DEPARTMENT OF GENERAL PRACTICE.CARDIFF
The school medical examination in an
integrated group practice
C. J.WlNTLE, M.B.,B.Ch.
R. H.Davis, d.m.,f.r.cg.p.
The General PracticeUnit,
Departmentof social andoccupational medicine,Welsh National School of Medicine
able for this section of thepopulation,and served to uncover agreatdeal of ill health
whichrequiredtreatment. Morerecently theyhavelargelyformedpartof theprocess
ofscreeningchildren for defects which are either amenable totherapyorrequiresub¬
medical examination needs re-assessment in thelightof current anddeveloping patterns
of thedeliveryof medical care.
The medical staff of the General Practice Unit of the Welsh National School of
Medicine, togetherwith health visitors and district nurses seconded from the Cardiff
Local HealthAuthority, provide generalmedical services from a health centre for most
of thepopulationof a newhousingestate in Cardiff. We also undertake school medical
examinations on behalf of the local healthauthorityfor theprimary schools which
serve the estate.
The records of the Unit have beendesignedtointegratethe data
accumulatedby doctors,health visitors andnurses,thusbringing togetherthe records
of thegeneral practitionerand the local healthauthority (WallaceandDavis, 1970).
Theopportunityto evaluate the school medical examination in the context ofintegrated
communityhealth care wasconsequently possible.
the firstyearof thestudy.
Duringtheperiodof thestudythere were twoprimaryschools whichmainlyserved
theexpanding populationof a newhousingestate in Cardiff.
entrants(134 children)to these two schools underwent a routine school medical examina¬
Ninetyof these children wereregisteredwith the General Practice Unit and
formed thegroupunderstudy. There were 46boysand 44girls. Theaverage agewas
Each child was examinedbya health visitor(S.C.)and a doctor(C.J.W.) in accord¬
ance with the routinegenerally acceptedfor school medical examinations. The school
medical record card(10 M)wascompleted and,inaddition,a record was made ofany
Somedevelopmentalabnormalities such as knockknee, mild
tonsillarenlargementand flat feet were considered to bephysiologicaland thus omitted.
Dentalcaries,unlessvery gross,was so common as to be almost a normal feature and
was also not included.
Subsequently, the General Practice Unit medical record of
Journal,Royal College of GeneralPractitioners, 1972, 22,327
medical examinations have been aprominentfeature of child health care
formany years. They originatedat a time when medical care was notfreelyavail¬
In common with manyother traditionalmethods, the school
Thispaperrecords the results of
Earlyin 1971 all the
each child wasperusedto see whether the abnormalities recorded at the school medical
Forty-seven defects were noted at the school medical examination.
are shown in tableI,column 1. The cases of otitis media were all of recent onset. The
child with bronchitis hadonlybeen taken ill thatday. In the three children withsystolic
murmurs the murmur wasveryfaint andthoughtto beinsignificant.The child with
faecal incontinence had an analfissure, and in the child withpectusexcavatum the
deformitywas minimal. Forty-one (87 per cent)of the above defects were not noted
in the General Practice Unit records(columns2 and3).
Findings at school medical examination of 90 children(averageage Fiveyears)
C. J.Wintle,S.Clay,R. H. Davis
Acute otitis media
It was estimated that 38(81 per cent)of the defects could have been detectedbya
suitablytrained nurse(column 4),and that nine ofthe defects(19 per cent)wouldrequire
a doctor to detect theabnormality (column 5).
tosuggestthat the cases of otitis media and bronchitiswould,in the course of the next
fewdays,have beenbroughtto a doctor. The heart murmurs were allgradeIsystolic
murmurs. One was so faint that it was not discerniblebyanother doctor.
it was considered that these murmurs were notsignificantand that furtherinvestigation
Of these nine defects it is reasonable
THE SCHOOL MEDICAL EXAMINATION IN AN INTEGRATED GROUP PRACTICE
was not justified.
Thus, only one child with maldescended testes would have been
missed if a nurse had conducted the school medical examination alone.
School medical examinations are currently regarded largely as a method of screening
One of the accepted criteria for evaluating screening procedures
is that the method shoujd give a reasonable yield.
is discovered should not already be known.
Horner (1967) compared the results of the school medical examination with data
obtained from a questionnaire circulated to general practitioners in Croydon.
fortunately only 63-7 per cent of the doctors replied to the request for information.
He found that 67 per cent of the defects discovered at school medical examinations
were not apparently known to the general practitioner.
actual notes of all the children were available, 87 per cent of all the defects noted at
school medical examination were apparently not known to the general practitioner,
health visitor or district nurse, or at least had not been recorded.
At first sight, the school medical examination seems to be eminently justified, but
we have suggested that most (81 per cent) of the defects which were discovered at the
school medical examination could have been detected by a suitably trained nurse, and,
further, that all except one of the defects, which we consider could only have been
detected by a doctor, were acute conditions which would have been brought to a doctor
in the course of a few days.
in the same way.
It should be emphasised that this study has been undertaken in rather special
circumstances. The majority of the children were patients of one group practice.
practice uses a system of recording from which data can be readily retrieved and which
combines the records of both the doctor and the health visitor.
we suggest that a school medical examination could be undertaken by a suitably trained
nurse, and that examination by a doctor is not justified in terms of the yield. We
appreciate that the data upon which this conclusion is based are small, but suggest
that the results warrant further studies of the same nature or, even better, a suitably
designed controlled trial.
We also appreciate that the circumstances in which this
study was undertaken do not at present exist in most parts of the United Kingdom.
The rapid development of group practice and health centre practice may change this
state of affairs in the near future.
Implicit in this criteria is that what
In the present study, where the
It is not possible to analyse the results of Horner's study
In such circumstances,
We are grateful to Dr D. J. Anderson, Medical Officer of Health for the City ofCardiff, for permis-
sion to use the data obtained during the school medical examinations.
Henderson, P. (1968).
Horner, J. S. (1967). Lancet, 2, 882.
Wallace, B. B. & Davis, R. H. (1970). Journalofthe Royal College ofGeneralPractitioners, 20, 163.
British MedicalJournal, 2, 259.
Alcoholics are those excessive drinkers whose dependence on alcohol has attained such a
degree it shows a notable mental disturbance or interference with bodily or mental health, their
interpersonal relations and their smooth social and economic functioning or who show the
prodromal signs of such development (they therefore require treatment).
W.H.O. Akcohol Subcommittee-W.H.O. Technical Series, 48.