Community orientation ðŸ§
Descriptors and examples for the RCGP Trainee
Community orientation is just what it says on the tin: it’s all about management of the health and social care of the practice population and local community.
💠Example Reflection
Tanner staging 🌰
Description
We had an interesting case come into the clinic. A child had presented with his mother. They were concerned he had not reached puberty (he was 16 years old) and had thought to come in to get seen.
He did have multiple medical conditions in the background, some of which could have affected on his development. After a detailed history they all seemed to be well under control and very unlikely to have caused anything untoward.
Looking at his growth charts, he seemed to be a late bloomer in terms of his weight and height. I knew that these children often present with delayed puberty, especially in boys, so I reassured him that everything looked well on the history. Both his parents had been late bloomers as well for their heights, which was also encouraging.
On examination (with a chaperone present) his pubic and axillary hair growth seemed to have started. The orchidometer showed his testicular development to have begun as well. Penile length was normal for his age and height. There were no other significant anomalies on examination.
The patient’s main concern was that he was not going into puberty at all, but we reassured him he definitely was. He did not look convinced so we discussed Tanner staging with him in detail and he looked much happier after that. We then advised coming back in for a followup in a few months.
He was worried what would happen if he had not gotten better by then and we discussed things like bone age, bloods to check hormone levels, and testosterone injections. He seemed happy to hear there were options available and left in a much better mood than when he had arrived.
Reflection: What will I improve, maintain, or stop?
This was a case of delayed puberty which is something I do not have much experience with. Fortunately with the endocrine consultant guiding me managing it was much easier.
I struggled a little with the Tanner stages at first but we found local resources that told us exactly what to do.
The boy was understandably nervous at getting an intimate examination done but I had a little chat with him and explained that he could stop us any time he felt uncomfortable and we didn’t have to do it at all if he wasn’t feeling up to it. This seemed to put him at ease and he allowed us to check him over without any issues.
Treating delayed puberty was something I had no experience with, though I was familiar with the theory side of it. With the consultant there to supervise I easily formulated a management plan that she approved of and that the patient and his parent were happy with.
Learning needs identified from this event
Tanner staging is a little difficult at times. With this boy it was easier but things like differentiating between a BII and BIII for a girl might get quite difficult. I need to gain some more experience in this field to get more confident at it. I also need to read up on common aetiologies of delayed and early puberty to help me get better at the subject.
Community orientation
Trainee: During the consultation, I used local guidance available on our intranet to look up Tanner staging and what to do about the different stages. I also arranged for local follow-up with the consultant by contacting the secretary who books patients in. The above demonstrate how local services have been used to enhance patient care, and that I have some understanding of local referral pathways and services.Trainer: Good use of local guidelines, computer systems and local clinics.
Clinical management
Trainee: This was a case where the clinical management of slightly delayed puberty was the reason the child had presented. I adopted a wait-and-see approach but also safety netted and put in place a follow-up plan that I confirmed with the paediatric consultant.Trainer: Sounds like appropriate use of watchful waiting based on evidence with follow up arranged
Organisation, management and leadership
Trainee: I used the IM&T systems I had just recently learnt about, including iGrow, to aid my clinical decision making during the consultation. I recorded everything that was done during the consult in a timely manner following the record-keeping standards of the organisation.Trainer: Good use of computers, & coding findings using Tanner scale.
