Mitch Blair, Lucy Pickard and Kate Dhamarajah
Consultants spend many hours seeing children in outpatient clinics. Despite this, there is relatively little formal training in how to run clinics effectively; often trainees carry them out with minimal supervision and are expected to pick up the tricks of the trade by osmosis. Many trainees are drawn to the adrenaline of emergency and inpatient care, but outpatients provides a more personalised service where the individual clinician and family can share problems and solutions in a more considered way. This article is designed to give trainees some tips on how to make the best of this experience during their training and to put the fun back into this form of medical practice.
The mindset when you go into outpatients should be one of preparation and support for primary care colleagues who are typically referring children to us for a further opinion. One of the recurrent issues we face is not knowing precisely why a patient has been sent to us; is it diagnostic uncertainty, is it the need for parental reassurance, or is it simply that our GP colleague has been unable to access particular investigations or treatments? Primary care colleagues deserve our utmost respect for being experts in risk management and continuity of care within the constraints of 10 minute appointments. Paediatricians will tend to have twice that time to dedicate to an outpatient consultation. Developing this appreciation as well as being clear about our role in the whole system is key.
Now let’s look at the specific skills required:
- Clinical reasoning
- History Taking
- Maximising Learning
- Narrative based medicine
It is estimated that the clinical history contributes to approximately 70% of the final diagnosis, and examination and investigation contribute the remainder. One of the interesting challenges for trainees is how to piece the jigsaw puzzle together in such a way as to arrive at a differential diagnosis which is accurate and useful for further decision making around investigations and management.
There are several forms of clinical reasoning, but the two most commonly used in our clinic are pattern recognition and hypothetico-deductive reasoning.
How do these approaches differ?
Pattern recognition– the ability to listen carefully and recognise the patterns of reported symptoms in the history that would fit well with a particular disease. As experience increases, the clinician is able to more quickly recognise the typical patterns of asthma, constipation, headache types, abdominal pain, etc. This type of clinical reasoning does not require a great deal of thought because it is essentially picking up cues that trigger the representation of that diagnosis in one’s memory bank- a form of “fast” thinking.
Hypothetico-deductive reasoning – this approach involves taking a particular problem posed in the referral letter and thinking about it within an existing theoretical framework; developing potential hypotheses based on likelihood, age, demographics, and then testing those hypotheses with the subsequent questions in the history.
Both approaches work better with some pre-clinic preparation – reading the notes and checking results you already have before the patient arrives.
For example, an eight year old boy who presents with headaches for the last four months might have a number of causes for that headache. We tend to use a biomedical “explanatory framework” called TINCANBED. This has been taught to many medical students, either in this form or a different form, e.g. a surgical sieve, and stands for the following:
The Table below shows how such a framework might be applied in this case
|Trauma||Physical injury that may have been sustained during games or cycling.|
|Infection||Infection of the ears, nose, throat, sinusesTB, EBV Post immunisation ( MMR uncommon but known adverse effect)|
|Neoplasm/Nutrition||Neuroblastoma, Leukaemia, ( remember HEADSMART) Poor diet, fluid intake|
|Autoimmune||Allergy, hayfever, Chronic fatigue (ME) , Systemic lupus|
|Biochemical||Sodium / potassium imbalance/ Hypoglycaemia|
|Endocrine||Hypothyroidism , Diabetes mellitus, insipidus|
|Drugs, doctors, degeneration||Analgesic headaches , Lumbar puncture , Many drugs ( see BNF), degeneration is very unlikely to be a cause of headaches alone.|
By using such a framework for most symptoms, trainees are encouraged to look at possible pathological causes from first principles. This allows the questions that are posed to the family to be thoughtful and to test a hypothesis that would include or exclude the above conditions. As the history progresses you are able to refine the diagnoses accordingly, based on other aspects of the history including nutrition and social history.
As you become more experienced in the social and cultural aspects of patients seen in a locality, you’ll be able to frame the problems presented within a bio-ecological framework. The ecology, meaning both the physical and psychosocial environment, requires as much attention as the biology.
General Structure of History;
“Approximately 70% of your time should be spent on taking a focussed history around the symptoms themselves. “
- juniors and students tend not want to seem foolish or inexperienced in front of parents. Subsequently, the obvious questions are not asked at all or are asked inappropriately.
- eg pain – a full history would include, Site, Onset, Character, Radiation, Alleviating factors, Timing, Exacerbating factors and Severity (SOCRATES).
- Omitting the social history around who is caring for the child during the day. Particularly important for small children with behavioural difficulties where there may well be inconsistency of carer parenting styles between grandparents, child minders and parents themselves.
- Poor nutritional history taking. It is estimated that only 5% of medical school training includes aspects of nutrition. Most trainees do not have sufficient training in ascertaining nutritional adequacy in children. There are some excellent resources that will help, including child nutritional guides from the Caroline Walker Trust. Consider a fluid intake table, urine colour charts & the Bristol stool chart.
