Introduction
Musculoskeletal presentations represent a significant proportion (20%) of general practitioner (GP) workload [
1]. In the UK, knee pain is the most common musculoskeletal presentation in general practice, after lower back pain [
1]. The burden of knee pain on healthcare resources is increasing, and knee pain accounts for the greatest number of new consultations seen in Irish secondary care orthopaedic clinics with meniscal pathology being the most common knee diagnosis after osteoarthritis [
2,
3]. Meniscal pathology in adults who are middle aged (35 years) and older, is frequently referred to as a degenerative meniscal tear (DMT) [
4], and is considered to be an early part of the whole continuum of degenerative knee disease [
5]. A DMT is different from an acute meniscal injury associated with significant trauma or sports injury. DMTs are usually considered atraumatic and often present spontaneously or after low-energy injuries [
6].
Exercise therapy, as part of a conservative management approach, is recommended as first line treatment for a DMT [
7]. Meta-analyses of clinical trials demonstrate that improvements in pain and function with exercise therapy are comparable in effect size to improvements with surgical treatment, over three-to-60-month follow-up studies [
8]. Based on these trials, clinical practice recommendations advise against the use of meniscal surgery in favour of a conservative management approaches such as exercise therapy, oral or topical pain medication or injections [
7]. Nonetheless, while the rate of surgery (i.e. arthroscopic meniscectomy) globally has declined over the past two decades [
9‐
12], it remains a commonly performed orthopaedic procedure. In England, the annual incidence of surgeries was 120 per 100,000 persons in 2017 [
13]. A similar but higher annual incidence was reported from the Netherlands in 2014 (164 surgeries per 100,000 Dutch inhabitants) [
10] and from Florida, USA (291 surgeries per 100,000 persons) in a 2018 study [
11].
Qualitative research with people attending Irish secondary care with a diagnosis of DMT identified an expectation of surgery and a reluctance to engage with physical activity for fear of exacerbating structural damage [
14]. The beliefs of primary care health professionals, including GPs, were identified as contributing to these negative expectations in relation to the role of exercise therapy in managing DMTs [
14]. The influence of clinicians’ beliefs on a patients’ understanding of their musculoskeletal problem and their recovery expectations is well established [
15].
Achieving implementation of clinical practice recommendations can be challenging. Research in low back pain suggests GPs have substantial awareness of guidelines, but the practical implementation is more uneven. Providing patient centred care within a broader psycho-social context and operating within a limited health service are some of the challenges to applying low back pain guidelines that GPs face [
16,
17]. Numerous studies have also explored the barriers to implementing clinical guidelines for osteoarthritis in primary care [
18], but none specifically exploring practice related to DMTs. While there is overlap with osteoarthritis management there are also distinctions, for example, there exists a surgical treatment option for a DMT that is no longer recommended but has not been fully de-implemented [
19]. Exploring GPs’ experiences of working with individual patients with DMTs and understanding the wider contextual factors at play is warranted to further explore gaps in the implementation of clinical practice recommendations. Hence, this study aimed to explore GPs’ views and experiences of managing people with knee pain attributed to a DMT.
Theme 1: GPs’ experiences of relational aspects of care
This theme relates to GPs’ personal encounters working with people with knee pain attributed to a DMT, focused on their experience of relational aspects of care. In the main, GPs worked to maintain relationships with patients while simultaneously trying to balance patient priorities with their own beliefs about the best course of action. In some cases, GPs described how they stalled or slowed down clinical decisions in an attempt to delay any escalation of care. This theme also describes the challenging emotional experiences of GPs working with this group, including feeling ‘stuck’, having exhausted conservative management options and the difficulty of caring for patients within a health system under strain.
GPs described feeling pressure to arrange injections, imaging or referral to orthopaedics in response to patient expectations. This was particularly the case regarding imaging, where GPs often perceived the patient expected a scan or x-ray, and this expectation was at odds with their own beliefs about best practice. GPs typically described either accommodating patient preferences, or negotiating with the patient to find a compromise:
“So maybe we make a deal of, let’s give this two weeks … and that we’ll make the decision together as to whether we need to step into the next frame of intervention” (GP14).
