Establishing rapport, listening, establishing the illness framework of the whole family, the open-closed cone, signposting the examination and performing it with sensitivity, explanation in terms the child and parent can understand.
reassurance, interviewing more than one person at a time, (see under Adolescence),humour and fun.
list the skills and behaviours
which might be most helpful when consulting with children and their parents.
It is difficult to realistically role play a small child, but setting up roleplays where there are parental concerns work well. Examples could include: concern about normal development, what a febrile fit might indicate, and discussing the prognosis of wheeze in a nine month old baby.
review of interviews of a parents and children are easily come by in
family practice. Observing live consultations with an interested and
experienced paediatrician who underlines and analyses useful skills as well as
sharing his thinking process with learners, is invaluable.
Try paired listening exercises where you ask learners to think how it might feel as a parent to find that their child is suddenly seriously ill, or to think themselves into the role of a 10 year old child who is being physically or sexually abused; encourage the learner to summarise their feelings and thoughts, and what they might need from a parent and a doctor. Link this exercise with a problem-based approach, “what am I trying to achieve in this interview”, to generate a structure and framework, as well as the precise skills needed for that particular interview and similar problem interviews.
the research evidence and theory
There is vast literature on the psychological stages through which children go. A working knowledge of, for example of what a child understands by death and illness at different ages is useful.. Introduce the research done by Korsch et al (1968) with parents and children attending clinics where it was established that if adults were allowed to voice their concerns, they were likely to be more satisfied and to adhere to the treatment which was being suggested for their children. Increasing the involvement of children in their own health care has been shown to increase children’s knowledge of how their medications should be taken and also their knowledge of asthma management skills. (Lewis et al 1990). Kai (1996) suggests that parents need more information and education; he cites their anxieties, and bewilderment at inconsistent prescribing patterns, unhelpful explanations and decision making.
Talking with children in Talking with patients. ed. Myerscough P.
Oxford Medical Publications Oxford
and Bor (1996) Guidelines in communication
with young children in, Communication skills for medicine
Churchill Livingstone New York
and Pantell (1995) Interviewing paediatric
patients in M.
Lipkin et al. (eds.) The Medical Interview. Clinical Care, Education and
Research. Springer-Verlag, New York
Adolescents have a difficult time consulting their doctors. Adolescence is not a single stage of development; young people show considerable variation in psychological and physical development. A working knowledge of teenage culture is useful, especially for older doctors, and an understanding of contemporary interests and concerns. Adolescents are in the main healthy and suffer from few serious illnesses. The common reasons for consulting include:
· pregnancy and contraception
· minor illnesses which never the less are important to them such as acne and glandular fever
· drug and alcohol problems
More serious but less common problems include:
· diabetes mellitus, juvenile rheumatoid arthritis,
· sexual abuse, depression and parasuicide
· eating disorders
· traumatic injury
All these issues have important psychosocial dimensions.
Listening, building rapport, acceptance, support, understanding the patient’s perspective, sensitivity when examining.
Taking the young person seriously and being their advocate, (do not be seen to be siding with the parents); openness; tackle difficult direct questions, signposting their intent, (“I need to ask you a difficult question which I ask all people of your age in this situation....can you tell me how much alcohol you drink / do you take recreational drugs?”); confronting appropriately at the same time as showing care and concern on such topics as the risks of unprotected sexual intercourse and not controlling diabetes mellitus; showing sensitivity when interviewing the patient with a parent, negotiating when and how to ask either the patient or the parent to leave the room, so that each can be interviewed separately.
charting the difficulties that learners have with adolescents is a
constructive exercise. The
following points will probably come up:
As the teacher you can then
facilitate a free discussion
about the concerns that come up. Many
doctors find that they are representing an
authority figure, such as parent, teacher or older sibling to the adolescent
patient, which needs to be brought out into the open. For example, one strategy the group might try when
interviewing adolescents, particularly if the doctor is middle aged, is the
following approach; “I expect I remind you of your grandmother, and that might
be difficult for you. I’d like to
reassure you that I’m really interested in what you want to tell me, and
anything you say will be completely confidential and not go back to your
parents.” Consulting with more
than one person at a time requires thought about what you as the doctor want to
achieve, and how the patients in front of you want you to behave.
Not all teenagers want to be seen alone; some are very nervous and wish a parent to do all the
talking. Below is a list of helpful strategies for interviewing more than one
person at a time which apply to any combination of patients in any situation.
Asking learners to list what works well for them when they try to get young people to “open up” with the doctor may give them hints. Two useful strategies for patients who won’t talk at all is to ask them to draw a family tree, and this usually encourages a teenager to talk about family members. A variation on this theme is to ask the patient to draw a circle in the middle of a piece of paper which represents herself, and then ask her to draw all the other people in her life as circles and place them in the appropriate places on the drawing to represent how close her family and friends are to her. This exercise can quickly lead into the patient telling you about the important relationships in her life. If the adolescent finds talking to the doctor too difficult, it is usually best to terminate the discussion and offer another appointment, possibly with another doctor or other member of the health team.
These work well with medical students
and young doctors. Try a
paired listening exercise:“Remember what it was like when you were a
teenager - think for a minute of a time when you needed to see a doctor.
What did you need from him?”. Then
feed it back in a
round and discuss what
Ask learners to roleplay a difficult adolescent who comes in to see the doctor with her mother; the mother complaining that she is not eating properly, and other similar situations, and then working out the structure and communication skills which proved helpful, with the opportunity for rehearsal and further feedback.
patients telling their stories
Asking a real patient to tell their story is also a good lesson in empathy for learners. Watching an experienced practitioner interview a teenager and /or a parent is very useful. The use of a two way mirror, or watching a video of a live interview are methods which are widely used in training child psychiatrists and therapists.
E., Thompson P. (1993) Family solutions in Family Practice Quay Publishing
(1992) Talking to adolescents in “Talking
with patients.” Myerscough
P. Oxford Medical Publications
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