The inadequacy of musculoskeletal knowledge after foundation training in the United Kingdom

Serum Urate Monitoring Among Older Adults With Gout: Initiating Urate-Lowering Therapy in Ontario, Canada

OBJECTIVE

To assess the proportion of, and factors associated with, older adults with gout receiving a serum urate (SUA) test after starting urate-lowering therapy (ULT).

METHODS

We performed a population-based retrospective cohort study in Ontario, Canada in patients ages ≥66 years with gout, newly dispensed ULT between 2010 and 2019. We characterized patients with SUA testing within 6 and 12 months after ULT dispensation. Multilevel logistic regression clustered by ULT prescriber evaluated the factors associated with SUA monitoring within 6 months.

RESULTS

We included 44,438 patients with a mean ± SD age of 76.0 ± 7.3 years and 64.4% male. Family physicians prescribed 79.1% of all ULTs. SUA testing was lowest in 2010 (56.4% at 6 months) and rose over time to 71.3% in 2019 (P < 0.0001). Compared with rheumatologists, family physicians (odds ratio [OR] 0.26 [95% confidence interval (95% CI) 0.23-0.29]), internists (OR 0.34 [95% CI 0.29-0.39]), nephrologists (OR 0.37 [95% CI 0.30-0.45]), and other specialties (OR 0.25 [95% CI 0.21-0.29]) were less likely to test SUA, as were male physicians (OR 0.87 [95% CI 0.83-0.91]). Patient factors associated with lower odds of SUA monitoring included rural residence (OR 0.81 [95% CI 0.77-0.86]), lower socioeconomic status (OR 0.91 [95% CI 0.85-0.97]), and patient comorbidities. Chronic kidney disease, hypertension, diabetes mellitus, and coprescription of colchicine/oral corticosteroids (OR 1.31 [95% CI 1.23-1.40]) were correlated with increased SUA testing.

CONCLUSION

SUA testing is suboptimal among older adults with gout initiating ULT but is improving over time. ULT prescriber, patient, and prescription characteristics were correlated with SUA testing.

A History of Musculoskeletal Medicine and Its Place and Progress in Undergraduate Medical Education

Musculoskeletal diseases are responsible for some of the most prevalent conditions affecting population health in the world. Despite the prevalence of these conditions, musculoskeletal medicine has a fraught history within the world of undergraduate medical education. We review the origins of musculoskeletal medicine, its evolution in undergraduate medical education, and progress that has been made over the last decade as a result of global initiatives such as the Bone and Joint Decade. Understanding the history of musculoskeletal medicine is essential to contextualizing the problems that exist today and creating comprehensive solutions to fill the gaps that persist in musculoskeletal curricula.

Knowledge of Musculoskeletal Medicine in Junior Doctors in Australia: Is It Adequate?

PURPOSE

The incidence of musculoskeletal disease is increasing in Australia and around the world. However, medical student education does not necessarily reflect current and projected trends in musculoskeletal medicine. The aim of this study was to assess junior doctors' competency in musculoskeletal medicine using the Freedman and Bernstein Basic Competency Examination in Musculoskeletal Medicine questionnaire.

METHODS

We conducted a cohort study of interns (first year post medical school) across four teaching hospitals in Australia. Interns were asked to take the Freedman and Bernstein examination during organised intern teaching sessions, and results were analysed using the original Freedman and Bernstein marking criteria and validated pass mark.

RESULTS

The mean score for the 92 interns was 13.9 out of 25 (55%) with scores ranging from 8 to 20.8 (29-83%). Only 8 of the 92 interns (8.7%) achieved a score of greater than 73%, the pre-specified pass mark.

CONCLUSION

Our study identifies inadequacies in musculoskeletal medical knowledge in Australian interns. Review of undergraduate medical education may be required to reflect current and predicted trends in the prevalence of musculoskeletal disease and adequately prepare junior doctors.

Advanced practice physiotherapy in paediatrics: Implementation results

Objectives

This study aimed to evaluate the implementation of an advanced practice physiotherapist (APP) clinic in our paediatric institution and assess APP and orthopaedic surgeon satisfaction.

