After a few rather philosophical posts I thought there might be a preference for a return to something practical in regards to teaching a particular topic of the curriculum.
Here’s the problem
Musculoskeletal presentations are incredibly common in general practice (as reported by BEACH data), next to skin/dermatology, and yet many GPs lack confidence and enthusiasm in dealing with them. Those who are keen tend to veer towards (and specialise in) sports medicine and this does not help the vast numbers of the ageing population whose main practical problem is often musculo-skeletal in nature (but not of the elite sports variety).
Why is there lack of confidence and what can be done? How do we prepare learners for future practice?
There is an increasing tendency for patients to go first to physios or even chiropractors as primary carer – which seems reasonable in many ways but also tends to deskill GPs and decrease continuity of care. Ongoing management is often tricky in terms of sufficient access to allied health care when needed and, of course, many problems are difficult to cure or remediate (and others get better with time). Imaging has also become a point of contention. In addition there is not a single specialty to ask for advice and problems encompass broken bones / traumatic soft tissue injuries / rheumatological and degenerative conditions / disability etc. More commonly these days, falls and frailty are also part of the picture.
Is there also some gender stereotyping: tears and smears vs cutting and injecting?
Reflect on your own skills and enthusiasm. I got better (for a while) by:
- studying for the FRACGP – when I read a lot and then ensured I did full examinations on appropriate patients
- teaching musculoskeletal topics – we all know that teaching is an important way to learn
- experiencing symptoms myself over the years
Most trainees are young and healthy (but some are ex physios or heavily involved in sport), all are studying for their exams and opportunities for peer to peer teaching can be organised.
The breadth of knowledge relevant to MSK problems is illustrated anecdotally by a recent experience of mine. Six months ago I was improving my musculoskeletal health by exercise (sports medicine) and fell off my bike. This resulted in a Colles’ fracture (orthopaedics). After the cast was removed I discovered I had a ruptured EPL. Meanwhile the pre-existing OA in the PIP and DIP joints on my “good” hand were aggravated (rheumatological). I still have the functional deficits associated with the tendon rupture, some of the lingering problems were soft tissue related on the ulnar side and I still have decreased range of flexion and extension of my left wrist – not to mention an officially increased “fracture risk” on algorithm and a small amount of subjective “fear of falling” that I didn’t have before (falls and fractures / geriatrics !) I certainly have a lot more breadth of knowledge now about Colles fractures than I did when I straightened dozens of them in ED under Bier’s blocks years ago. However, I have long since lost my skills and confidence in dealing with them as my clinical exposure is now so rare (practical skills).
Given the topic’s importance and all the competing demands it is sometimes necessary to fight for an appropriate place in the curriculum and appropriate experiences in practice.
- Small group learning – but this needs to be well structured
- Case based – should be well prepared and resourced
- Practical sessions are always requested – but bear in mind that these can degenerate into just standing around and not using the time optimally
- Practice based – this is probably the most useful resource and yet the most difficult to organise. There is unpredictable variability in the interest and expertise of supervisors in such areas which is quite reasonable. It would be of educational value to know the learning environments, potential experiences and resources of placements across the full sweep of training for each registrar but this is difficult with rapidly increasing numbers of practices and decreasing personal knowledge of them. Orchestrating the learning environment is becoming less popular and being replaced by testing competencies
- Internet resources – these have multiplied over recent years and are always changing. It is useful to ask your registrars what they have become aware of (often from undergraduate years). Examples to explore would be the University of Wisconsin, department of family medicine http://www.fammed.wisc.edu/category/media/musculoskeletal/ or just search youtube (preview any you plan to use and note their quality and how long they are)
- Peer to peer teaching – this could involve guidelines’ review or recruiting learners with existing expertise (if you know them)
- Registrars are often good at guidelines for acute conditions – you can build on this
- Other evidence-based resources such as Choosing Wisely, National Prescribing Service, Cochrane Database are useful – although they often have a limited focus (particular conditions, imaging, medications, procedures)
The best educational outcomes result from considering the total learning environment so if lectures and workshops can be linked to practice experiences this will enhance learning. Some people also learn best from hands-on experiences so practical sessions should be included. Musculoskeletal medicine is also an area where interdisciplinary collaboration is crucial so get to know some allied health presenters who are keen to engage with GPs. If you aren’t an expert, have someone there who is. Any educational session should be well planned (ask yourself what are you aiming at, how are you going to achieve it, what methods might work best, what was the previous feedback, how will you measure your success). Elements of a Flipped Classroom can be included by sending out links to short videos or other online resources as preparation. Take the opportunity in small groups to interact with the learners and ask them about their experiences and clinical experience so far as this can motivate others or reveal learning opportunities. As always, a case-based approach is appreciated and a patient-centred approach adds value.
Finally, this is an area in which to encourage excellence and advise those who are keen (or not so keen) about other opportunities for further study. If you are good at something you tend to feel good about it. As with other areas of general practice, the experiences and engagement that occurs during training often dictates the direction and enthusiasm of future practice (beyond just exams).