Routine "anythings"

Not to belabor the point, but, honestly, folks, not including preschoolers,
how many of you have found anything significant during a routine annual or
biennial PX? An occasional hernia? A .000025 mm. node that a parent is
concerned about? Most abdominal masses are found by parents. Most serious
conditions are accompanied by symptoms and therefore come under the aegis
of a sick visit.

Stuff that we should be doing such as visual exams (i.e. VAs and cover/uncover
tests) are frequently omitted and shunted to the eye guys.

Shouldn't most routines go the way of the dinosaur. I'd like to hear from
some of our U.K. brethren. Patients report that there are no routine
checkups in Great Britain. Is that so?

Bob Schwartz (no flaming, please)

Hugo,

Perhaps you would like to pay us a visit up the road at Lansdowne, and ask
how the school health service really works. For the sake of our foreign
brethren, and other UK doctors who may have got hold of some wrong ends of
sticks...

> The parents if they are concerned pester the family physician
> (please remember the community based pediatricians in the UK are
> attendings trained in community medicine that have clinics where the
> kids are referred by the school, the community pediatric nurse or the
> family practioner. there is no direct access by concerned parents.
>

Specialists in Community Child Health are fully trained specialists,
accredited by the RCPCH etc in Paediatrics, who have special skills in
educational, social, neurodevelopmental etc. medicine, often
subspecialising in audiology, vision etc., but always with a concentration
on multidisciplinary and interagency working. What this means is that we
generally have a handle on children with complex multisystem disorders that
require special help in order to benefit from education, from their social
environment, etc.

> The sort of things they do are eye tests for schools, some vaccination
> programs and hearing tests.
>
With the exception of vacc and imm, almost exclusively done by GPs, all
these are carried out by school nurses. Height, weight, vision and hearing
with a health questionnaire are administered at school entry; H&W normally
repeated once, H and V repeated at intervals throughout primary and
secondary school age. School Dr discusses any worries that come out of this
process with school nurse; may see child himself or refer back to GP or on
to another specialist.

> Most GPs (family phyicians) offer a Well baby check once or twice in the
> first three months. After that contact is at the parents request or at
> vaccination time.
>

Routine suggested by Hall (Health for All Children Ed 4, 1996) is 6/52 and
8/12 checks medically, 7/12 distraction, 18/12 growth & milestones, 3 yr
ditto (we also do a 4-yr handover from HV to school HS, but often does not
need to see well child). This is on top of neonatal bloods, but virtually
no other invasive screening tests, although Fe and Hb electrophoresis are
under discussion for at-risk groups.

> The worried parent often takes the child to the emergency room where
> they are seen initially by junior staff. If indicated the child is
> reviwed by the junior pediatrician (first or second yr resident). More
> often than not the child is admitted if its out of office hours.
>

All the evidence suggests that the worried parent stays at home and worries
a lot. Pharmacists see more illness in children that Drs do. GPs come next.
Although I know a lot of illness arrives in Acc&Em, it's really a small
fraction of all that is really out there.

> To put it in perpective there not too many fresh diagnoses we make in
> emergency medicine that have been so longstanding that they would have
> been picked up when the child was asymptomatic in a six monthly
> review!!!
>

I agree that there is a lot of misplaced faith in "screening" tests. This
often seems largely to be profit-driven, as few schemes actually survive a
real cost-benefit analysis. Has anyone analysed the number of skin and
lymphoid cancers caused by unnecessary IVUs done as a result of
false-positive urinalyses in children? There was an article some years ago
looking at the cost to families of neonatal screening. There were mothers,
years after a false-positive PKU test, who found some entirely unrelated
problems with their offspring: "Ooh doctor, you know he had something wrong
with his blood test when he was born." These things scar.

On the other hand, many of the things you do see in emergency medicine are
related to diagnoses we could make in primary health care and in general
paediatrics. Head injuries in children without cycle helmets, acute asthma
where the parents won't stop smoking, behaviour disorders, child abuse etc.
etc. Don't figure that a broken leg starts when Johnny falls off the monkey
bars; it starts with the adults that put up the apparatus, with the parents
who can't or won't understand the developmental age of their children, with
the lack of supervision...

I'm going on a bit aren't I? :)

Come and see us some time
All the best

TimF

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