Methods

In this retrospective cohort study, all patient records from the APP clinic's second year (March 2017 to March 2018) at CHU Sainte-Justine were reviewed. These were compared with the records of patients seen by orthopaedic surgeons within the gait clinic the year before implementing the clinic. The following data were collected: demographic, professional issuing referral, reason for referral, consultation delay, clinical impression, investigation, and treatment plan. We also documented every subsequent follow-up to rule out any diagnostic change and identify surgical patients. Clinician satisfaction was assessed by the Minnesota Satisfaction and PROBES Questionnaires along with a short electronic survey.

Results

Four hundred and eighteen patients were assessed by APPs and 202 by orthopaedic surgeons. APPs managed patients independently in 92.6% of cases. Nearly 86% of patients were discharged following the initial visit, and 7.4% were referred to a physiotherapist. Only 1% of APP patients eventually required surgery compared with nearly 6% in the orthopaedic group. The mean waiting time for consultation was greater in the APP group (513.7 versus 264 days). However, there was a significant reduction in mean waiting time over the last 3 months surveyed (106.5 days).

Conclusions

The feedback from all clinicians involved was positive, with a greater mean score on the Minnesota Satisfaction and PROBES Questionnaire for APPs. The APP gait clinic appears to be an effective triage clinic.

Level of evidence

III.

Undergraduate education of trauma and orthopaedic surgery in the UK

Aims

Evidence exists of a consistent decline in the value and time that medical schools place upon their undergraduate orthopaedic placements. This limited exposure to trauma and orthopaedics (T&O) during medical school will be the only experience in the speciality for the majority of doctors. This review aims to provide an overview of undergraduate orthopaedic training in the UK.

Methods

This review summarizes the relevant literature from the last 20 years in the UK. Articles were selected from database searches using MEDLINE, EMBASE, ERIC, Cochrane, and Web of Science. A total of 16 papers met the inclusion criteria.

Results

The length of exposure to T&O is declining; the mean total placement duration of two to three weeks is significantly less than the four- to six-week minimum advised by most relevant sources. The main teaching methods described in the literature included didactic lectures, bedside teaching, and small group case-based discussions. Students preferred interactive, blended learning teaching styles over didactic methods. This improvement in satisfaction was reflected in improvements in student assessment scores. However, studies failed to assess competencies in clinical skills and examinations, which is consistent with the opinions of UK foundation year doctors, approximately 40% of whom report a “poor” understanding of orthopaedics. Furthermore, the majority of UK doctors are not exposed to orthopaedics at the postgraduate level, which only serves to amplify the disparity between junior and generalist knowledge, and the standards expected by senior colleagues and professional bodies.

Conclusion

There is a deficit in undergraduate orthopaedic training within the UK which has only worsened in the last 20 years, leaving medical students and foundation doctors with a potentially significant lack of orthopaedic knowledge.

Cite this article: Bone Jt Open 2022;3(7):549–556.

Assessment of knowledge of junior doctors and non-specialists about musculoskeletal medicine

Objectives:

To assess the knowledge and confidence of junior doctors and non-specialists in examining and making a diagnosis of patients with musculoskeletal (MSK) diseases.

Methods:

This was a Cross-sectional study of 121 doctors working in medical clinics at a tertiary hospital between October and December 2019. Data were collected using a questionnaire. Doctor’s awareness regarding different MSK examination methods including gait, arms, leg, spine (GALS), pediatric gait, arms, leg, spine (pGALS) and regional examination of musculoskeletal system (REMS) was noted. Undergraduate teaching of these methods and use in their daily practice was surveyed.

Results:

Majority of the doctors lacked awareness about different MSK examination techniques. Awareness about GALS, REMS and pGALS was 44.6%, 59.5% and 18.2% respectively. There was significant correlation of GALS/REMS awareness with the undergraduate teaching and doctor’s clinical experience (p-value <0.05). Confidence level of doctors in diagnosing patients with adult MSK pathologies was 55%. Only few doctors were satisfied with their musculoskeletal education (29%).

