To date, this study is the most comprehensive survey that includes all 33 (non-new) medical schools in the UK to assess the duration of undergraduate T&O rotations. Adequate training in MSK conditions is essential for medical students for several reasons. MSK conditions are on the rise globally with an ageing population and rapid increase in prevalence of obesity. It has been recorded that 28.9% of the population are living with MSK conditions.2 MSK conditions also account for 30% of GP consultations.3 With such a high MSK workload for GPs, a high degree of skill in dealing with MSK complaints would be expected. However, studies have shown that GPs and GP trainees lack confidence in managing MSK disorders.4
Studies have highlighted UK medical schools’ failure in ensuring students’ competence in MSK conditions, strongly advocating for better quantity and quality in MSK teaching.5 In 2014, BOA published the undergraduate T&O syllabus to guide the provision of teaching in medical schools.6 The new syllabus was designed to reflect the needs of graduating students and cater for those who would become GPs. Ensuring a strong knowledge base of T&O in medical students is crucial to ensure that medical students who go on to become GPs have sufficient knowledge to manage patients in the primary setting and make appropriate referrals for specialist input. The need for consistent T&O teaching and exposure during undergraduate training is paramount for future GPs to ensure that these students have been exposed to enough conditions before completion of training, especially when GP training is shorter in duration than hospital-based specialities.
Goff et al. 2016 explored why GP trainees feel under prepared in MSK pathology. They postulated that the reduced confidence stems back to lack of exposure at an undergraduate level.4 For UK GP trainees, there is a similar lack of training at a postgraduate level for MSK conditions. Only 10% of GP training posts included a rotation in orthopaedics.7 For GPs, solid basic knowledge of MSK conditions is essential to enable efficient and timely service to patients. It is essential for GPs to make appropriate referrals to rheumatologists or orthopaedic surgeons. This is highlighted by a recent article in the BMJ, which discusses GPs uneasiness with managing MSK complaints preferring to refer to hospital specialists.8 Inappropriate referrals add to the long waiting times for hospital outpatient reviews, inconvenience to patients and untimely management of patients.
Ensuring adequate T&O exposure in undergraduate training is not only important for future GP trainees. Research has shown that positive student experiences during surgical rotations may lead to students deciding to pursue a career in surgery.9 Having time in theatres, access and communication with surgeons, professional relationships and mentor-mentee relationships, amongst others, play a role in this positive experience. Johnson et al. found that the primary influence on student’s career choice was their third-year medical school placement.10 Adequate exposure to T&O is crucial to inspire and attract the next generation of orthopaedic surgeons and to ensure the speciality maintains competitiveness to select the best candidates. Boutefnouchet et al found that students felt that seeing patients within the clinical setting and the quality of teaching were the greatest motivating factors in developing interest in T&O as a career.11 Redlich et al. found that direct contact with surgeons in theatre and student’s experience in theatre were also positive factors.12 Other authors have also found that quantity of attending surgeons, role models in surgery and communication with surgeons were also important factors.13–14
These papers highlight the importance of having adequate exposure in T&O as this can influence one’s career choice. To maintain a speciality that selects the best candidates for training, it is imperative to maintain competitiveness for the speciality. BOA recently published an article raising concerns about the decline in surgical post application rates.15 There will undoubtedly be a higher demand for T&O surgeons with an increasing ageing population and prevalence of lifestyle diseases. Therefore, it is essential to ensure that the competitiveness of the speciality is maintained by ensuring medical students have enough exposure to the speciality to realise their interest. Mentorship is seen as an essential tool in shaping students and trainees. A systematic review and meta-analysis found that mentorship was one of the key factors in choosing a specialty.16 Mentor-mentee relationships can be better realised when students have sufficient time on placement in a speciality to build these relationships.
There is a global need for improvements in MSK education, with studies in America, Australia and Egypt recommending re-evaluation of undergraduate and postgraduate MSK training.7, 17–19 This was highlighted by the World Health Organisation (WHO) in ‘the bone and joint decade 2000–2010’.20 They promoted changes to medical school programmes globally, with aims of programmes having at least 6 months of MSK teaching.
The authors have looked at the duration of T&O placements as one of the measures of exposure to T&O. The authors have defined and measured interest in having a career in T&O as being an active member of BOTA. This data was taken cross-sectionally in March 2020. From those included in this study, the top four medical schools with highest number of graduates between 2014–2020 registered to BOTA were Manchester (12), Birmingham (10), Newcastle (9) and Oxford (8), (see Table 2). Oxford university was the fourth university with the highest number of members registered to BOTA which was also one of the top four universities with the longest total length specifically for T&O in days.
The mean total duration of teaching or placement for T&O in all 33 universities was 18 days, ranging from 3 to 50 days. There was no direct correlation between duration of T&O teaching and exposure and the number of BOTA members at a particular university. The universities that had no members in BOTA were Keele, Liverpool, Plymouth, Lancashire and St Andrews. It is important to note, there will be no record of individuals graduating from St Andrews as students are transferred to other universities for clinical training and proceed to ‘graduate’ from the university they have transferred to, therefore St Andrews has been removed from Table 2 and discussions. Keele, Liverpool, Plymouth and Lancashire had below the average number of days in T&O, ranging from 3 to 15 days. This relationship could be explained by a ‘plateauing’ effect, where minimum number of days are required to form an interest in students however after a certain number of days, there is a saturation effect where having more days in T&O does not significantly lead to an increase in interest in T&O. The crucial ‘certain number of days’ may need to be long enough to expose students in clinics, theatres and on the ward. The results show that there is a large discrepancy in the length of T&O placements in the UK. There is an obvious need for more consistent durations across the UK, ensuring that students are adequately exposed to T&O.
A recent study investigating T&O undergraduate teaching in the UK found that medical schools were failing to adequately train medical graduates to manage T&O patients.21 The authors suggested a minimum duration of T&O placement to be implemented nationally. They suggested that educational boards and medical schools should work together to improve the delivery of undergraduate teaching. The authors also agree with the suggestions from this study. This study however only looked at 13 medical schools. One of the limitations of their study was also that some of the delegates who filled out the survey had not yet had their T&O placement which could have affected their final data and results. It is clear that further research and discussions are required to establish the minimum duration of T&O at an undergraduate level. The authors advise that medical schools aim to increase the duration to the national average of 18 days if they are not already meeting this duration.
The main limitation of this study is that the authors have to presume that the syllabus has not changed since the time of the authors’ efforts to gather the data. The authors also acknowledge that the validity of the results from the dissemination of the survey relies on one data source for each university. However, majority of the participants of the survey had also provided the relevant medical school handbooks which detailed the T&O teaching delivered in the curriculum. Hence, this allowed us to cross-check the data received in the questionnaire.
More dedicated time in T&O would be beneficial to engage students with the specialty. This, however, will take many years to achieve. Some initiatives to keep students engaged would be through involvement of clinicians in surgical societies in delivering lectures and courses, hosting shadowing schemes and offering meaningful projects for students.
All T&O training responsibilities do not lie with undergraduate training. There are post graduate training opportunities. During and post foundation training, individuals can undertake fellowships and taster weeks. However, in foundation training there can be limited opportunities for clinics and theatres due to the ward cover workload and responsibilities. Fellowships can offer greater exposure to T&O however interest in the speciality is normally realised before undertaking the role.