- Although often forgotten by young people themselves, mobile phones can monitor the length of time spent using the screen with a ‘screentime’ function. We recently discovered that a child seen in the clinic with severe migraine was using her phone nine and half hours a day, as discovered via her phone’s ‘screentime’ calculation. Importantly she was able to show a reduction over time once this was pointed out, and this served as an effective visual reminder for her.
Clinical examination needs to be focussed and again should be directed towards proving or disproving possible diagnoseswhich have emerged from the preceding history taking.
Best results are obtained by:
- Looking at the whole child, spending enough time to make sure you see:
- Gait as they walk into clinic
- Demeanour and state of mind
- Cleanliness and hygiene
- Palpating deep enough to ensure you’re able to feel stool in the intestine if present
- If an orthopaedic examination is required, remember to be thorough, assessing , including for scoliosis and postural variations of the lower limbs.
- Looking out for more subtle neurological findings – hypotonia, developmental co-ordination disorder, through cranila berves exaimantion
As these are not often performed in the acute setting, close consultant supervision and observation with feedback of the examination process itself will help you get to your best – ask or this whenever you can.
Top tips after Clinic
Dictation – Try to dictate your letters immediately. Dictating letters with the parent in front of you is highly efficient, acts as a summary for parents consultation, and gives an opportunity for correctional clarification.
Letters should be structured with the following at the beginning;
arrangements for follow-up
Keep the bulk of a typical general clinic letter to half a page
Follow-up: often results can be given over the phone or in writing.
Try where possible to empower the GPs. They have advised us that giving the responsibility to the parent to make appointments (for results, monitoring) is the best way to, for example, monitor the iron intake of a child or check growths.
Maximising Learning from The Clinic
During every clinic, there is a particular question that needs to be answered if one remains curious. Curiosity keeps the mind active and maintains your interest in patient care. We set ourselves, and each other ‘educational prescriptions’ order to clarify the evidence base behind a particular decision. Examples are given below.
- What is the normal range for attainment of faecal continence in toddlers/pre-school children?
- What is the clinical features difference between metapneumovirus and RSV?
- Can Sumatriptan be used for abdominal migraine?
- What are the agreed features of Marfan’s syndrome?
- Which foods are highest in vitamin C?
- Which breakfast cereals have the highest fibre content?
Developing your skills further
A different (?) approach to history taking: Narrative-Based Medicine- Really listening to the patient story
A very important skill to develop when taking a history is careful listening. The average time doctors give patients for the consultation is less than 30 seconds before they interrupt. Most parents will speak if uninterrupted for two to three minutes. Usually we are taught the concept of taking a history as a way of making sense of what the patient is saying and fitting their reported symptoms into a schema to lead to a diagnosis. However, a very different approach, and a more relaxing way of taking a history, is for the parents to explain why they have come to the doctor and for you to build upon the statements they make.
For example you might be taking a history from the family about a seven-year-old boy who presents with abdominal pain and during the history, the family make some reference to a house move or a school move. You may be tempted to go onto the framework that has just been described above (SOCRATES), however attending to the family’s statement then, instead of waiting to address it after the social history, allows you to pick up the thread as directed by the family and not by your own framework. In this particular case, the move may well be perceived as an important trigger for the symptoms for a number of reasons, whether stress related or environmental, such as lead poisoning from old paint and dust.
Connecting with the last thing that the family or the child has said gives the family the sense of being listened to and their own agenda being paramount. This is a highly skilled form of history taking, because you still need to develop your hypothesis, excluding and including potential diagnoses, but with practice is actually a far more revealing and relaxing way of getting to the nub of the problem in an efficient way. The secret here is to combine both types of approach in as natural a style as possible.
The Future of Outpatients?
The COVID-19 pandemic has upskilled us in other tools such as telemedicine, advice lines and email access, which should be a far more efficient way of obtaining specialist advice than the traditional written letter and the complex sequence of processes that are necessary to arrange an appointment for the child to be seen by paediatrician.
In summary, outpatient medicine is a very skilled part of the paediatrician’s job and is both intellectually challenging and satisfying.
Find you own style, remain curious, teach your craft and you will have great professional satisfaction for many years.
Thinking, Fast and Slow by Daniel Kahneman (2011)
How not to be a doctor and other essays. John Launer, 2007 Duckworth Books
Narrative-Based Practice in Health and Social Care, John Launer 2007
Useful websites for clinic:
Blair M, Wortley E, McGuff K. Placing education at the centre of the outpatient clinic improves learning and experiences for everyone using the multilevel attainment of learning, teaching and support (MALTS) approach Archives of Disease in Childhood – Education and Practice 2020;105:2-6
Mitchell R, Jacob H, Morrissey B, et al Managing outpatient consultations: from referral to discharge Archives of Disease in Childhood – Education and Practice 2017;102:200-206. https://ep.bmj.com/content/102/4/200.citation-tools