Conclusion:

The GALS examination is a useful screening tool for junior doctors and non-specialists in a direct access setting to rule out musculoskeletal problems.

Current State of Undergraduate Trauma and Orthopaedics Training in United Kingdom: A Survey-based Study of Undergraduate Teaching Experience and Subjective Clinical Competence in Final-year Medical Students

OBJECTIVE

To assess the quality and duration of trauma and orthopedics (T&O) training in medical schools in United Kingdom (UK), and to evaluate final-year students' self-perceived level of competence in essential T&O skills.

DESIGN

This was a survey-based study of final-year medical students that attended 1-day undergraduate T&O courses held between Feb'17 and Feb'19. Outcome measures were duration and perceived quality of undergraduate T&O placements, students' self-rated competence in essential T&O skills, and impact of teaching methods on their subjective future competence.

SETTING

Four courses held at education centers in 3 different locations in UK (London, Nottingham, and Leeds) PARTICIPANTS: All 414 course attendees from 13 UK medical schools completed the questionnaire.

RESULTS

19.3% of students had not experienced a placement in T&O. Mean duration of T&O placements was 2.5 weeks. 37.4% described their training as "poor". Majority of students attended 1-5 sessions of: lectures (50.5%), small group teaching (58.7%), trauma meetings (58.7%), clinics (65.7%), and theatres (72.5%). Lowest competency scores were reported in management of T&O emergencies, fracture management, and interpretation of T&O radiographs. Self-rated competence in essential T&O skills was significantly higher in students with previous experience of a T&O placement (p < 0.05). There was a strongly positive correlation between small group teaching attendance and perceived competence in management of T&O patients in different clinical settings (p < 0.001).

CONCLUSIONS

Medical schools in UK are currently failing to adequately train medical graduates to manage T&O patients, with students reporting low competency scores in all basic T&O skills. To mitigate the current situation, a minimum duration of a T&O placement for all students must be implemented nationally. Educational boards and medical schools must work in collaboration to improve the delivery of undergraduate T&O curriculum, the structure of the clinical T&O placement, and efficacy of the commonly encountered learning environments.

The perceptions and attitudes of medical students towards trauma and orthopaedic teaching: a cross-sectional study

Objectives: This study aimed to identify how undergraduate students perceive learning opportunities available to them and to determine whether students with an interest in trauma and orthopaedic (T&O) surgery have different perceptions and attitudes towards learning.

Methods: All fourth year medical students from the University of Birmingham Medical School (UK) were surveyed regarding their career intentions and their attitudes towards the teaching received in trauma and orthopaedic surgery. The questionnaire was designed to capture student perception of learning environments, core knowledge and career motivations.

Results: Of the 157 respondents, 35 (22.3%) expressed an interest in a career in trauma and orthopaedic surgery. Medical students who reported educational value for trauma and orthopaedic surgery revealed that bedside teaching with a consultant was perceived extremely useful by 57.8% (n = 89). A similar ranking was awarded to small group teaching seminars and bedside teaching with a junior doctor or trainee by 54.5% (n = 85) and 51.6% (n = 79) of students, respectively. In contrast, trauma meetings and operating theatre learning environments were perceived to be of low educational value. Seeing patients within the clinical setting and the quality of teaching received were reported as the most motivating factors in career interest towards trauma and orthopaedic surgery, rated 43.9% (n = 69) and 35% (n = 55), respectively.

Conclusions: Perceptions of educational benefit derived from each learning environment vary among undergraduate medical students. Overall the most valuable learning environment perceived by the students is formal patient-based teaching. Despite diverging speciality choices students demonstrate similar learning needs.

Examination of the musculoskeletal system: junior doctors' perceptions of the usefulness of the Gait, Arms, Legs and Spine (GALS) technique

BACKGROUND

Musculoskeletal (MSK) conditions affect millions of people around the world. Gait, Arms, Legs and Spine (GALS) is a simple and useful screening tool for routine MSK examination in hospitals and general practice and has been integrated into the undergraduate medical curriculum. Despite this, there is evidence that doctors lack competency in MSK examination and that GALS are underperformed routinely.

