
1 3 2 4 5 7 6 8 10 9
174 (69.6) 76 (30.4) 68 (27.3) 50 (20.0) 49 (19.6) 48 (19.3) 31 (12.4) 27 (10.8) 22 (8.8) 17 (6.8)
1 2 3 4 5 6 7 8 9 10
This survey shows that more registrars had held a rheumatology SHO post during training than previously and that these were perceived to be of educational value. These GPRs were more confident in the use of soft tissue and joint injections. Other studies looking into the relevance of hospital posts have shown that the content of teaching is not always appropriate to primary care [14]. This may be improved with the advent of innovative posts where GPRs divide their time between a hospital speciality and general practice. There are, however, differences between the range of musculoskeletal disorders seen in secondary care and those managed in primary care. This must be taken into account when training GPRs and provision made. An ideal time and location to improve musculoskeletal education is in the general practice part of a registrar’s training. This can be through the half day release teaching sessions and tutorials and also opportunistically during surgeries. In general, this teaching is a case-based teaching which is both effective and valued by trainees [15]. Unfortunately, only 42 % of the registrars reported having teaching during their day release sessions and only 32.1 % had attended regional
Confidence at knowing when to inject
Confidence at performing injections
5 4 4 7 4 5 4 2 2 3
4 3 3 7 2.5 – – – – –
Clin Rheumatol Table 5 Confidence at managing the following conditions (1=not confident at all/10=very confident) Conditions
Confidence 1995
2004
Gout
8
7
Back pain Sports injuries Osteoarthritis Soft tissue/periarticular lesions Locomotor disorders in children Diagnosing inflammatory arthropathies Safety monitoring of second line drugs (DMARDS) Osteoporosis Asthma Hypertension
8 6 7 6 5 6 6 6 9 8
8 5 7 6 5 6 5 7 8 8
study days. It may be that the terminology used in the questionnaire, i.e. ‘regional study day’ was an issue and affected the response. These results are analogous to those from a questionnaire study of 20 vocational training schemes which showed that on average only 1.3 half day release teaching sessions were allocated to musculoskeletal disorders in a year [16]. In many vocational training schemes, the half day teaching is informal and the agenda is determined by the GPRs. It may therefore be that the GPRs are not aware of musculoskeletal medicine having a high priority or being a learning need. Only 70 % of registrars reported having tutorials on musculoskeletal conditions. This could be an underestimate as it may be that they are recalling only formal teaching and not the opportunistic case discussions/problem case analysis that they receive—estimated at about 37 min of teaching per week [17]. It is interesting to compare what they recall being taught on to the prevalence rates from the General Practice Research Database (see Table 1). For example, both gout and rheumatoid arthritis are common tutorial topics, whereas in practice, they are seen less commonly than, e.g. soft tissue disorders. This may reflect the continuing influence of teaching from secondary care consultants in medical school.
Table 6 Sources of learning Teacher
Percentage (1995)
Percentage (2004)
Trainer Self-taught Rheumatologist Orthopaedics Physician Other
26 31 26 35 6 –
27.9 20.1 11.7 15.1 7.3 17.9
Joint injections, as recognised in the 1995 survey, are not necessarily the most important outcome of training but are an identifiable endpoint. As in the original study, there was a high level of acquisition of knee injection skills, but further questioning of the respondents revealed that these skills are not being used in their general practice attachments. This probably indicates that experience is being gained in both medical and accident and emergency posts but then is possibly lost as the opportunity to use them in general practice does not arise. In comparison, shoulder injection skills are less commonly learnt. This may reflect the fact that 20 % of the registrars report that they are predominantly ‘self-taught’ in the management of shoulder pain or it may be because the opportunities for learning may not arise. For example, cases of bicipital tendonitis and De Quervain’s tenosynovitis rarely appear in GP surgeries and so may not be seen during the registrar year. Interestingly, a survey of GPs in the ‘Wessex’ region in 2005 revealed that 66.4 % of respondents carry out injections themselves with tennis elbow, glenohumeral joint, knee, supraspinatus tendonitis and carpal tunnel syndrome being the most common injections performed [18]. GP trainers are therefore a major