Old Lad

I’ve always had an interest in joints since I started Medical School in 1966. No, not cannabis which I have never used, but the structure and workings of the human skeleton. I think it was due to the way the curriculum was structured in Liverpool where we spent the first year studying anatomy, and painstakingly dissecting a human body. Part of the materials we needed for the course apart from textbooks was our own skeleton ( or half skeleton to be precise). These came in the form of a wooden box of bones and the tradition was that you sold yours on to the next intake at the end of the year. They were real skeletons as well – which are now frowned upon as we have different attitudes to human remains, and medical students now use plastic models or computer simulations. Because we had such an intensive course we got a good grounding in how muscles and joints worked and the relationships between different parts of the body.

When I qualified in 1971 I thought I might train for the specialty of Rheumatology because at that time it encompassed a wide range of conditions from rarer but serious ones such as rheumatoid arthritis, to the common ones of back pain, shoulder disorders, tennis elbow etc. Orthopaedics did not interest me because Orthopaedic Surgeons seemed to spend all their time screwing things together or replacing joints – high grade carpentry really! However in the early seventies it became apparent that rheumatology as a specialty was becoming very narrow and largely confined to the treatment of inflammatory joint problems, and I couldn’t see myself spending all my days in clinics with a narrow range of conditions. So I thought general practice might be worth a try, and for somebody with an interest in musculoskeletal conditions it was the right choice. Statistically something like 30% of GP consultations involve this group of conditions and a large proportion are spinal problems. What rapidly became apparent was the rather nihilistic approach to joints, particularly back problems. I had the good fortune to be able to combine being a GP with a couple of sessions a week working alongside one of the old style rheumatologists whose job title was Conultant in Rheumatology and Physical Medicine. He taught me a lot about how to do a detailed examination of joints and also simple manipulation techniques to help with back and neck problems. As most of our practice patients worked in heavy industries there was no shortage of customers! And if you took the trouble to visit workplaces such as the local steelworks or down a coal mine, which I did, it became apparent what a damaging effect the jobs had on the skeleton.

There was, and still is, a lot of prejudice and cynicism about the problem of chronic back pain. This manifested itself early on in my GP career when all the local GPs were invited to lunch with the General Manager of the local steelworks who proceeded to harangue us about the fact that, in his opinion, we were giving his workers too many sickness certificates for back pain! Now I personally have always found managing back pain an interesting challenge and there are in fact many strategies to help with it other than painkillers, a sick note and an explanation that it’s probably old age! But the prejudice still persists. Only this week the Government is suggesting that people who are disabled by low back pain should receive a lower level of disability benefits than those with other conditions. I suppose they mean “respectable conditions “ such as heart disease or strokes. The effect of chronic pain and restrictions in movement can have significant effects on quality of life and stigmatisation of people with back pain does not help with their self esteem, particularly as in many cases the problem is the result of years of heavy physical work.

A major problem in this area of medicine is that there has never been a concerted effort to prevent joint problems like there has been in other conditions like cancer, strokes or heart failure. And targets in the Health Service never apply to musculoskeletal problems. So we have to put up with underinvestment and things like a 16 week waiting time for physiotherapist appointments. I am fortunate in that as an Old Lad who now has a back problem I know how to cope with it using a strategy of keeping active, doing a range of tailored exercises, and the wherewithal to be able to afford to pay for private physio advice. But there are many Old Lads ( and Lasses) who’ve been told “there’s not a lot we can do so keep on taking the tablets”. And it’s not fair and not good enough!