Explaining or justifying their decision-making to patients was a time and energy consuming process for some GPs. Where patients had a strong preference for a particular intervention i.e. injection or imaging, several GPs described how it was easier to acquiesce to these demands than trying to “swim against the tide” when a patient was insistent:
“It’s a great way to end a consultation to say you’ll order a scan. If you’re not going to do an MRI, you have to do an awful lot of explaining. Often, it’s just the easiest way” (GP4).
Another reason given for conceding to patient demands was to maintain the doctor-patient relationship. The potential to “break the patient relationship” (GP9) when a patient’s expectations were not met was acknowledged, with one GP explaining “I may not see them for a long time again” (GP12).
Some GPs had perceived a shift in the dynamics of the doctor-patient relationship away from GP controlling decision making towards care that was more led by patient views and expectations:
“I mean, they’ve gone from, “oh you’re the doctor, whatever you say is grand” to “I want this, I want that, I want the other” (GP3).
This feeling GPs had of care dictated by the patient was also exemplified by the practice of patients requesting referrals for imaging or orthopaedics over the phone, being reluctant to attend in-person. This left GPs feeling excluded from a care pathway dictated by the patient or physiotherapist “they want the MRI … then they want the referral for the orthopaedic surgeon, and I am simply a barrier or an enabler … I am essentially an arranger of referrals” (GP5):
Another important aspect of the GP-patient interaction was reassuring patients about the nature of their knee condition. Particularly, more experienced GPs emphasised their role in allaying patient concerns by examining the knee and setting positive patient expectations because “if given time these things will probably sort themselves out” (GP6). A key component of this approach was about slowing down the decision-making process to allow natural history to take its course:
“I say “Well do you want to try the exercise for maybe three months first and see how you get on and often there is a peak in the pain and the natural history is, it will be a lot better in 3 months anyway, do you want to wait?” (GP11).
Patients were generally amenable to this approach when GPs explained it was about delaying rather than withholding further interventions or imaging. An established and trusting therapeutic relationship was viewed as an advantage in these conversations, particularly when it involved delaying any escalation of care:
“When they trust you, you have the option of “Look we will see how this goes for a few weeks and come back in a couple of weeks and we will review it again”. You know they are much more amenable to that” (GP1).
GPs expressed a strong sense of solidarity and empathy with their patients, particularly for those who had a prolonged wait for orthopaedic services, while continuing to experience significant knee symptoms. GPs described feeling “very stuck sometimes” and that their “hands are tied” with patients who had not improved despite exhausting conservative management options. Feelings of helplessness, guilt or unease were expressed by GPs when they felt they had no option apart from prescribing increasing doses of analgesics:
“Even though you feel so sorry for this patient, and you know it’s wrong pumping them with all this stuff (analgesia), but you know you don’t have anything else to offer” (GP13).
Some GPs described feeling isolated, left alone to care for patients and compensate for the failings of the wider health service. GPs also expressed a tension between trying to conserve healthcare resources in a system under strain, while also considering the needs of individual patients:
“We’re expected to balance being the gatekeepers of resources and having the patient satisfied leaving, and somewhere in between practice medicine in the best we can” (GP2).
Theme 2: GP beliefs about what constitutes best care for patients with DMT
This theme relates to GPs beliefs about what constitutes best care for patients with a DMT. Exercise was considered the first line treatment, but GPs also believed patients often sought a ‘quick fix’, affecting their engagement with exercise. Imaging wasn’t viewed as a necessary part of management by most participants, however some reported that arthroscopy could be beneficial.
GPs believed exercise to be the core treatment approach and the “the bedrock” of management. GPs’ preference was for strengthening exercise to reduce stress on the joint. General physical activity was also promoted as part of recovery, with a preference for aerobic exercise “with reduced weight bearing and impact” (GP11):
“The emphasis for me, is to keep them active. I think if I can keep them active a lot of things will resolve, you know” (GP8).