OBJECTIVES

The study explored the views of junior doctors (JDs) on how they were taught MSK examination as undergraduates; the usefulness of GALS as a technique for excluding significant MSK problems; why MSK examination was often poorly carried out and how this could be improved.

METHODS

A qualitative study was performed with data gathered through focus group interviews from 32 JDs working in two acute NHS hospitals. Six interviews were conducted over a 6-week period from mid-June to the end of July in consecutive years 2013 and 2014.

RESULTS

Ninety JDs were invited to participate in the focus group interviews; 32 (36%) agreed to participate, 28 (88%) of whom had graduated in the UK. The perception of JDs was that undergraduate training for GALS and regional MSK examination was adequate, but reasons for lack of MSK competency in the workplace are multifactorial and complex.

CONCLUSIONS

Proposing more practical and interactive sessions to reinforce MSK skills during postgraduate training may not resolve issues of MSK competency among JDs. Recognition of the complexity of workplace learning and the influence of tacit learning is required if MSK competency is to be enhanced.

The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom

BACKGROUND

Musculoskeletal symptoms are common reasons for patients seeking medical attention. Basic competency in musculoskeletal medicine is therefore essential for all clinicians. To our knowledge, this is the first assessment of the competency in musculoskeletal medicine of medical students in the United Kingdom.

METHODS

Medical students were enrolled after passing final university examinations and being awarded degrees of Bachelor of Medicine, Bachelor of Surgery (MBBS) or Medicinae Baccalaureus, Baccalaureus Chirurgiae (MBChB) in 2013 and were assessed with use of the Freedman and Bernstein musculoskeletal cognitive examination tool.

RESULTS

Two hundred and thirty students were recruited, of whom 210 were suitable for inclusion. Only 21% (forty-four students) passed the assessment. Mandatory exposure to musculoskeletal medicine during medical school consisted of orthopaedics for 100% of participants for a mean duration of 2.65 weeks, rheumatology for 96% of participants for a mean duration of 2.5 weeks, and sports medicine for 1% of participants for a mean duration of two weeks. There was a significant difference (p = 0.002) in scores between those with career interests in musculoskeletal specialties (69.3%) and the rest of the cohort (54.9%). There was also a significant difference (p = 0.001) in scores between participants with career interests in general practice (42%) and the rest of the cohort (56%). Only 40% of participants considered themselves competent in musculoskeletal medicine. Fifty-five percent thought that musculoskeletal conditions would be an important component of their future practice.

CONCLUSIONS

Our findings suggest that medical schools may be currently failing to ensure that medical students have a basic competence in musculoskeletal medicine. Further investigation is warranted to fully assess the current training provided by U.K. medical schools in musculoskeletal medicine, and appropriate steps must be taken to improve the quantity and quality of training in musculoskeletal medicine in the United Kingdom.

Lack of proficiency in musculoskeletal medicine among emergency medicine physicians

OBJECTIVES

Emergency medicine (EM) physicians are frequently responsible for evaluating and treating patients with urgent or emergent musculoskeletal conditions, so it is critical that they achieve a basic level of proficiency in musculoskeletal medicine. However, inadequacies in musculoskeletal education have previously been documented among medical students, residents, and attending physicians in a number of specialties. The goal of this study was to assess the proficiency with musculoskeletal medicine among EM physicians in particular.

METHODS

A validated musculoskeletal medicine competency examination was administered to the EM residents and faculty at a university-affiliated level 1 trauma center. Demographic data and satisfaction with musculoskeletal education were also surveyed.

RESULTS

Twenty-three EM residents and 21 attending physicians completed the survey. Thirty-five percent of residents and 43% of attending physicians failed to demonstrate proficiency on the examination. Pass rates were not significantly different among junior residents, senior residents, or attending physicians. Twenty-three percent of respondents indicated that they were dissatisfied with their musculoskeletal education.

