Musculoskeletal Medicine in Family Practice. Editorial - Keith K W Chan

(The Hong Kong Practitioner June 2010, Vol12:1-2)

Editorial 
The HK Practitioner June 2010, Vol12:1-2

Musculoskeletal Medicine in Family Practice
Keith K W Chan陳國維

Keith K W Chan, MMPhysMed (Mu.sk) (Syd)
President,
Hong Kong Institute of Musculoskeletal Medicine.

Correspondence to: Dr Keith K W Chan, Room 1201, 12th Floor, City Landmark I, 68 Chung On Street, Tsuen Wan, N.T., Hong Kong SAR.

Many people ask me whether I have switched my practice from family medicine to musculoskeletal medicine. My answer is always: “No, I’ve never changed my specialty. Practicing musculoskeletal medicine is, actually, part of my family practice!” In my view point, a good musculoskeletal physician is no different from a competent family physician. They are all holistic, know their patients well, understand their relationship with families, have a good patient-centered consultation skill and practice preventive medicine. The only difference is that a musculoskeletal physician has to have an in-depth knowledge and skill in musculoskeletal medicine that needs further training.

The uniqueness of musculoskeletal medicine

Musculoskeletal Medicine is the medical discipline that deals with acute or chronic musculoskeletal injury, disease or dysfunction. Its aim is to address the somatic dysfunction, which is an impaired or altered function of the components of the somatic (body framework) system. The somatic system includes the skeletal, arthrodial and myofascial structures with their related vascular, lymphatic and neural elements. Although there is overlap in disease spectrum with orthopaedic surgery, their scopes are different. While orthopaedic specialists are in a best position to deal with traumatic and neoplastic diseases of the bony skeleton, musculoskeletal physicians centre their work on the chronic pain and biomechanical dysfunction from the soft tissue injuries and dysfunctions. In fact, the two disciplines can be supplementary to each other and in other countries like Australia and USA; it is not uncommon to find orthopaedic surgeons and musculoskeletal physicians working together as a team.

Clinical needs and provision of care in the discipline

According to a local study, musculoskeletal problems ranked the 3rd commonest cause of consultation in primary care both in general practice setting and with the A&E department in Hong Kong . It has been estimated that one in four consultations in primary care is caused by problems of the musculoskeletal system and that these conditions may account for up to 60% of all disability pensions². With the ageing population, one would anticipate this situation will further escalate and that musculoskeletal problems will contribute more and more workload for family physicians. There is a definite need for further training in musculoskeletal medicine for all family doctors . Apart from quantitative needs from patient demand, there are also qualitative needs for better patient care. Musculoskeletal problems can have a wide spectrum of presentations that can mimic other diseases. For example, a man with chronic epigastric pain was diagnosed to be psychosomatic because all his investigation results including endoscopies and abdominal ultrasound were normal, but later found to have his pain originating from trigger points in his rectus abdominis. A lady who was stressed out from her persistent occipital headache was put on antidepressant because her headache was not relieved by analgesics; her MRI brain and X-ray cervical spine were otherwise normal, but was found to have cervical dysfunction of C2/3 causing impingement on the lesser occipital nerve. To accurately diagnose these common clinical presentations from unusual underlying musculoskeletal problems require in-depth knowledge in musculoskeletal medicine.

Family physicians are at the right position to take up musculoskeletal medicine

Family physicians are at the right strategic position to provide professional musculoskeletal medical care to patients. The commonest symptom of musculoskeletal diseases is pain. By definition, pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.  It entails great diversity of causes and complicated by many contextual factors from the physical, social and psychological domains. Family physicians are at the advantage here as we are trained to deal with these undifferentiated clinical problems that span across the physical and psychosocial domains. Besides, family physicians are skilled clinicians who demonstrate competence in the patient-centered consultations; integrating a sensitive, skillful, and appropriate search for underlying cause of problems, be it structural or biomechanical; understanding patients’ experience of feeling unwell (particularly their ideas, emotion, and expectations) and the impact of illness on patients’ lives. We, family physicians, make use of comprehensive approach (with consideration of biopsychosocial factors) to manage disease and illness in the context of the patients, their families and the community. These skills are in perfect match with the multi-facets and multi-disciplinary nature of musculoskeletal medicine.

Looking Toward the Future – Building competency

The burden of illness in musculoskeletal medicine will only increase in future years. Inadequate preparation will not meet the demands of the population. It is imperative that the College of Family Physicians should step up her effort in providing postgraduate education in musculoskeletal medicine to equip the family physicians to be better-rounded and to adopt the strategic role in providing better musculoskeletal care to the public. Like any branch of medicine, musculoskeletal medicine needs training and continual medical education. The competency in this discipline bases upon thorough knowledge of body anatomy, pathophysiology and biomechanics. It encompasses fluent skills in history taking, physical examination, investigations and dynamic musculoskeletal ultrasound imaging aiming at making positional diagnoses of musculoskeletal disorders, i.e. to localize a complaint to a specific region and, if possible, a specific anatomical structure, and to define its malfunctioning biomechanical relationship to movement and function. It requires understanding on the inter-linking between the physical, psychological and social perspectives and how they operate in contributing musculoskeletal dysfunction and pain in a person. To be competent in musculoskeletal medicine, a long training pathway after the completion of the family medicine training is mandatory. However, the fruitful results and the unsurpassable professional satisfaction will make such effort worthwhile.

References:

1. Lee A, Lau FL, Hazelett CB, et al. Morbidity patterns of non-urgent patients attending accident and emergency departments in Hong Kong:cross-sectional study. HKMJ 2001;7:131-138.
2. Editorials. Understanding the burden of musculoskeletal conditions. BMJ 2001;322:1079-1080.
3. International Association for the Study of Pain