GPs felt that exercise was best prescribed by a physiotherapist and cited a lack of confidence, or not having “the time, knowledge or expertise” (GP13) to prescribe exercise.
Participants believed that the patient should be proactively involved in treatment and didn’t advocate for the use of passive therapies:
“You have to get them onboard from day one. You won’t get everybody on board. In fact, you’ll get a very small number of people on board. Most people will want to have the passive stuff done” (GP6).
Patients’ lack of engagement was believed to be an important reason for failure to improve with exercise. Adherence to prescribed exercise was seen as the patient’s responsibility, and poor adherence was viewed as a lack of commitment or discipline on their behalf. Linked to this, GPs were aware of high rates of non-attendance at public physiotherapy appointments:
“And then after they’re coming back and say “oh it’s not getting better” but do they actually do the proper exercise you know to strengthen the muscles and do everything? I’m not quite sure” (GP9).
One GP spoke about his efforts to address this lack of engagement by exploring barriers to exercise and judging patients’ readiness to engage:
“I’ll give them options; explore why they’re not interested. If they’re just not interested, I won’t spend excess time and lecture them and drain myself” (GP2).
GPs identified patients’ desire for a “quick fix” or “to have the passive stuff done” (GP4) such as surgery or an injection as a frequent barrier to engaging patients in a more active recovery:
“I do think there’s some bit of reluctance for people to go for physio sometimes. It’s the society we live in now. It’s much easier if there are quick fixes to these things. They want a pill for everything in some ways” (GP12).
A contraindicatory view was voiced by one older GP who believed nowadays patients had a better understanding of their own role in recovery compared to previous generations:
“There was a lot more magical thinking then. Now they accept that they’ve to work on it and understand that they have to chip in with the treatment” (GP16)
While generally surgery was not advocated as first line treatment, some GPs believed arthroscopy was beneficial for patients who didn’t respond to exercise or conservative management and had a large or “significant tear” on magnetic resonance imaging (MRI). A subset believed a DMT was a structure that could be sutured or repaired. More commonly participants perceived a meniscal tear in middle-aged adults as part of an osteoarthritic spectrum of “wear and tear”. Several GPs intuitively believed that for long-term joint health it might be better to avoid arthroscopy. Contrasting beliefs were expressed about the outcome from arthroscopy, while some thought it led to good outcomes, others felt it increased risks of ‘arthritic change’ (GP14).
Most GPs didn’t believe an MRI was necessary and they emphasised this to patients:
“You’ll be saying, “It probably won’t change your management” I bring it back to that. That just because we have the MRI, it’s not going to change anything, it probably doesn’t have a role” (GP1).
They stressed an MRI was not “a cure” and some GPs were wary of unearthing findings of questionable significance, that they believed could be distressing for patients:
“Unfortunately, then it (MRI report) comes back with all this noise around it, which says that things aren’t fine. Then the patient is very distressed when you’re explaining about the bones and osteophytes and things like that going on” (GP4).
Several GPs held a contrasting view, believing that an MRI could be reassuring for patients and had value in providing patients with the certainty they wanted. They believed “a clear diagnosis” according to MRI could create greater engagement with conservative management and reassurance around decisions not to pursue surgical options:
“Sometimes it does put it to bed a little bit in their heads that “Okay, I have the MRI now and they’re still saying they’re not going to do any surgery on my knee” (GP12).
Theme 3: How GP practice is enacted within the current healthcare setting
This theme describes how GPs enact their practice within the healthcare setting. Limited access to public physiotherapy and orthopaedic services hampered GPs’ efforts to provide care and negatively impacted patients. GPs sometimes practiced pre-emptive referral to orthopaedics as a response to long waiting times. Referring patients to the orthopaedic surgeon without the expectation of surgery was another practice described by GPs. Patients’ having private health insurance had a key influence on clinical decision making. GPs expressed a need for more musculoskeletal training and patient resources that were directly applicable to the primary care setting.
