1 Rheumatology, Newcastle Hospitals NHS Trust, 2 Rheumatology and 3 Child Health, Newcastle University, Newcastle upon Tyne, UK
Correspondence to: A. Myers. E-mail: andrea.myers{at}ncl.ac.uk
Sir, We read with interest the paper by Dubey and colleagues describing the trainees perspective of rheumatology training in the UK [1]. The authors highlight some of the factors that may adversely affect the quality and success of rheumatological training in the UK. We note that in this study the quality of training in paediatric rheumatology was ranked very low by the trainees and this was only marginally better than training in primary care rheumatology and sports medicine. A poor exposure to paediatric rheumatology training has previously been reported in UK primary care trainees [2].
We wish to share with you our work which demonstrates that trainees in paediatrics also have an unmet need in their training in rheumatology. We believe that this is an important omission in their training, given that musculoskeletal problems (MSK) are common in children and adolescents and can be the presenting features of severe, even life-threatening illnesses such as leukaemia, osteomyelitis or non-accidental injurythe performance of a competent MSK assessment (including history taking and examination), with an understanding of the age-dependent variation of normal joint appearance, may be the only way to facilitate diagnosis and referral to specialist teams.
We have recently reported a study in three UK hospitals showing that case note documentation of MSK assessment is poor compared with that of other bodily systems in general paediatric medical in-patients and that paediatric specialist registrars (SPRs) have low self-rated confidence in MSK assessment compared with their clinical skills in examining other systems [3]. In addition we have completed an audit of children attending the paediatric day unit at the Royal Victoria Infirmary, a busy teaching hospital within Newcastle Hospitals NHS Trust. Over 10 000 children attended this day unit in a 12-month period, of whom approximately 70% attended electively for investigations and treatments, minor surgical treatments or review by health-care professionals. Of the acute medical admissions, 3% (84/2800) had a MSK presenting complaint, with limp, non-weight bearing, swollen joint and pain [in a limb] being the most common complaints, in descending order of frequency. The median age was 5.5 yr (range 015.5 yr). Retrospective case note review revealed that the affected joint (where stated as the presenting complaint, e.g. painful knee) was examined in the majority of cases (94%), but invariably the documentation of the examination was limited, e.g. swelling of knee as the sole entry. In no cases was use of the GALS screen [4] documented. Only 31% of these children had documentation of all their joints being examinedwe regard this as mandatory due to the non-specific nature of the history in children (e.g. my child is limping), the difficulty in eliciting a history in young children and the importance of referred pain (e.g. hip disease presenting as a painful knee). It was also noted that many children (64%) were discharged without a definite diagnosis and that few were referred to orthopaedics (n = 16) and even fewer to paediatric rheumatology (n = 7) or physiotherapy (n = 0).
This audit of general paediatric day unit attendances corroborates the findings in our study of general paediatric medical in-patients [3] showing that MSK assessment is poorly documented, suggesting that MSK assessment is rarely performed; this may also reflect competence in clinical skills. A survey of general paediatric senior house officers (n = 11) and GP trainees (n = 12) within our Postgraduate Deanery (Northern), during the same time period as the day unit audit, and using the same postal questionnaire used to survey SPRs [3], showed low self-rated confidence in assessing the MSK system compared with other systems. With regard to MSK assessment, 3/23 felt they had no confidence, 19/23 had some confidence and 1/23 had confidence in most aspects. This was in contrast to other systems (namely, cardiovascular, respiratory and gastrointestinal), in which most rated themselves as being confident in most aspects or very confident. Confidence in MSK examination ranked lowest behind neurological, eyes and skin. Many respondents (30%) recalled some exposure to paediatric rheumatology teaching in their undergraduate and postgraduate training, but nonetheless their competence and confidence in MSK assessment is low compared with other systems.
There is clearly an unmet need in paediatric rheumatology education for trainees in rheumatology, primary care and paediatrics in the UK and this may well be the case for other specialities such as orthopaedics and accident and emergency. This is important as children with MSK problems may present in a variety of ways to different specialities in primary and secondary care. There are likely to be several explanations for these observations including paediatric MSK assessment not being a core skill in UK medical schools [5], standard paediatric textbooks containing little information to reinforce clinical skills [6] and there being no validated MSK screening examination in children or consensus as to what constitutes a paediatric MSK regional examination [7]. Furthermore there is a lack of paediatric and adolescent rheumatology clinical services in the UK [8, 9], which will inevitably have an adverse impact on the awareness of paediatric rheumatology as a speciality and provision of paediatric rheumatologists as potential teachers to promote education in clinical skills. We strongly suggest that there is a need to improve paediatric rheumatology training at both an undergraduate and postgraduate level with the aim of facilitating diagnosis, giving access to appropriate teams and ultimately improving patient care.
The authors have declared no conflicts of interest.
References
|