CONCLUSIONS

Significant deficiencies in musculoskeletal education exist among EM physicians in training and attending staff. Given the frequency with which these physicians evaluate and treat acute musculoskeletal conditions, additional resources should be committed to their training.

Musculoskeletal education in general practice: a questionnaire survey

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 confident in managing a significant proportion of their workload. Identifying learning needs for primary care would inform future educational interventions.

Nonelite exercise-related injuries: participant reported frequency, management and perceptions of their consequences

This mixed methods study explored the frequency of sport/exercise-related injuries in nonelite sport, participant-reported management and perceptions of potential injury consequences. Focus group participants, who trained two to four times a week and had previously sustained musculoskeletal sports-related injuries, reported seeking medical advice secondary to advice from teammates or online research. General practitioners were viewed as gatekeepers to specialist secondary care and less able to effectively treat sport-related injuries. Participants displayed limited awareness of potential future implications of injury, and considered physical and psychological benefits of exercise more valuable than potential injury-associated risks. In the survey of physically active people, over half reported sustaining an exercise-related injury (562/1002, 56%). Previously injured respondents were less likely to consider consulting a health professional for injury-related advice than those with no injury history (45% vs 64%; P < 0.001) and more likely to continue exercising despite injury (51% vs 37%; P < 0.001). Concerns about injuries largely related to short-term issues; only 32% were concerned about possible long-term joint problems including osteoarthritis. Exercise-related injury was common in nonelite exercise participants. There was some dissatisfaction with care pathways for sports-related injuries and a lack of awareness about appropriate injury management and potential consequences of injury, particularly in the long-term.

Smartphones in orthopaedics

With the introduction of the European Working Time Directive, surgical trainees are facing limited training opportunities and doctors are required to maximise their training opportunities. Smartphone sales have been rapidly increasing over the last five years and can be used as a training tool for the orthopaedic trainee and surgeon. Common uses include applications (AO, eLogbook and PubMed), Ebooks, online Logbooks, Guidelines and surgical techniques. In addition, smartphones can be used to immediately complete work-based assessments, in the absence of computers, hopefully increasing completion rates and reliability. Some journals now provide podcasts and video tutorials which may be accessed on smartphones, which is useful for higher examinations. Smartphones can also be used in the clinical setting to take photographs of wounds. Smartphones are enjoying increased uptake and application in the workplace and we review their use for orthopaedic surgeons and trainees to allow them to make the most out of their training opportunities.

Musculoskeletal examination--an ignored aspect. Why are we still failing the patients?

Over the past two decades, rheumatologists from around the world have not only championed the musculoskeletal system examination but also modified the undergraduate teaching curriculum. This has led to the development and adoption of the gait, arms, legs and spine (GALS) screening along with regional examination techniques. The purpose of this study is to review current practice, determining the frequency of patient exposure to appropriate examination and confidence of junior doctors when dealing with MSK conditions. Two district-general hospitals (non-teaching) and one teaching hospital in North-East London were chosen. At each site, 50 patient notes were reviewed from the acute admission wards for medicine and surgery and the medical assessment unit. Factors considered included whether GALS screenings had taken place, documentation of MSK examinations and assessment of confidence of junior doctors in assessing MSK conditions. GALS screenings were performed for 4% of patients on the medical assessment unit, 7% of acute medical and 0% of acute surgical patients on admission. Examination of the MSK system yielded better results with 16%, 22% and 10% on each of the respective wards. Interviews with junior doctors found 10% routinely screening for MSK conditions, despite 87% feeling confident in taking MSK histories. This prospective audit of clinical practice highlights that patients failed to have a minimal assessment of the MSK system through GALS screenings. When examining the MSK system, results were somewhat better, although still fewer than expected. It is curious that the majority of junior doctors in training felt confident in dealing with MSK disease but few did it in practice. This begs the question of whether current teaching curricula and strategies are adequate. At a time where there is ever-increasing national momentum to address issues on obesity and cardiovascular health, our patients are still deprived of a standard MSK examination by the medical faculty.