Guest guest Posted March 21, 2003 Report Share Posted March 21, 2003 (Now here is the kind of doctor we need for CMT - a bit long but worth reading ~ G) Article from BMJ 2003;326:S89 ( 22 March ) Musculoskeletal medicine Skew puts the case for making musculoskeletal medicine a specialty in its own right, and Usamah Jannoun shares his experience of working as an associate specialist musculoskeletal doctor The emerging specialty of musculoskeletal medicine is a fusion of skills and techniques from general practice, rheumatology, orthopaedics, pain management, physiotherapy, osteopathy and chiropractic, occupational health, sports medicine, rehabilitation, psychology, and psychiatry. Eight hospitals in the United Kingdom already have musculoskeletal departments: Birmingham, Edinburgh, London (Homeopathic Hospital), Doncaster, Newport, Gloucester, Southampton, and Salisbury. In addition, a few multidisciplinary private clinics are run by musculoskeletal doctors and orthopaedic surgeons. Surveys of musculoskeletal medicine clinics in the NHS have shown cost savings of a third for patients with musculoskeletal problems treated in the established specialties. Work absence and ill health retirement may be mitigated or improved by more urgent, prompt, and appropriate treatment with a musculoskeletal doctor. Outside the United Kingdom In Europe doctors with skills in musculoskeletal medicine are found under different job titles. Outside the current European Union many Eastern bloc countries have very similar, differently named, medical practitioners. The Australian Association of Musculoskeletal Medicine has a university faculty that has received a grant of A$8m (£2.9m; $4.7m; 4.3m) from the state. A specialty in its own right Any emerging specialty has to clarify where its special expertise lies and identify the patients it wishes to serve. In the United Kingdom, the case for musculoskeletal medicine was helped by the Clinical Standards Advisory Group's back pain report of 1994,2 which showed the inadequacy of service for patients with acute low back pain and the consequences of not treating them until six months later. Other common areas of acute musculoskeletal injury and pain also exist that are poorly understood and treated, such as whiplash, work related upper limb disorders (WRULD types I and II), and many sports injuries. A specialty concentrating on these conditions would allow more focused research and treatment. Making musculoskeletal medicine a specialty in its own right would satisfy the demands of patients with a particular pattern of problems. Soft tissue injury, back pain, whiplash, work related upper limb disorder, and sports injury in the general population all demand a broad based set of skills for their appropriate diagnosis and treatmenta set of skills not available in the established specialties. The current situation At present, after prolonged periods of waiting, patients with musculoskeletal problems tend to attend one or more of up to 10 different specialties, such as rheumatology and orthopaedics. Patients are finding alternatives to the NHS by using osteopaths, chiropractors, private physiotherapists, and a host of practitioners of less well regulated disciplines. The demand for a cohesive service is undeniable. The existing system has many problems, but no one has offered any solutions. Practising musculoskeletal medicine After completing vocational training as a general practitioner I pursued my passion for musculoskeletal medicine. I first encountered this specialty during a house officer post in Germany. I passed the Diploma in Manual Therapy, equivalent to the Diploma in Musculoskeletal Medicine. The Diploma in Musculoskeletal Medicine is organised by the British Institute of Musculoskeletal Medicine (BIMM). It is open to all fully registered doctors. After completing theory modules on the upper limb, the lower limb, and the spine, I wrote a dissertation entitled " The Value of the Axial Patella View Taken in the Supine Position. " When I was working in the United Kingdom as a general practitioner (GP) an advert for an orthopaedic doctor caught my eye. Local GPs decided that a back triage service was needed as a waiting list initiative. Most patients seen in orthopaedic outpatient departments don't require surgery, but they wait a long time to be told. A back triage service where patients with chronic back pain are assessed, treated, or referred is a prompt and efficient solution to this common problem. My associate specialist post in the back triage service helped me to develop my knowledge and skills. I developed the clinic with two senior physiotherapists and work closely with a spinal surgeon. He used to take most referrals for patients with back pain. Now, patients are referred to the back triage clinic, where I assess complex presentations, rule out emergencies, perform manipulation, give spinal injections, and refer for investigations or to orthopaedics, rheumatology, or surgery. Communication with GPs has improved. Spinal orthopaedic surgical waiting times have been reduced. Sadly, only a handful of these hospital posts exist. My