teaching resource for musculoskeletal medicine. What is interesting is that the GPR respondents in the 1992 study may now be trainers themselves. If these doctors were not confident at managing musculoskeletal disorders then, have they gained enough knowledge and skills since to make them proficient GPR trainers? Are we perpetuating poor musculoskeletal training for GPs? An attempt by the Arthritis Research UK to try to improve training by the production and dissemination of the ‘Learning guide for general practitioners and general practice registrars on musculoskeletal disorders’ [10] appears to have had little impact as the results from both the original questionnaire and this repeat survey are very similar and only 10 % of the responding registrars were aware that the guide exists. Since the original study, general practitioners with special interests (GPSIs) have increased in number, and these could be an important resource for general practice training. Improved GPR and GP training could have both implications for patients and NHS resources as studies have shown that GPs who have undertaken musculoskeletal training courses show sustained reductions in NSAID prescribing [19]. Roughly £170 million of the NHS drug budget in 1999 was spent on NSAIDs, and they are known to cause significant morbidity and mortality. Intake of NSAIDs has been associated with an estimated 2,000 deaths a year in the UK and a fourfold to fivefold increase in gastrointestinal bleeding [20]. General practice training has changed since 2004 with the introduction of Modernising Medical Careers, a new focused and streamlined training programme. All doctors will complete a 2-year Foundation Programme immediately after qualification and prior to entering their chosen speciality. GP
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training currently lasts for 3 years with 18 months based in general practice. There are plans to extend this to 4 years with 24 months in primary care, which may have a negative effect on musculoskeletal training as the chance to do a hospital post in either orthopaedics or rheumatology is reduced and there will be limited innovative posts including a musculoskeletal element. In conclusion, despite the introduction of compulsory vocational training, a highlighted need for improved education in 1995 and the efforts of Arthritis Research UK, rheumatology education for GP registrars still appears to be inadequate. It is essential that registrars receive sufficient training to enable them to be confident in managing the large number of musculoskeletal disorders that present to general practice, and it will be interesting to see what effect the development and introduction of the 2012 curriculum for general practice has [21]. Ethics This project was discussed with the chair of the local research ethics committee, and formal ethical approval was not required. Acknowledgments We thank Ann-Marie Smith for her administrative assistance, Dr. Peter Lanyon for allowing us to use his questionnaire, Dr. Graham Davenport, Dr. George Taylor and Professor Frank Smith for assisting with the access to the four deaneries, Dr. Adrian Dunbar and Dr. D John Dickson for their comments and Wyeth, Proctor & Gamble and Pfizer for providing postage costs. Disclosures None.
References 1. Lanyon P, Pope D, Croft P (1995) Rheumatology education and management skills in general practice: a national study of trainees. Ann Rheum Dis 54:735–739 2. Black C. Working for a healthier tomorrow. London: TSO; 2008. http:// www.dwp.gov.uk/docs/hwwb-working-for-a-healthier-tomorrow.pdf. Accessed 5 Jul 2013 3. Clarke AM, Croft PR, Jordan K, Symmons DPM (2005) New estimates of prevalence rates of major musculoskeletal conditions in the UK based on consultation in general practice. Rheumatology 44(supplement 1):i51
4. Bajekal M, Prescott A (2003) Health survey for England 2001: disability. The Stationary Office, London 5. A heavy burden, The University of Manchester 2011. http://www. inflammation-repair.manchester.ac.uk/musculoskeletal/aboutus/ publications/heavyburden.pdf. Accessed 5 Jul 2013 6. Margham T (2011) Musculoskeletal disorders: time for joint action in primary care. Br J Gen Pract 61(592):657–658 7. Kay LJ, Deighton CM, Walker DJ, Hay EM (2000) Undergraduate rheumatology teaching in the UK: a survey of current practice and changes since 1990. Rheumatology 39:800–803 8. Spencer J (1998) What can undergraduate education offer general practice? In: Harrison J, van Zwanenberg TD (eds) GP tomorrow, 2nd edn. Radcliffe Medical Press, Oxford, pp 49–66 9. Lillicrap MS, Byrne E, Speed CA (2003) Musculoskeletal assessment of general medical