While GPs believed exercise prescribed by a physiotherapist to be the desirable management approach, access to publicly funded physiotherapy was restricted due to long waiting times:
“So I say, “Let’s try physio first”. The problem however with the physio is that with the public service, the waiting list at the moment, I think it’s four to six months” (GP11).
GPs described a community physiotherapy service that was overloaded and difficult to reach leading to GP’s feeling pressure to prescribe more pain medication or escalate care by referring for further imaging or orthopaedic opinion in response to patient frustration and patient suffering:
“You refer in and nothing happens. Then, of course, the patient is in pain, so they’re taking pain relief. Then the anti-inflammatories blow their stomach, so they’re on PPIs. Then because they blew their stomach, they’re now put on opioids” (GP13)
Long waiting times to access a public orthopaedic appointment frustrated most GPs and were a significant barrier to caring for patients with persistent symptoms. Some participants described the futility of trying to influence these waiting times and described the negative impact on patients who “just deteriorate in front of my eyes” (GP13) while waiting:
“It’s a fantasy. It’s fairy-tale. You’ll always refer, but you refer in the absolute knowledge that they’re never going to be seen. No matter how many letters you write you are just bouncing your head off the wall” (GP4).
In response to public orthopaedic waiting lists, many, but not all, GPs described the practice of “early referral” to compensate for long waiting times. This practice of pre-emptive referral was in the best interests of the patient, but some GPs acknowledged it resulted in unnecessary referrals:
“When you refer them, you probably refer them earlier, even if they mightn’t need to be referred. In your own head, because you know they’re going to be years waiting, you don’t want to waste time” (GP17).
Several GPs explained that when they referred for an orthopaedic opinion, they understood that a surgical intervention was unlikely but hoped the patient would receive “good authoritative advice” (GP6) on the importance of exercise in their rehabilitation. Nonetheless the tendency for patients to “lean back a bit” (GP16) was noted whereby patients disengaged from conservative management upon referral to an orthopaedic surgeon:
“People sometimes say, “Well, there’s nothing else that will fix this or address this until I’m seen in that clinic” and you say, “But things can change over time, and we’re going to talk to the physio” and they would sometimes say “but why do I need to do that? You’ve told me it’s bad enough that I need to go and see an orthopaedic surgeon?”” (GP10).
Private health insurance was another key influence on how GPs enact their practice within the healthcare setting. GPs described distinct pathways from the outset for patients availing of public or private care. Caring for patients with private health insurance was “more straightforward” and allowed for more “realistic” conversations when planning care:
“At the end of the consultation I ask him “Look do you have insurance? Do you have you have private cover because we can get this sorted relatively quickly?” and you’re almost dreading the answer if he doesn’t, because like your consultation and your management plan is totally different” (GP10).
Private care was not always viewed as a positive influence on clinical decision making. It was perceived by many GPs as a key driver of patient demands for more imaging or escalation of care beyond physiotherapy. Also in the private sector some GPs had observed a trend for arthroscopy to be performed more frequently or more hastily “it can be jumped into a bit” (GP3). While other GPs contradicted this viewpoint:
“I think the surgeons treat every knee the same. I think they do really. I wouldn’t think they wouldn’t do something for a public patient that they wouldn’t do for a private” (GP17).
Finally, GPs acknowledged that although musculoskeletal care was a core part of their caseload, it was under-represented in their training and ongoing education:
“I never did an orthopaedic rotation and yet here I am, the nuts and bolts are back pain, knee pain, hip pain” (GP16).
There was a desire for more musculoskeletal training that was directly applicable to the primary care setting. GPs also expressed a need for more patient friendly resources for exercise prescription and self-management:
“I find it hard to find resources online for patients that are consistent … something that is practical, an entry point to low level ‘let’s get started’ pain management and strengthening exercises” (GP3).
“Obviously, if you can access physio, great just go and work with the physio, but if they don’t, having an online tool, “Here’s your web link. You’re going to get a virtual program here through this.” That would be ideal in helping people navigate that” (GP14).
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