Commentary

To date, generally there has been little research in general practice, outside academic departments, and for this reason, the DAMASK Trial Team are to be congratulated in managing to recruit 533 patients for their study.¹ GPs tend to be reluctant to recruit their patients due to time pressures and more importantly due to the perceived risk of placing them at a disadvantage in the type of treatment they may receive. They also, perhaps, see their role as service providers rather than responsible for academic engagement with their patients. The potential for serious research in primary care, led by GPs, is enormous but unfortunately lacking the sort of infrastructural support available in secondary care.

In this study patients were randomised to either an orthopaedic referral or an MRI scan.¹ However, in the MRI group GPs made a concomitant provisional referral to orthopaedics, in case patients would eventually need it. Few of these referrals were subsequently cancelled and 82% of the MRI group ended up attending an orthopaedic clinic. Interestingly, more patients initially randomised to the MRI group ended up with an arthroscopy than the group randomised to orthopaedic referral. The design of this study may therefore not be a true reflection of practice. In reality, GPs tend to arrange a test, review the result, and then decide on a referral. The weakness in this study design appears to have been considered necessary to ensure that GPs felt at ease about recruiting their patients.

The underlying problem of trying to compare different management pathways for patients, such as diagnostic tests, is the long waiting times for NHS outpatient appointments and until these can be significantly reduced, research, such as this paper, will struggle to be conducted in a realistic way.