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Abstract
Many young people have an unacceptably long delay in referral to tertiary services often undergoing unnecessary invasive investigations. A validated examination screening tool, pGALS (paediatric gait, arms, legs, spine)1 has been developed but trainees have low confidence examining paediatric joints.2 Local audit data highlights the lack of musculoskeletal examinations in paediatric clerking compared to examinations of other body systems in response to clinical red flags.3
Aims To review the impact of educational clinics on trainees performing pGALS screening examinations and how successful they are at identifying active arthritis (swollen joints) or restricted movement of joints compared to the examination findings of a paediatric rheumatologist performing a pGALS in the same patient.
Identify the trend in personal confidence of junior doctors in diagnosing childhood arthritis using the pGALS screening tool with increased exposure to patients with clinical signs of arthritis.
A prospective service review of teaching clinics within a tertiary paediatric rheumatology department was performed. Medical students, adult rheumatology trainees and paediatric trainees were invited to attend. Confidence questionnaires were completed before and after clinic attendance. A pGALS proforma was completed by the trainee per patient and sealed in an envelope. A second proforma was completed on the same patient by the consultant before teaching commenced. Data was analysed using sensitivities, specificities and Cohen’s Kappa inter-observer agreement.
Adult rheumatology trainees had a higher overall sensitivity for detecting active arthritis (42%) and detecting restriction in movement (45%) compared to other trainee groups (paediatric trainee 34% and 40% respectively, medical student 35% and 33% respectively). Overall specificity was good for active arthritis (90–100%) and restrictive movement (90–100%). Inter-observer agreement was ‘moderate’ for detection of active arthritis and detection of restricted movement ( Table 1 ). A statistically significant (p < 0.05) increase in confidence was seen for the trainee cohort examining the joints of those under 16 years of age, even after only one clinic attendance.
The significant improvement in confidence in joint examination is a very positive finding. Performing increased numbers of pGALS examinations increased the sensitivity of picking up abnormal joints. This study has demonstrated the benefit of the pGALS tool as an educational intervention in clinical practice.
References
Foster, HE, Kay, LJ, Friswell, M, Coady, D and Myers, A. Musculoskeletal Screening Examination (pGALS) for School-Age Children Based on the Adult GALS Screen. Arthritis & Rheumatism (Arthritis Care & Research). 2006;55(5):709–716
Jandial, S, Myers, A, Wise, E and Foster, H Doctors likely to encounter children with musculoskeletal complaints have low confidence in their clinical skills. The Journal of Pediatrics. 2009;154:267–71
Abusrewil, W, Whiteley, A, McMahon, A and Al-Obaidi, M. A, B, C, don’t ever forget the joints. Oral presentation at the Royal College of Paediatrics and Child Health meeting 2013. (Personal communication with Dr W. Abusrewil)