in-patients—joints still crying out for attention. Rheumatology 42(8):951–954 10. Myers A, McDonagh JE, Gupta K, Hull R, Barker D, Kay LJ et al (2004) More ‘cries from the joints’: assessment of the musculoskeletal system is poorly documented in routine paediatric clerking. Rheumatology 43(8):1045–1049 11. Underwood M, Brown P, Burn L, Campbell A, Davenport G, Dickson J, et al (2000) Learning guide for general practitioners and general practice registrars on musculoskeletal problems. Arthritis Research Campaign: London 12. Barclay S et al (2001) Not another questionnaire! Maximizing the response rate, predicting non-response and assessing non-response bias in postal questionnaire studies of GPs. Fam Pract 19(1):105–111 13. Al-Nammari SS, James BK, Ramachandran M (2009) The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom. J Bone Joint Surg Br 91(11):1413–1418 14. Bedward J, Davison I, Burke S, Thomas H, Johnson N (2011) Evaluation of the RCGP GP Training Curriculum. The University of Birmingham: Birmingham 15. Spencer JA, Jordan RK (1999) Learner centred approaches in medical education. Br Med J 318:1280–1283 16. Booth A (1990) General practice training in musculoskeletal disorders. Br J Gen Pract 40(338):390 17. (2003) Pearce C. Corridor teaching. ‘Have you got a minute…?’ Australian Family Physician. 32, No 9 18. Liddell WG, Carmichael CR, McHugh NJ (2005) Joint and soft tissue injections: a survey of general practitioners. Rheumatology 44:1043–1046 19. May FW, Rowett DS, Gilbert AL, McNeece JI, Hurley E (1999) Outcomes of an educational-outreach service for community medical practitioners: non-steroidal anti-inflammatory drugs. Med J Aust 170:471–474 20. Osteoarthritis and rheumatoid arthritis - COX 2 inhibitors. National Institute of Clinical Excellence. Technology Appraisal 27. http:// www.nice.org.uk/nicemedia/pdf/coxiifullguidance.pdf. Accessed 29 Apr 2008 21. Royal College of General Practitioners Curriculum 2012. http:// www.rcgp.org.uk/gp-training-and-exams/~/media/Files/GP-trainingand-exams/Curriculum-2012/RCGP-Curriculum-3-20Musculoskeletal-Problems.ashx. Accessed 15 July 2013
ORIGINAL ARTICLE
Musculoskeletal education in general practice: a questionnaire survey E M Wise & D J Walker & D A Coady
Received: 15 July 2013 / Revised: 16 December 2013 / Accepted: 24 December 2013 # Clinical Rheumatology 2014
Abstract Musculoskeletal education in primary care has previously been shown, in 1995, to be inadequate [1]. The aims of this study were to evaluate the current musculoskeletal education and skills during vocational training for general practice and to see if progress has been made. Questionnaires were sent to General Practice Registrars, in general practice attachments in June 2004. Four UK General Practice Deaneries participated (Northern, Mersey, Yorkshire and Wessex). Questionnaires were received from 251 (44 %) registrars. Of the responders, only 77 % reported receiving specific clinical rheumatology teaching at medical school and 30 % had not received any tutorials on musculoskeletal conditions during their vocational training. Of the registrars, 16 % reported having completed a rheumatology post, and an additional 19 % had been able to attend rheumatology outpatient clinics; 70 % of the registrars had injected or aspirated the knee although less than half of these (22 %) had done this in a primary care setting. Lack of experience was associated with low confidence at knowing when to perform the injection and with performing the injection itself. A significant proportion of registrars reported being pre-dominantly self-taught for performing injections (soft tissue=10.7 %, joint injections= 8.7 %) and for the management of shoulder pain (20.1 %). Registrars rated their overall musculoskeletal training as inadequate. Primary care musculoskeletal education remains inadequate and needs to be improved to enable registrars to be E. M. Wise City Hospitals Sunderland, Sunderland, UK D. J. Walker Department of Rheumatology, The Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK D. A. Coady (*) Department of Rheumatology, City Hospitals Sunderland, Kayll Road, Sunderland SR4 7TP, UK e-mail: [email protected]
confident in managing a significant proportion of their workload. Identifying learning needs for primary care would inform future educational interventions. Keywords Education . Family Practice . Musculoskeletal diseases
