As a birthday treat (mine not hers) my five year old daughter took me to see Operation Ouch Live! It’s one of the few television shows we watch as a family in our house so I thought I’d share you some (non-clinical) lessons I have learnt from Dr Chris and Dr Xand.
What is Operation Ouch?
It’s an educational British television programme aimed towards children. It’s shown on CBBC in the UK and on ABC, here in Australia. As well as hospital based segments focusing on the usual paediatric minor injuries – lacerations, fractures and things where they shouldn’t be – there are also segments on basic anatomy and physiology including those things that all children find endlessly fascinating (poo, wee and farts).
Who are Dr Chris and Dr Xand?
The Van Tulleken twins are real doctors. ‘Dr Chris’ Van Tulleken trained in Oxford and is currently doing a PhD in Molecular Virology. His older brother (by seven minutes) ‘Dr Xand’ Van Tulleken focuses his time on humanitarian medicine. For identical twins it is easy to tell them apart – Dr Chris wears the blue scrubs.
And do my eyes deceive me? Isn’t that….
…Simon Carley? Why, yes it is. The hospital-based segments were filmed in Alder Hey, Manchester and Sheffield so you might spot a number of friends of DFTB lime-lighting. You might even consider a Operation Ouch Friends of FOAMed bingo card if you can spot Alan Grayson, Gareth Hardy or Helgi Johannsson.
Whilst my children love to see the (not gory) medicine I marvel at how good the twins are at communicating complex medical ideas with children, as well as grown ups. We have all seen specialists come in and talk to patients and parents about a procedure only to have the family come up to us afterwards asking us to translate from Medical-ese into English. Effective communication, or the lack thereof, can make or break the therapeutic relationship and, like a lot of skills in medicine, it can be learned. I spent of lot of time, when I was doing my psychology BSc, filming and watching medical students interacting with patients – both real and simulated. We had been taught the technique of using open questions for the broad details and then closed questions to help us drill down to the nitty gritty so it is interesting to find that families perceive this yes/no interrogation technique as impersonal and suggestive of a lack of interest. This can lead to failure to disclose vital information, whereas asking parents to express any concerns seems to improve parent satisfaction without needlessly lengthening the history taking process.
How you talk to the patient really depends on their age and developmental level. Notice how I stated that this is about how you communicate with the patient. The focus should be on them and not the caregiver. I thought it would be good to learn from excellence and so crowd-sourced* some ideas about talking with young children. We’ll leave teenagers for another time.
Some general thoughts
Kate Granger reminded us of the importance of proper introductions. Just because you are talking to a child it doesn’t mean that basic good manners should be thrown out the window.
“Hello Grace. My name is Andrew. I’m a doctor. Do you mind if I have a chat with you and Mummy and Daddy?”
Of course, in this era of blended families it’s important to ascertain just who is accompanying the patient first. Don’t assume the grey bearded man is the grandfather.
I’m 6’3″ so I tower over most of my adult patients let alone the paediatric ones so I make sure I always get down to their eye level to talk. If that means sitting in some tiny chair like a scrubs-wearing Goldilocks then that is fine with me (as long as it holds my weight). Being at eye-level allows you to observe things from a child’s perspective, to watch them and to interact and play. It also creates a subtle shift in the dynamic between parents and doctor. With you sitting, literally, at their feet you remove a lot of the paternalistic hierarchy. A quick smile from their child and you have gained their trust.
Children do have a tendency to take everything you say literally so you have to be careful with your choice of words. Last week, after hearing someone say that they would,”Kill for some sushi” my five year old asked me who would they kill?
“Grace, do you mind if I ask Mummy and Daddy some questions now?”
Once you have an ‘in’ with your young patient you can switch it up for the details from the caregivers. you need to be open ended in your questions, reflecting back the answers and trying to elicit their concerns, what they are really worried about.
“Grace, who have you brought with you today? Can I take a look at Wozza Bunnies tummy?”
Examining young children can be a challenge so it’s important that they trust you before you even touch them. You need to respect them and ask their permission before lifting up a t-shirt.
“It seems as if Grace may have something called mesenteric adenitis. Do you know that that is? Just like you can get swollen glands in your throat you can get them in your tummy too.”
