nmrcgp for consultants

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Rheumatology/Musculoskeletal

This is what our GP trainees need to achieve during their time at your department. We've classified them under the six main compentency domains for general practice..

1. PRIMARY CARE MANAGEMENT

• Manage primary contact with patients who have a musculoskeletal problem.
• Explain the aetiology and natural history of common and important musculoskeletal conditions.
• Describe the roles of the primary health care team, allied health professionals, complementary therapists and secondary care (e.g. in shared care protocols), and referring to them appropriately.
• Understand the indications for referral within a suitable timeframe to the most appropriate healthcare practitioner (e.g. GPwSI, physiotherapist, podiatrist, osteopath, chiropractor, orthopaedic surgeon, rheumatologist).

The knowledge base

Symptoms
• Inflammation - pain, swelling, redness, warmth
• Lack of function – weakness, restricted movement, deformity and disability
• Injuries - cuts, bruises, wounds
• Systemic manifestations - rashes, tiredness, nerve compression etc.

Common and/or important conditions
• Acute back/neck pain
• Chronic back/neck pain
• Shoulder pain
• Knee pain
• Soft tissue disorders
• Osteoarthritis
• Osteoporosis
• Somatisation/fibromyalgia and allied syndromes
• Pain management
• Acute Arthropathies
• Chronic inflammatory arthropathies
• Polymyalgia rheumatica and allied conditions
• Awareness of rare diseases
• Chronic disability
• Common injuries
NB - these topics should be considered throughout the age range including children

Investigation
• Indications for plain radiography, ultrasound, CT and MR scan including the use of tools such as the “Ottawa Rules”
• General rules of X-ray Interpretation
• Implications of "Misses" on X-rays, common errors.
• Indications for additional investigations for example blood tests.

Treatment
• Understand principles of treatment for common conditions managed largely in primary care including the use of NSAIDs and disease modifying drugs
• Knowledge of when joint injections and aspirations are appropriate in general practice and the ability to perform when appropriate e.g. Shoulder and knee joints and injections for Tennis and Golfer’s Elbow
• Understand the roles of allied health professionals (nursing, physiotherapy, chiropody, podiatry, occupational therapy, counselling and psychological services)
• Chronic disease management including systems of care, multidisciplinary team work and shared care arrangements

Emergency care
• The initial management of the patient who has been burnt
• To be aware of the safety of the patient, the scene of the incident and medical staff
• To be aware of how to summon help in an emergency
• Be competent in basic life support (adult and paediatric), the use of simple airway adjuncts (for example oropharyngeal airway and pocket mask) and the safe use of a defibrillator
• Be competent in stopping haemorrhage
• Be competent in reducing pain by the use of analgesia or other methods.
• Be aware of the principles of major incident management
• Referrals requiring emergency action to save life or prevent serious long term sequelae

Prevention
• Advise regarding appropriate levels of exercise
• Heath promotion regarding accident prevention

2. PERSON CENTRED CARE

• Communicate health information effectively to promote better outcomes e.g. use positive terms such as “wear and repair”.
• Communicate truthfully and sensitively to patients for whom therapeutic options have been exhausted, and share uncertainty when the patient wants this.

3. PROBLEM SOLVING SKILLS

The knowledge base

Treatment
• Understand principles of treatment for common conditions managed largely in primary care
• Understand the roles of allied health professionals (nursing, physiotherapy, chiropody, podiatry, occupational therapy, counselling and psychological services)
• Chronic disease management including systems of care, multidisciplinary team work and shared care arrangements

Prevention
• Advise regarding appropriate levels of exercise
• Heath promotion regarding accident prevention

Specific problem-solving skills
• Intervene urgently when patients present with trauma in a primary care setting e.g. basic life support, control of haemorrhage, summoning help.
• Describe the epidemiology of musculoskeletal disorders at all ages, and apply this when developing a differential diagnosis.
• Assess the mechanism of injury when considering diagnosis.
• Distinguish inflammatory from non-inflammatory conditions.
• Assess the possibility that musculoskeletal symptoms can be due to psychological causes (somatisation).
• Describe when blood tests and imaging methods are required for diagnosis, how to interpret them and how they influence management.

4. COMPREHENSIVE APPROACH

• Describe problems that can be caused by the treatment of musculoskeletal disorders (e.g. GI bleeds, osteoporosis, coronary heart disease, radiation damage) and explain primary and secondary prevention of these.
• Advise patients regarding what they are physically able to do, according to their level of disability.

5. COMMUNITY ORIENTATION

• Explain how to access available resources e.g. educational material such as the ARC information leaflets, support groups.
• Facilitate self-help strategies to empower the patient e.g. self-treatment measures, the expert patient programme (DH), Challenging Arthritis Programme (Arthritis Care) and local exercise programmes.
• Avoid investigations or treatment that are unlikely to alter outcomes, so that availability of these resources is increased (e.g. imaging methods)
• Appreciate the resource implications of incapacity for work due to musculoskeletal conditions.
• Prioritise referrals accurately so people with minor conditions do not potentially compromise the care of those with more serious conditions (e.g. referrals for joint replacements, non-life threatening orthopaedic conditions).
• Identify when referral to complimentary medical services is justified, considering that many services have limited NHS availability or are only available privately.

6. HOLISTIC APPROACH

• Recognise that psychosomatic symptoms are commonly described as musculoskeletal problems, and that musculoskeletal problems often have an important psychological component.
• Consider the physical, psychological and social impact of musculoskeletal conditions on individuals and their carers (e.g. problems with fatigue, altered body image, work, impact on family relationships and sexual issues).
• Recognise the psychological effects of trauma (e.g. post-traumatic stress disorder).
• Assess the likelihood of occupational exposure as a cause of musculoskeletal disease (e.g. repetitive strain injury) and advise regarding the likely prognosis in relation to the occupation.

All these 6 domains have a

7. Contextual Aspect

• Understand where services are deficient and have frequent long waiting times (e.g. imaging services, physiotherapy and allied professions, hospital based services including consultant opinion and interventions)
• Recognise how geographical distance influences the treatment of trauma in a primary care setting.
• Understand the systems of care for rheumatological conditions, including the roles of primary and secondary care, shared care arrangements, multidisciplinary teams and patient involvement.

8. Attitudinal Aspect

• Demonstrate empathy and compassion towards patients with incurable, disabling or painful musculoskeletal conditions.
• Provide adequate information for informed consent before any procedure is undertaken.
• Recognise the emotional impact dealing with trauma and disability can have on the general practitioner.

9. Scientific Aspect

• Understand and implement the key national guidelines that influence healthcare provision for musculoskeletal problems (e.g. the NICE guidelines, RCGP low back pain guidelines, SIGN guidelines etc.)