qualification in musculoskeletal medicine has allowed me to use diagnostic ultrasound in private sports injury practice. I also apply guidance on radiography and fluoroscopy for spinal injections. The Diploma in Musculoskeletal Medicine has been revised and updated. It now consists of eight modules taken over two and half years. It is particularly relevant to GP specialist registrars in rheumatology, orthopaedics, and pain medicine; occupational doctors; and sports doctors. Further information Go to the BIMM website for more details: www.bimm.org.uk, email info@..., or phone Deena on 01923 220999 Usamah Jannoun Both industry and the government have identified the problem and started the " Back in Work " project, a government sponsored initiative looking for prompt appropriate treatment for musculoskeletal conditions. Meanwhile, while patients are off work waiting for appointments (commonly six weeks for physiotherapy, six months for orthopaedics or rheumatology), the employer, their insurer, or the Department of Social Security has to pay them sick pay. The costs are dependent on contract and grade but, according to various sources, government statistics, and private company assessments, average £300 a week. Rheumatologists and orthopaedic surgeons already have too many patients. Non-disease and non-surgical cases block their clinics. In my opinion, it is inappropriate for a trained rheumatologist to see " necks, backs and `frozen' shoulders " while patients with rheumatoid arthritis wait six months for a first appointment. The " service need " case for musculoskeletal medicine has been accepted by both the Royal College of General Practitioners (RCGP) and the Department of Health (DoH) with the publication of the document Implementing a scheme for General Practitioners with Special Interests.3. It includes musculoskeletal medicine as a topic. Training Providing doctors who have trained in musculoskeletal medicine still remains the responsibility of organisations such as the British Institute of Musculoskeletal Medicine (BIMM), the Society of Orthopaedic Medicine (SOM), and the Primary Care Rheumatology Society (PCR) with modular and distance learning packages over periods of up to 30 months. The London College of Osteopathic Medicine (LCOM) runs a 13 month part time osteopathy course for doctors and, in partnership with University College London, an MSc course in musculoskeletal medicine and osteopathy. Course funding has to be provided by trainees themselves, who also have to take time from study or sabbatical leave over a period of up to two and a half years. Currently the course comprises eight modules, at £650 per module. A diploma examination in musculoskeletal medicine is available from the Company of Apothecaries. Clinical skills are picked up during an attachment with established practitioners in hospitals or private practices. GPs with a special interest in musculoskeletal medicine seem a reasonable alternative, but support for such GPs requires hospital posts for more invasive interventions, from doctors who will appreciate what the GP specialist has already done and why. Such specialist GPs would be able to integrate osteopathy, chiropractic, and physiotherapy services for more cost effective use. Making musculoskeletal medicine a specialty in its own right would satisfy the demands of patients with a particular pattern of problems. Musculoskeletal medicine needs to become a specialty in its own right. For legitimacy and a future, the current training path must be accepted, validated, and encouraged, with recognition of the certification of the completion of specialist training (CCST) and a training number. How will existing musculoskeletal departments be staffed in the future, without a proper training programme? Skew, president British Institute of Musculoskeletal Medicine, Watford WD17 4AH Usamah Jannoun, associate specialist musculoskeletal physician Royal Hampshire County Hospital, Winchester Further information British Institute of Musculoskeletal Medicine (BIMM; www.bimm.org.uk/): 34 The Avenue, Watford, Hertfordshire WD17 4AH Society of Orthopaedic Medicine (SOM): 6 Court View Close, Lower Almondsbury, Bristol BS32 4DW Primary Care Rheumatology Society (PCR): PO Box 42, Northallerton, North Yorkshire DL7 8YG London College of Osteopathic Medicine (LCOM): 8 Boston Place, London NW1 6QH Worshipful Company of Apothecaries of London: Blackfriars Lane, London EC4V 6EJ Australian Association of Musculoskeletal Medicine (AAMM; www.musmed.com/about.html): 29 Craigie Road, Newtown, 3220, Australia References 1. Musculo-skeletal physician care among orthopaedic outpatients unlikely to require surgery: the OMENS trialan opportunistic evaluation. Health Bull 2001; 59: 198-210. 2. Clinical Standards Advisory Group. Back pain. London: HMSO, 1994. 3. Department of Health, Royal College of General Practitioners. Implementing a scheme for general practitioners with special interests. London: DOH/RCGP, 2002. © 2003 BMJ Publishing Group Ltd Quote Link to comment Share on other sites More sharing options...
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