Tuesday, 4 January 2011

Children as Patients

One of the things I miss now that I am no longer practising as a GP is the children who were brought to me as patients. GPs are privileged in this respect because they are (still) trusted.  There is a particular knack to working with children as a doctor, not least because they are often feeling ill (of course) and may be frightened. So one has to be patient and strive to put them gently at ease. I made a point of talking to them directly, however little they might be, of telling them what I was going to do and do my best to explain why. Any examination was preceded “I’d like to look at (ears, throat, tummy etc). Is that all right?” And I would explain to the parents, too, what I was on the look out for when doing an examination.

Parents would often express concern that they might be “wasting the doctor’s time” with what they thought the doctor would perceive as a “trivial” problem, and judge them accordingly as being “over anxious”. But I never saw it in that way, although I believe that some of my colleagues might have done. This may have had to do with the fact that I was a parent (and latterly a grandparent) of young children myself and knew first hand how frightening the spectacle of an unwell child can be. Also, a doctor whose response – even body language - is perceived as unsympathetic or dismissive risks laying up trouble for her or himself. Doctors do not get it right every time: a small minority of children presenting with what is concluded, even quite reasonably, to have a benign and self limiting illness may end up severely ill in hospital through an unexpected turn of events. In such circumstances parents are not always forgiving.

So, far better to listen to what you are being told, to show that you are taking all on board and taking it seriously. Not only will the doctor be felt by the parents to be trying to understand what they are wanting to put across, but as well he is far less likely to miss the occasional vital clue to something more significant going on. I endeavoured always to be at pains to reassure the parents that their concern was never inappropriate. Were I to believe, after careful and attentive assessment, that the child’s condition was most likely not serious and that recovery would be natural and complete, I qualified my explanation and reassurance with the observation that they had been quite right to bring the little patient in to see me. And that if things did not go as I predicted, or if indeed they had any further “worries” they should not hesitate to seek advice again. As a younger doctor I was occasionally told by those who thought they knew better than I that this only “encouraged” anxious behaviour, and that I would pay for my softness with having to meet ever increasing demand, demand that I had stoked up by failing to “discourage” the inappropriate use of my precious time. As my years in practice accumulated I grew to realise that this view was complete nonsense.

No, the truth is that we doctors sometimes credit our patients with less sense than they really have. And conversely, it is knowing that they have a doctor who will take them seriously and not treat them as if they were stupid in truth makes them more confident in themselves.

Step back and look: most new parents, being by definition fit and young, have had not much to do with their local surgery. The awesome responsibility that parenthood places upon them changes all that. And this in turn gives the doctor – and all the surgery staff – a great opportunity to get to know the new family. While doctor and patients do and should work in partnership together (the doctor is after all just a resource, and not an agent who somehow takes over responsibility for her patient’s health), a sound relationship based upon understanding and mutual respect can be created and nurtured in the arena which is represented by the new family. Continuity of care was always one of the great joys of general practice. Indeed, many family doctors of my era saw perhaps three generations come through their consulting room doors over the decades. In my final years I spoke with more than one smiling young mother who reminded me that it was I who brought her into the world.

When a family feels their doctor to be approachable then the chances of presenting a potentially serious illness late are surely diminished. And more takes place in the consultation than just an assessment, diagnosis, reassurance and advice. Guidance can be given as to how similar illnesses might be managed in the future, and what is called “health education” in a broader sense.

It always brought a smile to my face when a child was brought in to me by a mother who looked rather sheepish and then confessed “he was so much worse when I telephoned. To look at him now you’d think I’d been having you on”. But it is a fact that a breath of fresh air and a change of scenery – doctors’ surgeries are fascinating places – can brighten an unwell child up no end. I would respond along the lines that it always cheered me to see a child who was perking up, and also said, again, that there was no question so far as I was concerned that she had been right to bring him.

Children are fun in the consulting room. I loved their endless questioning when they began to feel at ease. Stethoscopes were tried out on younger siblings, lights shone into the ears of teddy bears and dolls. “Now you’re being a trouble to the doctor” the mother would chide. But no, never. It is in a child’s nature to be curious about everything. We must encourage it, and answer as best we may every one of them.

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