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• RE: Letter to the Author
  Ravi Patel, Matthew Knights
  Published on: 19 July 2021

• Published on: 19 July 2021

  RE: Letter to the Author

  • Ravi Patel, Medical Student Hull & York Medical School
  • Other Contributors:
    • Matthew Knights, Medical Student

  A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time

  Ravi Patel & Matthew Knights

  A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.

  Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachm...

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  A medical student perspective on history-taking for a child presenting with a limp: doing it for the first time

  Ravi Patel & Matthew Knights

  A child presenting with a limp, is a common presentation in primary and secondary care in the UK. It can be due to a number of different aetiologies with varying degrees of severity. A concise history offers the opportunity to identify key risk factors, mechanisms of injury, duration of symptoms and a collateral history from family members, thus is an important skill for all healthcare professionals irrespective of speciality. [1,2] However, many medical students and newly graduated junior doctors feel-ill prepared to take one. [3] Missing key red-flags, delaying diagnosis and referral for appropriate management. We present our own experiences of history taking and discuss how improvements can be made within the medical school curriculum.

  Key factors in making history taking a challenge for children presenting with a limp for medical students or clinicians include; quantifying duration and pain the child is experiencing, the precise location of pain, establishing the true mechanism of injury, weather a non-accidental injury is questionable, cultural differences when taking a collateral history and the birth and developmental history. This applies even more so to those with inadequate training. A recent survey conducted by the University of Newcastle medical school found average duration of the T&O attachment being 5 weeks in all 23 UK medical schools.[4] With such short exposure to a large subject may encourage superficial learning which medical education is specifically trying to avoid. It is estimated that 30% of all GP consultations in the UK are Musculoskeletal, of which a quarter who visit their GP are <18 years old. [5,6,7] This is fundamentally important as 50% of all medical graduates in the UK will be training to become GPs.[8] We believe from our clinical experience in numerous primary care and secondary care sites that observation of clinicians alone may be an ineffective method in acquiring the key skills to conduct a concise consultation.

  When asked to take our first history for a child presenting with a limp in new patient clinic, we found difficulty phrasing sensitive questions about non-accidental injury, asking about childhood obesity as well as establishing a clear contralateral history from family members. This uncertainty sometimes led us to neglect certain parts of the history entirely. One case, when observing a FY2 led to a partial delay in diagnosis of an acute on chronic slipped capital femoral epiphysis (SCFE). As the plain anteroposterior radiographs of the pelvis were unremarkable as the slip was subtle and the child was not overweight, nor was there any endocrinal abnormalities such as hypothyroidism and growth hormone deficiency from the patient history. When reflecting, we feel additional techniques should be implemented in other aspects of clinical education alongside history taking under supervision in order to prevent pit-falls in core principles as a clinician. For example, practicing with simulated patients has given us a greater degree of confidence when handling difficult discussions, having an index of suspicion for abuse cases and identifying good clinical practice when communicating with children and parents. The removal of the fear factor in a safe environment prior to seeing patients additionally helped. When examining the literature further, it shows simulated patients are as effective learning resource in the orthopaedic training of undergraduate medical students as real patients. [9] Driving changes by Royal College of surgeons Ireland to implement more SP training as part of the undergraduate syllabus.

  From Student Feedback across 5 hospital sites across the Yorkshire and Humber region, our medical school is now adopting a multi-modal approach. In which simulated orthopaedic patients has now been adopted as part of the curriculum, alongside sexual health and ABCDE masterclass SP teaching sessions. We hope our efforts provide the foundations for a more competent and confident medical students in identifying issue in relation to with a child presenting with a limp.

  References
  [1] Perry D C, Bruce C. Evaluating the child who presents with an acute limp BMJ 2010; 341: c4250 doi:10.1136/bmj.c4250
  [2] 1. Al-Nammari SS, Pengas I, Asopa V, Jawad A, Rafferty M, et al. (2015) The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom. J Bone Joint Surg Am 97: e36.
  [3] 2. Pinney SJ, Regan WD (2001) Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am 83: 1317-1320.
  [4] J.R. Williams. A review of undergraduate teaching in orthopaedic surgery in the United Kingdom. Orthopaedic Proceedings Vol. 85-B, No. SUPP_I. British Orthopaedic Association/Japanese Orthopaedic Association Combined Congress. 21 Feb 2018
  [5] de Inocencio J. Musculoskeletal pain in primary paediatric care: analysis of 1000 consecutive general paediatric clinic visits. Paediatrics. 1998 Dec;102(6):E63. doi: 10.1542/peds.102.6.e63. PMID: 9832591
  [6] De Inocencio J. Epidemiology of musculoskeletal pain in primary care. Arch Dis Child. 2004;89(5):431-434. doi:10.1136/adc.2003.028860
  [7] Hassan Raja, Shehzaad A Khan, Abdul Waheed. The limping child — when to worry and when to refer: a GP’s guide. British Journal of General Practice 2020; 70 (698): 467. DOI: 10.3399/bjgp20X712565
  [8] Deakin N. Where will the GPs of the future come from? BMJ 2013; 346 :f2558 doi:10.1136/bmj.f2558
  [9] Gardiner S, Coffey F, O’Byrne J, et al. 0209 Simulated Patients Versus Real Patients As Learning Resources In The Clinical Skill Training Of Medical Students – A Randomised Crossover Trial Of Their Effectiveness. BMJ Simulation and Technology Enhanced Learning 2014;1:A23.

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  Conflict of Interest:
  None declared.

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