When practice isn't always perfect
Reproduced from Issue 110 of Arthritis Today
Doctors
might not always know best – especially when it comes to arthritis.
Jane Tadman looks at why GPs should do better.
When Pam Jackson's doctor told her she had advanced osteoarthritis in the neck and spine at the age of 53 she was terrified. "I thought by the time he had finished, I would end up in a wheelchair," says Pam, from Leeds.
"He told me I would not be able to do any housework again, and that I should take paracetamol. He gave me no information about the disease, nothing about diet or exercise or support groups. I know there is no cure, but surely he could have suggested something. He had a very negative attitude."
Alice Jerwood went to her GP with agonising pain in her legs and was told she had well-established arthritis of the spine. "He advised me to get Extra Strength Ibuprofen and paracetamol tablets, then at the end of the week when the pain got very bad again it was suggested that I try Solpadeine. Apart from being told that 'it won't kill you' I have been given no advice whatsoever," she recalls.
These are two typical stories the Arthritis Research Campaign's information officer hears time and time again. For although arthritis and associated musculoskeletal conditions account for 20 per cent of the average GP's workload, many doctors are woefully ignorant about rheumatic disease, offering inadequate treatment that drives many patients into the arms of complementary therapists.
This much was admitted by two eminent rheumatologists, Mike Doherty and Anthony Woolf, in a recently published paper. "Much of the current substandard treatment is due to ignorance – not recognising the clinical need, not knowing sufficiently the role of modern interventions and still retaining a mistaken negative attitude to conditions which are viewed as chronic, incurable, and often the inevitable consequences of age," they say. "As a result, the patients' problems are not properly recognised, or considered important by professionals".
One of the main reasons for this malaise is lack of training in rheumatology in medical schools. Says GP Peter Glennon, who trained in the 1980s: "As a medical student you could go on holiday for two weeks and come back to find you'd missed rheumatology altogether." In 2000 things don't appear to have improved very much, and a recent arc-funded survey of current practice in undergraduate teaching in the UK by Dr Lesley Kay, from the University of Newcastle, makes depressing reading.
Dr Kay found that while the majority of medical schools include rheumatology clinical skills teaching in their curriculum for all their students, in five schools up to half of the students receive no clinical rheumatology teaching at all.
"We are concerned, that, despite the importance and frequency of musculoskeletal complaints in everyday medicine, rheumatology appears to be losing its status as a core specialty in some medical schools' curricula," says Dr Kay. With the projected increase in the number of older people by 25 per cent in the next 15 years, and therefore more musculoskeletal disease, this is especially worrying.
"By then the students who entered medical school at the time of the survey will be consultants and GPs, and their musculoskeletal skills and knowledge of rheumatology will be more and not less relevant than those of current doctors."
The General Medical Council published guidelines in 1993 which sets out the principles to which medical schools should stick, and core skills which students must attain, but its recommendations are generic, and each medical school develops its own curriculum.
Various initatives are in place to improve this situation, although all these depend on the keenness of the individual to take an active interest in rheumatology.
arc has played a leading role in making things better over the years. It produces widely-used literature for medical students as well as promoting rheumatology through the arc Prize, and produces a series on medical reports on topical issues for GPs. It is also funding an education workshop for university rheumatology teachers with the aim of encouraging good practice among lecturers.
Ray Armstrong, a consultant rheumatologist in Southampton, has arc funding to produce an interactive CD ROM teaching package for medical students to access on the internet, which, he hopes, will fill the gaps in their knowledge. "It's long been recognised that the majority of medical schools in the UK provide less rheumatology teaching than would appear necessary," said Dr Armstrong. "In Southampton, for instance, apart from some sessions early in the course and in the final year, the main part of rheumatology teaching takes part in the third year, when just four afternoons are devoted to the subject."
Produced in collaboration with the Primary Care Rheumatology Society and the Royal College of General Practitioners, the arc has also published a new learning guide on musculoskeletal problems for GPs and GP registrars, which flags up topic areas which they are likely to encounter on a day-to-day basis, such as neck and back pain, osteoarthritis, and pain management.
The PCR also issues regular guidelines on the management of musculoskeletal conditions in primary care for GPs. And it runs a number of symposiums and workshops to train GP trainers, and a long-distance learning diploma affiliated to the University of Bath.
Patient Partners, a programme developed by Searle Pharmaceuticals in the US, and run in the UK by Arthritis Care, involves patients teaching doctors about joint examination. Around 150 'patient experts' have been selected so far by their rheumatologist and sent on joint examination courses. After training, they accompany the medics to give hands-on seminars, including the Bath course, using their own bodies as examination tools for students and doctors
Despite all those positives steps, Dr Glennon, a GP in Stoke, and a member of arc's education sub-committee, agrees that rheumatology provision in primary care across the UK is patchy. The key, he believes, to improving the service to patients is to understanding their fears about their health, and listening to them.
"Patients may have to be told that they have mild progressive osteoarthritis and be worried about that. You may not prescribe anything different to another GP, but if you can explore and address their fears that will help. I would also do a blood test to reassure the patient that their condition was not inflammatory, and perhaps discuss alternative treatment such as glucosamine sulphate.
"However, an average consultation lasts seven minutes, and a lot of patients come in with multiple problems and osteoarthritis might be fourth on the list. There is simply not much time."
Dr Gill Hosie, a GP in Glasgow, and President of the PCR, believes many GPs need to change their attitude to arthritis. "We are trying to educate GPs to take a more holistic view of arthritis and to change the negative vibes that exist. And we need to work together with patients, as it's important that they are involved in managing their own condition.
"There are a number of things that have been shown to be effective including patients losing weight, increasing exercise, and taking more control. But they have to realise that at the moment there is no cure – we don't know the cause or the cure – and we have no magic pill to make it go away."
Attitudes take a long time to change. It's only in the past ten years that the importance of early diagnosis and treatment of rheumatoid arthritis has been recognised, and that GPs should immediately refer patients with suspected inflammatory disease to a rheumatologist. Now a similar shift in attitude is required in the treatment of osteoarthritis in primary care. It's simply not good enough for GPs to argue that too much specialism leads to a loss in overall general skills in primary care. The least patients can expect is a diagnosis, and some idea of how to manage a condition which they will have to endure for the rest of their lives, not to be fobbed off with a prescription for NSAIDs, which can have serious side-effects.
Peter Glennon believes there is some light on the horizon. New Personal Development Plans for GPs will be introduced next year, which will involve doctors reviewing each other's performances and will lead to GPs actively seeking to address their weaknesses by further training.
And, slowly, rheumatology is increasing in popularity as specialty among medical students. But if doctors don't wise up about arthritis, patients will not tolerate their continued ignorance and look elsewhere for treatment; the internet, or complementary therapists. A recent email posted on arc's website makes the point succinctly: "You've given me more information in ten minutes than I've been able to get from my GP in two years. And my mind has been put at rest."