Medicine is a foreign language to most people. Sometimes we forget that and use long, scary sounding words. It’s fine to name a condition, in fact you should, but you then need to define it, to label it in terms that anyone, no matter what their degree of health literacy, will understand. I’ve lost count of the times I’ve heard the phrase “The arms is fractured? At least it’s not broken.”
I’ve often heard the advice to avoid the use of the phrase, “She is really sick” if a child is unwell enough to need admission. I think this is a where the use of the word, “poorly” is perfect though it doesn’t seem to have crossed over to this side of the world.
“I’m really glad that you all came to see us today. It’s much better that you come along and we can reassure you than you stay at home worrying. Whilst mesenteric adenitis is the most likely problem there are a few other things it could be. We’ve talked about some of the warning signs of other illnesses and if you see any of these you should come back to us.”
Parents, most of the time, are not trained healthcare professionals. Whilst little Gracie might be the fourth child you have seen that shift with vomiting it is important to be empathic. Recognising that it can be exhausting looking after child that has been vomiting all night is important so don’t make the rookie mistake of scheduling a review in the morning if you have sent the child home at 10pm.
And if you have to do something more than just examine them…
It is important to be honest. Young children don’t get abstract ideas so instead of telling them that you will only be a couple of minutes it would be better to say “This will be really quick“.
Never, ever lie! If it is going to hurt, tell them. Tell them it is going to hurt just a bit. If you tell them it’s not going to hurt at al and it does you are going to make things very difficult for every other healthcare professional they encounter.
So can you learn communication skills?
Of course. We’ve all learned how to communicate already, modelling our parents and siblings. Once upon a time we were brilliant at communicating with children because we were children. As we aged our interests changed, our use of language changed and our understanding of the way the world works has changed. If we can look at how we talk to kids through this lens then we can become better communicators. It has been suggested that formal training in communicating with children can lead to clinicians asking better questions, clearer questions as well as increasingly focussing on questions related to psychosocial health. It is another case of moving from unconscious incompetence through to conscious competence.
With communication skills highlighted by both ACEM and the RACP as a core competency it is worth seeking out opportunities for formal training and feedback.
If you want to get better at talking to children perhaps you should come and listen to Ian Summers at DFTB17?
* Thanks to the following for their ideas (in no particular order)
Luigi Zolio, Ash Witt, Mel Thompson, Ian Lewins, Stuart Duffin, Dan Magnus, Kristin Boyle, Ali Maddock, Pete Thompson, Damian Roland, Chris Nickson, Ian Summers, James Day, Ross Fisher, Pik Mukherji, Chris Elliot, Simon Carter, @abbieallergy, Andrew Mackay, Sascha Baldry, Casey Parker, Tim Horeczko
Levetown M. Communicating with children and families: from everyday interactions to skill in conveying distressing information. Pediatrics. 2008 May 1;121(5):e1441-60.
Purvis JM. The challenge of communicating with pediatric patients. AAOS Now. 2009;3(2).
Tates K, Meeuwesen L. Doctor–parent–child communication. A (re) view of the literature. Social science & medicine. 2001 Mar 31;52(6):839-51.
Wassmer E, Minnaar G, Aal NA, Atkinson M, Gupta E, Yuen S, Rylance G. How do paediatricians communicate with children and parents?. Acta Paediatrica. 2004 Nov 1;93(11):1501-6.
Keir A, Wilkinson D. Communication skills training in paediatrics. Journal of paediatrics and child health. 2013 Aug 1;49(8):624-8.
O’Keefe M. Should parents assess the interpersonal skills of doctors who treat their children? A literature review. Journal of paediatrics and child health. 2001 Dec 1;37(6):531-8.
Lorin MI. General Principles of Communicating with Pediatric Patients and Family Members. Communicating with Pediatric Patients and their Families: The Texas Children’s Hospital Guide for Physicians, Nurses and other Healthcare Professionals. 2015:13.
Frost KA, Metcalf EP, Brooks R, Kinnersley P, Greenwood SR, Powell CV. Teaching pediatric communication skills to medical students. Advances in medical education and practice. 2015;6:35.
Wood I. Communicating with children in A & E: what skills does the nurse need?. Accident and emergency nursing. 1997 Jul 31;5(3):137-41.