Introduction Musculoskeletal disorders are common, accounting for up to one third of general practitioner (GP) consultations [2, 3], cause a significant amount of disability [4] and have huge resource implications for the National Health Service (NHS). It is predicted that, in the future, as the proportion of older people in the population increases then the amount of musculoskeletal conditions will also increase [5] (Table 1). As GPs are the first point of contact for patients in the UK, it is important that they are adequately equipped to manage musculoskeletal disorders [6]. Studies looking at undergraduate teaching have highlighted concerns that future doctors may not be receiving adequate training in musculoskeletal medicine. A questionnaire study in 1997 showed that in five medical schools up to half of all students may receive no clinical rheumatological teaching at all [7]. It was also noted that little emphasis was placed on primary care musculoskeletal disorders. Primary care attachments in medical school may also be limited, students often spending only 2–4 weeks in general practice with their time also being taken up by lectures and tutorials [8]. This is insufficient time for the medical student to gain an appreciation of the importance of musculoskeletal disorders in primary care or to gain clinical skills. This pattern appears to be continued into postgraduate education where studies looking at medical and paediatric hospital admissions have shown that musculoskeletal
Clin Rheumatol Table 1 Musculoskeletal disease prevalence rates (per 100,000 person years at risk), GPRD 2001 [3] Disease
All ages (>16) (95 % CI)
All musculoskeletal events Soft tissue rheumatism and CWP Back pain Osteoarthritis
13,275 (13,215, 13,336) 4,068 (4,034, 4,104) 3,747 (3,715, 3,779) 1,724 (1,702, 1,746)
Rheumatoid arthritis Polymyalgia rheumatica Osteoporosis Ankylosing spondylitis SLE Scleroderma Gout
215 (207, 223) 165 (159, 172) 135 (129, 141) 37 (34, 40) 13 (12, 15) 6 (5, 7) 6 (4, 7)
assessments are rarely documented and when present are very limited, contrasting markedly with other systems. Self-rated confidence in assessment of musculoskeletal disorders is low compared to other systems [9, 10]. In 1995, Lanyon et al. published the results of a national questionnaire looking specifically at GP trainees/GP registrars’ (GPRs) rheumatology education [1]. This showed that by the end of their trainee year 35 % of the responding registrars had not received any tutorials on rheumatology topics from their trainers and only 43 % had had any rheumatology teaching on their central teaching sessions from the vocational training scheme. Trainees reported that they were under-confident at managing musculoskeletal disorders, and when asked to rate the amount of their rheumatology education, responded with inadequate. The authors suggested that a standardised rheumatology curriculum be developed and incorporated into all GP schemes. Following on from this, in January 2000, Arthritis Research UK published a Learning guide for general practitioners and general practice registrars on musculoskeletal problems, the content of which was decided by a multidisciplinary group representing Arthritis Research UK, the RCGP and the Primary Care Rheumatology (PCR) society [11]. The guide was distributed to general practice trainers throughout the country although what its uptake has been is unknown. The aims of this study were to repeat the questionnaire survey used by Lanyon et al. in a sample of four deaneries to see if, 10 years on, GPR teaching has changed and to see if the Arthritis Research UK Learning Guide has made any impact on GPR education.
Methods The previously validated questionnaire looking at musculoskeletal education and management skills was reviewed, and
three questions were added [1]. Two of these were to investigate further the GPR’s experience of injecting soft tissue lesions and joints. It was noted that in the original study 84 % of registrars reported that they had injected or aspirated the knee. This seemed a large number from the authors’ own experience and from the prevalence of knee disorders in primary care. We therefore asked that if they had answered yes to injecting/aspirating a joint/soft tissue lesion, had they performed the injection in general practice? The third question was added at the end of the questionnaire asking if the registrars were aware of the learning guide, and if they were, had it been used in their training/teaching? This was to try to assess the effect that the production and dissemination of the guide has had on general practice education. The new four-page questionnaire was disseminated to registrars in general practice posts (including innovative posts with a general practice component) in June 2004 in four deaneries. The deaneries (Northern, Mersey, Yorkshire and Wessex) were chosen for their ease of access, and each used their preferred method of distribution.
