Tips for GP trainees working in rheumatology

Welsh, Victoria

doi:10.3399/bjgp13x664450

Abstract

INTRODUCTION
One in four people registered with a GP will consult for a musculoskeletal problem over a 12-month period; this accounts for one in seven GP consultations.1 Musculoskeletal conditions significantly impact daily life through pain, disability, and psychological ill-health.2,3 A rheumatology rotation is therefore a relevant and practical rotation for GP trainees to undertake.

The key learning points from a rheumatology rotation include the early recognition of inflammatory arthritis to enable timely secondary care referral, the identification of the red flags of joint sepsis, and development of an understanding of the social and psychological consequences of chronic musculoskeletal conditions.

The basics
1. Before your first day, read current guidelines relating to common rheumatological conditions in both primary and secondary care, for example, the NICE guidelines for osteoarthritis and rheumatoid arthritis.4,5

2. Practice your examination skills. Although you are likely to be an experienced junior doctor, asking a friendly registrar to demonstrate their slick examination style and asking for tips will save you a lot of time in the future when clerking inpatients and outpatients.

3. Learn the monitoring requirements and side effects of the commonly used disease-modifying antirheumatic drugs. Seek advice on how to manage borderline results.

4. Practice joint injections at every opportunity. Ask your unit if they are planning to run a course or look online for your nearest one. This will also address the practical skills section on the Trainee ePortfolio.

5. Find out about local and national support services for your patients. Knowing and sharing information about such systems including 24-hour advice lines and patient support groups really does make a difference.

6. Read some patient information leaflets for tips on the less-discussed aspects of chronic musculoskeletal disease, for example, sex. Arthritis Research UK is an excellent resource for patients and clinicians.6

THE PATIENTS
7. People with rheumatological diseases span a wide range of age groups, socioeconomic backgrounds, and ethnicities. Treat each person as an individual; avoid stereotyping patients. Everyone has fears and concerns that are personal to them so don’t be afraid to ask.

8. Common concerns relate to fitness for work. Be supportive and realistic. Remember there is multidisciplinary team input to support employment for patients of working age.

9. Chronic pain, both current pain and the potential for future suffering, are real issues. Remember the psychosocial aspects of chronic pain. Analgesia isn’t just about medications; don’t forget other physical treatments and development of coping strategies. Learn from specialist pain teams, sit in clinics, and ask patients about their own pain-management techniques.

10. Attend as many lunchtime meetings as possible. This is where you meet the multidisciplinary team, put names to faces, hear about new research, learn from complex case studies, and receive clinical updates.

11. Get involved with medical student teaching, particularly clinical examination skills and running case-based tutorials. Teaching is a great learning opportunity and will address the ‘teaching, mentoring, and clinical supervision’ aspect of the ePortfolio.

INPATIENTS AND ON-CALL
12. Clerking rheumatology patients can take a significant amount of time. Factor this into your day and make the effort: the insights gained from really listening to the patient, considering their full case, comorbidities, medications, home circumstances, social aspects, and psychological health will be invaluable. Reflecting upon this holistic viewpoint and the ability to take a comprehensive approach all address aspects of the ePortfolio.

13. Be prepared. Rheumatology inpatients are often very complex to manage. Multisystem disease involvement, the presence of unrelated comorbidities, and conditions resulting from medical treatment all add to the challenge of clinical management. Accept that you cannot know everything.

14. You may be covering day case admissions for immunosuppressant or bisphosphonate infusions. Learn what goes on from a health professional and patient view point. This will help you appreciate your patient’s experience and assist you in answering patient questions.

15. Look forward to ward rounds. They offer a great opportunity to undertake case-based discussions, practice your presentation skills, and incorporate your critical appraisal skills when discussing new research relating to case management.

16. Remember, a patient with active synovitis from an inflammatory arthritis can also have a co-existing joint infection.

17. Don’t forget that access to certain investigations may not be possible in the rheumatology ward, for example arterial blood gases: you may need to refer the patient to an acute medical ward, don’t be afraid to do this if necessary.

OUTPATIENTS
18. Outpatient clinics are highly relevant to GP work; seeing new patients and instigating management plans is particularly beneficial. Listen to the patients’ stories, particularly around how the disease initially presented. This will stick in your mind when you see similar cases in primary care and help your decision making.

19. You may be working in a unit that supports research into new drugs. Take the opportunity to learn more about research in health care. At the very least, this will give you an appreciation of research participation and may even spark your interest in research.

THE MULTIDISCIPLINARY TEAM
20. Get to grips with the different roles of each team member, including physiotherapists, occupational therapists, specialist rheumatology nurses, and the pain team.

21. Spend time with the occupational therapists. They often have resources including fully-equipped kitchens complete with a range of assistive devices. Spend a few hours talking to patients about their daily functioning and the assistive devices available. You’ll be amazed at the array of implements available, including: tin openers, tap handles, jar openers, cutlery, and writing tools. Knowing about these devices and how to arrange their acquisition will help your future patients.

22. Shadow a physiotherapist in the outpatient department. Watching them at work will provide you with some gems of practical advice for patients that simply are not available from any other learning resource.

Journal Article Type	Article
Online Publication Date	Mar 1, 2013
Publication Date	2013-03
Deposit Date	Dec 1, 2023
Journal	British Journal of General Practice
Print ISSN	0960-1643
Electronic ISSN	1478-5242
Publisher	Royal College of General Practitioners
Peer Reviewed	Peer Reviewed
Volume	63
Issue	608
Pages	164-165
DOI	https://doi.org/10.3399/bjgp13x664450
Keywords	Family Practice

Tips for GP trainees working in rheumatology

Welsh, Victoria

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Abstract

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