Dr Sam Barke, Head of Sports Medicine
Last Friday, around 50 Meliora clinicians came together at Harrow School for our annual Clinical Education Day.
Our GPs, school nurses, sports doctors and physiotherapists sat alongside colleagues from adolescent medicine, orthopaedics, emergency medicine and psychiatry. On paper, the programme covered a wide range of topics. In reality, a common theme ran through almost every session.
One child. Many perspectives.
Children and young people rarely fit neatly into one clinical box. Their health, sport, school life and wellbeing are interconnected, and good care depends on understanding the whole picture.
That sounds simple. In practice, it can be remarkably difficult.
The presenting problem is only one doorway
One of the opening ideas of the day was that a child will often enter healthcare through whichever doorway happens to be closest.
A physiotherapist may see a stress fracture. A school nurse may see fatigue and recurrent illness. A school doctor may see low mood, amenorrhoea or weight change. A sports doctor may notice unexplained deterioration in performance.
Each clinician may make a perfectly reasonable assessment of what is in front of them. But they may all be seeing different parts of the same problem.
That was the central message of Dr Alex Maxwell’s opening session, Any Doorway, One Child: we may work in different services and see young people in different contexts, but those services are ultimately doorways into the same child’s life.
The challenge is therefore not simply to be good at recognising the problem within our own area of expertise. It is to remain curious about what might sit behind it.
Looking beyond the complaint in front of us
One of the most useful phrases from the day was: “Holistic is what you take in.”
A holistic consultation is not necessarily about doing more tests, making more diagnoses, or referring to more people. It is about the breadth of information you allow into your clinical thinking.
The complaint in front of us matters. So does the clinical picture behind it: growth, training load, pre-existing conditions and other health issues. But so too do sleep, nutrition, mental wellbeing, relationships, academic pressure, sporting selection and what may be happening at home.
None of those factors automatically turns a straightforward problem into something complex.
But sometimes one extra question changes the picture completely.
Alex gave the example of a physiotherapist seeing a young person with anterior knee pain. The assessment and rehabilitation plan were appropriate. But the physiotherapist also asked about sleep and discovered that the pupil was getting around five hours a night.
Then came the important question: why?
Without it, the consultation could reasonably have ended with a diagnosis and rehabilitation programme. With it, the clinician had identified information that might materially affect both the young person’s health and their ability to recover – and made sure that information reached the people who needed to know.
The same principle applies in school medicine. A pupil asking a nurse for paracetamol because of a headache may simply have a headache. But by the third similar visit, the pattern itself becomes information. In the example discussed during the day, one additional question revealed significant academic, sporting and social pressures.
This is not about turning every consultation into an exhaustive psycho-social assessment. It is about recognising when the problem in front of us may be only part of the story.
Adolescence is inherently interconnected
That matters particularly in adolescent healthcare.
Young people are developing physically, psychologically and socially at the same time. Their lives may include exams, sporting selection, training demands, friendships, family pressures, constant digital contact and, for some, the additional intensity of boarding away from home.
Many of those things are not clinical problems in themselves. But the combination can be.
The same principle was evident in Dan Elias’s session on youth injury and resilience. Growth and maturation, training load, sleep and fuelling were presented not as isolated risk factors, but as foundations that interact with one another.
His distinction between something being complicated and something being complex was particularly useful.
A complicated problem may still allow a relatively linear solution: follow the process, complete the stages and work towards an endpoint.
A complex problem behaves differently. Recovery may be shaped by growth, psychology, school, environment and a host of other influences. The same programme will not necessarily produce the same outcome for two different young people.
That does not mean abandoning protocols or evidence-based pathways. It means recognising what they cannot tell us.
The clinician is part of the picture too
Seeing the whole picture is not only about gathering more information about the patient. Sometimes we also need to understand the influences acting on us.
Dr Charlie Tweed’s session on the psychology of return-to-sport decisions explored how athlete identity, coach expectations and the clinician’s own relationship with sport can all influence decision-making.
His questions were deliberately uncomfortable. What am I feeling about this decision? What is not being said?
If this were a different athlete, in a different team, at a different time, would I make the same decision?
Clinical judgement is not made in a vacuum. Good decision-making requires not only knowledge and experience, but also enough self-awareness to recognise when external pressure, relationships or our own assumptions may be affecting the way we interpret the information in front of us.
That is another perspective worth adding to the picture.
Multidisciplinary does not mean everyone sees everyone
There is an important distinction here. Good multidisciplinary care does not mean that every child needs to see a GP, a nurse, a physiotherapist, a sports doctor and a psychologist.
Often, a single clinician is exactly what they need.
The value of a multidisciplinary system is that the clinician seeing them understands the limits of their own lens.
They ask the extra question when something does not quite fit. They recognise a pattern that might matter. They communicate information rather than allowing it to remain isolated within one consultation.
And when another perspective is needed, they know who to involve.
That is where genuinely joined-up care differs from simply having multiple healthcare professionals working in parallel.
One child, many perspectives
Our Clinical Education Day covered school medicine, injury and resilience, adolescent orthopaedics, complex concussion and the psychology behind clinical decision-making.
The subjects were different, but the underlying message was remarkably consistent.
Young people are not simply knees, shoulders, concussions, headaches or return-to-sport decisions.
Their health sits within a much bigger life.
For us, the challenge is to remain good at the problem in front of us while staying curious about the picture behind it.
A child may walk through whichever clinical doorway is nearest.
Our responsibility is to remember that there is always a whole child on the other side of it.