Monthly Archives: October 2017

And now for something more practical – MSK learning for general practice

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?

What works? 

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 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)

Summary suggestions

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).

What’s new, what’s old or what works (from AMEE)

Much of medical education today focusses on being “innovative” (or complaining that older methods cannot possibly be appropriate). A few weeks ago I was at the AMEE conference in Helsinki, looking for “what’s new” but was impressed by one of the keynotes addressing what actually might work in education. It was great to be challenged by some broader educational ideas (instead of just which particular testing method has temporarily replaced the previous one).

The address was by Pasi Sahlberg and looked at Finnish lessons for education – stimulated by their consistently impressive ratings in the PISA results (in school education) from the OECD. These came to light initially in 2001 and it took a few years, apparently, for the Finns to take them seriously and actually believe them – and, therefore, to start looking at reasons behind this. The country’s school children performed well in literacy, then maths, then science.

Australia’s response to their own falling position in the rankings has been to introduce more testing.

Countries that don’t improve

 Sahlberg speculated on some characteristics of countries that don’t improve in educational outcomes: they emphasise competition and choice; they have test-based accountability; teaching is de-professionalised and they are addicted to reform.

What might have worked – in Finland

There is an emphasis in many areas on everything being “faster” but Sahlberg claims that, by contrast, Finland is into “slow learning”.  He characterised the education systems that perform better as including:

  • Collaboration
  • Teacher involvement in curricular development
  • Trust based responsibility
  • Teacher professionalism
  • Systems improvement rather than reform.

An emerging feature was the relationship between quality and equity.

He also raised the issue of using small data.  Big Data has certainly proved useful for global education reform by informing us about correlations that occurred in the past. But to improve teaching and learning, it behooves reformers to pay more attention to small data – to the diversity and beauty that exists in every classroom – and the causation they reveal in the present. In some other venues he has flagged the increasing use of technology as influencing educational outcomes but also now dictating the research agenda.

His slides are here but don’t give the full flavour of his talk (such as playing “Knocking on Heaven’s Door” and getting the crowd of several thousand to sing along).  Of course the PISA rankings have produced their own problems and encouraged teaching to the test in many countries although they do now look also at broader equity issues.  Finland’s top position has been taken recently by several East Asian countries with very different approaches. Some commentators note that, compared to Australia, all these high performing countries have much more homogeneous populations (which is now changing in Finland) – but, on the other hand, Canada has also consistently maintained a higher position than Australia. Whatever that means.

Sahlberg addresses the pros and cons of PISA including increasing commercialisation in this area but also notes there have been austerity measures in Finland since 2008: Finally, what Finland should learn from these recent results is that reducing education spending always comes with consequences. It is very shortsighted to think that high educational performance ….. would be possible when resources are shrinking.

Relevance for medical education

Schools are a long way from the medical education environment (which can be quite privileged) but sometimes it’s good to stretch our minds and consider some broader concepts. Besides which, it is probably also of interest if you have children or grandchildren.  Like all education, the possible variables influencing outcomes are myriad and even the outcomes themselves are debated.  I won’t draw particular conclusions but suggest that it might be interesting to reflect on your own teaching/learning environment and the system in which you work.  Consider which concepts have relevance, the direction in which your education system is heading and the implications of this.

We often encourage post graduate trainees to reflect and there is some literature on whether one can teach “reflection” so perhaps we educators should also be trying to reflect on concepts such as: collaboration, competition, professionalism of and respect for educators, opportunities to use small data to improve, the reasons for reform, resources and funding priorities, the use of tests etc – and whether “slow learning” might be relevant for post graduate GP training?  Maybe an interesting workshop topic.


(silver birches in Finnish forest and airport sculpture)