Results Questionnaires were sent to 571 registrars in the four deaneries, and responses were received from 251 (44 %). Response rates were similar across the deaneries. There was a range of years of qualification and representation from the majority of medical schools within the country. Due to changes in GP training, we are reporting results from registrars at different points in their training, unlike the 1995 study which reported results from GPRs in their final months of training. Undergraduate teaching Of the registrars, 77 % reported receiving specific clinical rheumatology teaching at medical school. They rated the teaching in terms of its relevance to general practice as 5 (median, range 1–10) on a scale of 1 to 10 with 1 being not relevant at all and 10 being very relevant. Postgraduate teaching General practice registrars may receive musculoskeletal teaching from different sources and at different times: from the scheme, from hospital posts or from their trainer. Thirty-nine registrars (15.7 %) had a rheumatology post in their vocational training, and an additional 45 (19 %) were able to attend rheumatology outpatient clinics. Only 104 (42 %) registrars had received teaching on musculoskeletal conditions on vocational training scheme day release courses. Seventy-seven (32.1 %) had attended additional teaching in the form of
Clin Rheumatol
regional study days on the topic. On average, registrars estimated that they had spent an average of one half day on rheumatological topics. There was some variation across the deaneries with trainees in Yorkshire being more likely to have had rheumatology experience both as an SHO (26 % of GPRs compared to the average across all deaneries of 15.7 %) and as part of their day release sessions (70.7 % compared to the average of 41.8 %) although this may not be significant given the 44 % response rate. Most registrars recalled having tutorials on musculoskeletal conditions (173 (70 %)) with a median of only 2 h of teaching (Table 2). Back pain was the most commonly reported tutorial topic. Conditions such as childhood locomotor disorders and the management of musculoskeletal disability were less frequently discussed. Acquisition of injection skills Joint injection techniques were mainly taught by rheumatologists, whereas soft tissue injections were taught by the trainers (Table 3). A significant number of registrars claimed to be self-taught in both areas (10.7 % soft tissue, 8.7 % joint injections). Other sources of teaching included the following: A&E registrars/consultants; GPs other than the trainer; courses, e.g. minor surgery courses; and other medical staff. Most registrars (174, 70 %) had injected/aspirated the knee joint during their training although less than half of these had injected/aspirated the joint in a primary care setting. The most common soft tissue injection performed was for tennis elbow. Registrars were most confident at knowing when to inject the knee and at performing knee injections which corresponds with the knee being the most commonly injected site (Table 4). At each injection site, confidence scores were lower in those who had never injected compared to those who had injected. Registrars who had completed an SHO post in rheumatology were, on average, more confident about both knowing when to inject and at performing injections. Table 2 Tutorial topics reported by respondents (% of registrars who reported teaching, n=173) comparing 1995 data with 2004
Regional musculoskeletal examination Registrars’ perceived self-confidence at the regional examinations was high, with median ratings of 8 for examination of the back and knee, 7 for the shoulder and hip and 6 for the foot (1=not confident at all/10=very confident) (Table 5). The trainer was reported as being the person who predominantly taught GPRs how to examine and treat shoulder pain (27.9 %) although a significant number were self-taught (20.1 %). Fewer registrars reported having been taught by hospital consultants: rheumatologist (11.7 %), orthopaedic surgeons (15.1 %) and general physicians (7.3 %). Management strategies Registrars’ perceived confidence at managing specific musculoskeletal conditions was generally high and equivalent to their confidence at managing asthma and hypertension. Educational methods Preferred educational methods were as follows: trainer tutorials, small group teaching, rheumatology outpatient clinics and SHO posts (Table 6). Distance learning and attending symposia were the least popular. General practice registrars rated their overall VTS training on musculoskeletal conditions as inadequate, with a median response of 4 (1=totally inadequate, 10=completely adequate). Only 10 % of respondents were aware of the Arthritis Research UK Learning guide for general practitioners and general practice registrars on musculoskeletal problems.
Discussion Lanyon’s study was a national evaluation of general practice rheumatology education, but this survey looking at training in four deaneries offers an interesting comparison. Whether these
