No abstract

P rimary care physicians and paediatricians account for the majority of referrals to paediatric orthopedic outpatient clinics. This is with good reason because musculoskeletal complaints are the leading cause of visits to primary care physicians (1), with one in eight children requiring a physician visit each year for a musculoskeletal disorder (2). Unfortunately, a significant percentage of these referrals are for complaints that are within the accepted range of physiological variance. These 'physiological' referrals consume already limited paediatric orthopedic resources and delay care for patients who require specialist care. This is of specific concern in Canada, where the average wait time from referral to treatment by an orthopedic surgeon increased by 65% between 1993 and 2003 (3), leading family physicians to rate the majority of access to orthopedic specialists as 'poor' in the most recent National Physician Survey (4). Recent data from Ontario show that wait times for paediatric orthopedics are two weeks longer than the national average and are among the worst in the surgical subspecialties (5).A growing body of evidence suggests that physiological referrals may be secondary to insufficient musculoskeletal education. Less than 25% of medical schools in the United States offer a required musculoskeletal rotation in clerkship and greater than 50% have no mandatory instruction in musculoskeletal health whatsoever (6). Consequently, most medical students admit to a lack of confidence in examining and diagnosing musculoskeletal conditions (7). At the graduate level, primary care and paediatric residents feel poorly prepared in their musculoskeletal training (8) and 75% of first-year residents cannot pass a basic competency examination in musculoskeletal medicine (9,10). In Canada, where medical curriculums have been previously found to devote only 2.26% to musculoskeletal teaching (11), undergraduate medical educators have recently considered the implementation of mandatory musculoskeletal clinical rotations. Such rotations, as well as brief educational interventions, have been shown to significantly improve comfort in performing a proper physical examination (12) and overall competency in musculoskeletal medicine (13,14).Due to the decline in accessibility to orthopedic care in Canada over the past decade and growing concern for reducing health care expenses, we conducted a retrospective cross sectional study over two time periods to quantify the proportion of physiological referrals sent to paediatric orthopedic surgeons from the largest referral base, primary care physicians and paediatricians. We chose two eightmonth periods for analysis to account for changes in annual referral trends. A secondary objective of the present study was to identify which conditions were associated with the highest rate of physiological referrals to focus future educational efforts. bACKgRouNd/obJeCtive: Referrals to paediatric orthopedists for physiologically normal conditions consume limited resources and delay care for p...