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Teaching rheumatology in primary care
  1. A S M JAWAD
  1. The Royal London Hospital
  2. Bancroft Road
  3. London E1 4DG, UK
    1. J HOSIE,
    2. G HOSIE,
    3. P THORBURN
    1. The Surgery
    2. 1980 Great Western Road
    3. Glasgow G13 2SW, UK

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      I agree with Hosie1 that each group in primary care “has different needs at different times and educational activities must be sufficiently flexible to deliver what is needed at the appropriate time.”

      Over the past decade I have been teaching rheumatology to trainees in general practice in a district general hospital and over the past four years in a teaching hospital in the east end of London.

      Trainees find it more useful if musculoskeletal problems are discussed by region as they present in real life rather than as individual diseases. For example, the differential diagnosis of pain in the elbow includes medial and lateral epicondylitis, olecranon bursitis (traumatic, inflammatory, or crystal induced, but is not to be confused with tophi, rheumatoid nodules, or xanthomas), osteoarthritis, a loose body, and inflammatory synovitis.

      Musculoskeletal diseases are discussed as conditions presenting with mainly problems of arms, legs or spine. Each of the three regions is discussed in a two hour session. After one hour's tutorial, four to five relevant cases are presented to illustrate the conditions discussed.

      For established general practitioners we have started “teach and treat” sessions. This programme is funded for a year by the local primary care group. The rheumatologist visits a local multi-doctor practice every fortnight for a two and a half hour session. The general practitioners present six to eight patients that they would have referred to the hospital. The patients are examined and treatment is discussed and if a procedure is required, it is given at the same time.

      So far 14 practices have enrolled in the programme and three sessions have been completed. The response has been encouraging. Eighteen patients (10 female, 8 male) with an age range of 30–76 years (average 57.5) have been seen. The case mix included shoulder problems (five), symptomatic osteoarthritis of various joints (four), recent onset inflammatory polyarthritis (four), soft tissue lesions (three), and back problems (two). Ten procedures have been performed.

      Each session is being audited and appraised by the local doctors. Upon completion of the first round of sessions, we should have a better idea of the case mix and the difficulties the local general practitioners face. The final audit would help in further developing the training of local trainees (in general practice) and in the continuing professional development of general practitioners.

      Another added advantage is the improvement in communication between primary and secondary care and a better understanding of each other's problems. On the other hand, better awareness of musculoskeletal problems may lead to a paradoxical increase in the number of referrals. However, it should lead to a better patient care.

      References

      Authors' reply

      I agree with Dr Ali Jawad that teaching of general practitioners and general practitioner registrars is best done within primary care itself, reflecting the mix of musculoskeletal problems that present within the community.

      Various groups around the country are putting in place teaching similar to that described and, in particular, the Primary Care Rheumatology Society is setting up a series of meetings led by society members looking at common problems presenting to GPs.

      Our first round of training meetings is based on shoulder problems and the initial meetings have been greeted with enthusiasm by participating GPs. We hope to expand this programme to include other regional problems, osteoporosis, and inflammatory arthritis. I think that the main benefit of teaching in this way is that it produces positive practical outcomes for examination techniques, treatment options, and the demonstration and practice of practical procedures, such as steroid injections.

      Education for GPs, which is perceived to be generated from within primary care, with consultant input as appropriate, seems to be well received by GPs.

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