Tutorial topics
1995 Percentage (no.)
2004 Percentage (no.)
Back pain Osteoarthritis Osteoporosis Gout Soft tissue/periarticular disorders Rheumatoid arthritis Sports injuries Management of musculoskeletal disability Locomotor disorders in childhood
52.4 (563) 26.1 (280) 21.9 (235) 25.8 (277) 26.2 (282) 28.8 (319) 20.1 (223) 13.7 (147) 8.5 (91)
87.3 (151) 43.9 (76) 42.8 (74) 39.3 (68) 38.2 (66) 33.5 (58) 20.2 (35) 11.6 (20) 10.4 (18)
Clin Rheumatol Table 3 Injection sites reported by trainees showing differences between 1995 and 2004
Injection site
Given injections 1995 (trainees=1,075)
Knee joint Shoulder: glenohumeral joint Tennis elbow Shoulder: subacromial Elbow joint Shoulder: acromio-clavicular joint Plantar fasciitis Golfers elbow De Quervain’s tenosynovitis Bicipital tendonitis
deaneries are representative of the current training situation throughout the UK is unknown although there is no evidence to suggest that they are not. A response rate of 44 % is comparable to response rates in other general practice questionnaire studies [12]. Although this does raise the question as to whether the responses are more likely to be from registrars interested in musculoskeletal conditions and so more likely to have requested teaching, or conversely from registrars who feel that their education is lacking. The majority of registrars had received specific clinical rheumatology education at medical school although this was not regarded as being particularly relevant to general practice. This is consistent with the results of studies specifically looking at undergraduate musculoskeletal education [6]. As current medical school and foundation programme education in musculoskeletal disorders is deemed insufficient [13], there is an opportunity for vocational training to make up this gap and produce competent doctors. Unfortunately, in 1995, GPRs reported their education as lacking [1], and from this survey in four deaneries, it appears that not enough has changed. Table 4 Confidence at knowing when to inject joints/soft tissue lesions and confidence at performing joint injections 2004 data (1=not confident at all/10= very confident)
Glenohumeral joint Acromio-clavicular joint Subacromial bursa joint Knee joint Elbow joint Tennis elbow Golfers elbow De Quervain’s tenosynovitis Bicipital tendonitis Plantar fasciitis
2004 (trainees=251)
No. (%)
Rank
No. (%)
Rank
897 (84) 416 (39) 596 (56) 361 (34) 292 (28) 251 (24) 277 (27) 236 (23) 123 (12) 142 (14)
1 3 2 4 5 7 6 8 10 9
174 (69.6) 76 (30.4) 68 (27.3) 50 (20.0) 49 (19.6) 48 (19.3) 31 (12.4) 27 (10.8) 22 (8.8) 17 (6.8)
1 2 3 4 5 6 7 8 9 10
This survey shows that more registrars had held a rheumatology SHO post during training than previously and that these were perceived to be of educational value. These GPRs were more confident in the use of soft tissue and joint injections. Other studies looking into the relevance of hospital posts have shown that the content of teaching is not always appropriate to primary care [14]. This may be improved with the advent of innovative posts where GPRs divide their time between a hospital speciality and general practice. There are, however, differences between the range of musculoskeletal disorders seen in secondary care and those managed in primary care. This must be taken into account when training GPRs and provision made. An ideal time and location to improve musculoskeletal education is in the general practice part of a registrar’s training. This can be through the half day release teaching sessions and tutorials and also opportunistically during surgeries. In general, this teaching is a case-based teaching which is both effective and valued by trainees [15]. Unfortunately, only 42 % of the registrars reported having teaching during their day release sessions and only 32.1 % had attended regional
Confidence at knowing when to inject
Confidence at performing injections
5 4 4 7 4 5 4 2 2 3
4 3 3 7 2.5 – – – – –
Clin Rheumatol Table 5 Confidence at managing the following conditions (1=not confident at all/10=very confident) Conditions
Confidence 1995
2004
Gout
8
7
Back pain Sports injuries Osteoarthritis Soft tissue/periarticular lesions Locomotor disorders in children Diagnosing inflammatory arthropathies Safety monitoring of second line drugs (DMARDS) Osteoporosis Asthma Hypertension
8 6 7 6 5 6 6 6 9 8
8 5 7 6 5 6 5 7 8 8
study days. It may be that the terminology used in the questionnaire, i.e. ‘regional study day’ was an issue and affected the response. These results are analogous to those from a questionnaire study of 20 vocational training schemes which showed that on average only 1.3 half day release teaching sessions were allocated to musculoskeletal disorders in a year [16]. In many vocational training schemes, the half day teaching is informal and the agenda is determined by the GPRs. It may therefore be that the GPRs are not aware of musculoskeletal medicine having a high priority or being a learning need. Only 70 % of registrars reported having tutorials on musculoskeletal conditions. This could be an underestimate as it may be that they are recalling only formal teaching and not the opportunistic case discussions/problem case analysis that they receive—estimated at about 37 min of teaching per week [17]. It is interesting to compare what they recall being taught on to the prevalence rates from the General Practice Research Database (see Table 1). For example, both gout and rheumatoid arthritis are common tutorial topics, whereas in practice, they are seen less commonly than, e.g. soft tissue disorders. This may reflect the continuing influence of teaching from secondary care consultants in medical school.
Table 6 Sources of learning Teacher
Percentage (1995)
Percentage (2004)
Trainer Self-taught Rheumatologist Orthopaedics Physician Other
26 31 26 35 6 –
27.9 20.1 11.7 15.1 7.3 17.9
Joint injections, as recognised in the 1995 survey, are not necessarily the most important outcome of training but are an identifiable endpoint. As in the original study, there was a high level of acquisition of knee injection skills, but further questioning of the respondents revealed that these skills are not being used in their general practice attachments. This probably indicates that experience is being gained in both medical and accident and emergency posts but then is possibly lost as the opportunity to use them in general practice does not arise. In comparison, shoulder injection skills are less commonly learnt. This may reflect the fact that 20 % of the registrars report that they are predominantly ‘self-taught’ in the management of shoulder pain or it may be because the opportunities for learning may not arise. For example, cases of bicipital tendonitis and De Quervain’s tenosynovitis rarely appear in GP surgeries and so may not be seen during the registrar year. Interestingly, a survey of GPs in the ‘Wessex’ region in 2005 revealed that 66.4 % of respondents carry out injections themselves with tennis elbow, glenohumeral joint, knee, supraspinatus tendonitis and carpal tunnel syndrome being the most common injections performed [18]. GP trainers are therefore a major teaching resource for musculoskeletal medicine. What is interesting is that the GPR respondents in the 1992 study may now be trainers themselves. If these doctors were not confident at managing musculoskeletal disorders then, have they gained enough knowledge and skills since to make them proficient GPR trainers? Are we perpetuating poor musculoskeletal training for GPs? An attempt by the Arthritis Research UK to try to improve training by the production and dissemination of the ‘Learning guide for general practitioners and general practice registrars on musculoskeletal disorders’ [10] appears to have had little impact as the results from both the original questionnaire and this repeat survey are very similar and only 10 % of the responding registrars were aware that the guide exists. Since the original study, general practitioners with special interests (GPSIs) have increased in number, and these could be an important resource for general practice training. Improved GPR and GP training could have both implications for patients and NHS resources as studies have shown that GPs who have undertaken musculoskeletal training courses show sustained reductions in NSAID prescribing [19]. Roughly £170 million of the NHS drug budget in 1999 was spent on NSAIDs, and they are known to cause significant morbidity and mortality. Intake of NSAIDs has been associated with an estimated 2,000 deaths a year in the UK and a fourfold to fivefold increase in gastrointestinal bleeding [20]. General practice training has changed since 2004 with the introduction of Modernising Medical Careers, a new focused and streamlined training programme. All doctors will complete a 2-year Foundation Programme immediately after qualification and prior to entering their chosen speciality. GP
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training currently lasts for 3 years with 18 months based in general practice. There are plans to extend this to 4 years with 24 months in primary care, which may have a negative effect on musculoskeletal training as the chance to do a hospital post in either orthopaedics or rheumatology is reduced and there will be limited innovative posts including a musculoskeletal element. In conclusion, despite the introduction of compulsory vocational training, a highlighted need for improved education in 1995 and the efforts of Arthritis Research UK, rheumatology education for GP registrars still appears to be inadequate. It is essential that registrars receive sufficient training to enable them to be confident in managing the large number of musculoskeletal disorders that present to general practice, and it will be interesting to see what effect the development and introduction of the 2012 curriculum for general practice has [21]. Ethics This project was discussed with the chair of the local research ethics committee, and formal ethical approval was not required. Acknowledgments We thank Ann-Marie Smith for her administrative assistance, Dr. Peter Lanyon for allowing us to use his questionnaire, Dr. Graham Davenport, Dr. George Taylor and Professor Frank Smith for assisting with the access to the four deaneries, Dr. Adrian Dunbar and Dr. D John Dickson for their comments and Wyeth, Proctor & Gamble and Pfizer for providing postage costs. Disclosures None.
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