Children may have varied expectations of going to see a doctor, depending on age, what parents have said, and previous experience of health professionals. Many children might expect the doctor first to find out what is wrong, perhaps by asking questions, by prodding, by sticking a needle in, or by just knowing. I remember once, as a paediatric registrar in Hackney, asking a Bangladeshi father whose wife spoke no English what was wrong with their child. He said that I was the doctor, so I should know. I would have done better to ask the child.
Children may often be dissatisfied with their interactions with health professionals,1 but may not say so unless asked, unlike their parents, who may insist on having their say. A simplified case example follows to illustrate the need to allow children to voice their concerns. A 10-year-old boy has recurrent abdominal pain that often begins on schoolday mornings, mostly gets better on Friday evenings, and improves if he is driven to school by his dad. He had not told anyone, until his school nurse asked him directly, that he was being bullied on the bus on the way to and from school. In general practice children with social or educational stress very commonly present with symptoms that could be regarded as partly psychosomatic, such as bed-wetting, asthma, recurrent abdominal pain, and headaches.2
Children's ratings of the doctor's interviewing skills may not be as reliable as those of the parents,3 but it is likely that diagnostic assessment will be more accurate if the child contributes. The child will appreciate feeling heard and the treatment is likely to be more effective if the child is involved in discussing what can be done.
There are structured ways to assess and improve communication skills with adolescents4 as well as children.5,6 Trainees' communication skills can be improved by recording on videotape a proportion of routine consultations (Sue Laurent, personal communication, 2004). Triadic consultation skills can and should be taught in both general practice and paediatrics — but not in a single session. Ideally, four components should be involved:6
small-group or one-to-one learning;
observation (preferably involving video-recording and role-play);
detailed, individualised feedback; and
practice/rehearsal of skills.
All UK medical schools now teach communication skills, and a proportion devote part of this syllabus to communicating with children, but not all have a specific module on the triadic consultation skills necessary to interview a child and parent (or carer) together. This is more likely to be learned during postgraduate training, but it needs to be actively taught at an early stage. Two fascinating papers by Cahill and Papageorgiou in this issue focus on patients aged 6–12 years. They present a thorough review of relevant research,7 and a description of the authors' own well-designed study,8 with resulting recommendations.
There is some research on how to teach triadic communication skills;5,6 and on what actually happens in general practice and paediatric consultations, as reviewed by these two authors.7 There is less research determining the best techniques to use in triadic communication (in addition to those of a generic clinical consultation). The sparse literature is reviewed by Crossley and Davies.9 However, there is significant overlap between these three categories: how best to teach the skills specific to triadic consultation; what skills interviewers use in practice; and what skills are best to use. Researchers assess and trainers teach what they believe to be the most useful skills. Children's views on the skills of the doctor they have seen may provide useful individual feedback, although parents may be more consistent in understanding the questions, and give a better comparison of skills.3 Females at 14 years of age were found to rate videotapes of clinical interviews reliably,4 which could be used to determine the best triadic communication skills; however, younger children would have difficulty with the readability of the scoring items.4
>The recently published GMC guidelines10 were developed partly as a result of focus groups involving families.9 The research on which skills interviewers use in practice7 uniformly indicates that the child is involved for too small a proportion of the interview: ranging from 4% to 14%. Beyond that, there seems to be scope for professional consensus,9 and also for some disagreement about the best way to involve both parent and child.
For instance, there is the potential for disagreement with two small aspects of the recommendations these authors make (Avril Washington, personal communication, 2007). Firstly, the parent should not necessarily be allowed to speak first. The child could be greeted first in the waiting area and then, after some problem-free chat (if there is time), given the opportunity to provide a version of the presenting problem. Parents can be reassured that their version will be allowed later and, if possible, should not be allowed to impose their views on their child's. Secondly, the authors' advise against ‘motherese’,8 which presumably means a sing-song variation in tone that can be good at maintaining attention, but it is unclear whether there is enough evidence for this, particularly in younger children. The younger the child, the more effort the doctor must make to simplify concepts. Modulation of voice tone and syllabic stress can also helpfully be adapted to age; this is no more than an exaggerated version of ‘BBC-announcer-ese’ — if voices on the radio did not vary in pitch and emphasis, we would soon turn it off.
It seems that neither the existing literature nor the original research in this issue8 can be regarded as conclusive about these conflicting recommendations.
Most of the other recommendations by the authors may be less contentious: for instance regarding seating positions and lines of gaze; the child's need to have more time; and the helpfulness, at times, of closed questions, but these can sometimes lead to putting words into the child's mouth. Further ways of showing respect to the child can include inviting the child to contribute at every stage of the consultation: not only in explaining the symptoms (perhaps non-verbally), but also in deciding what to do next, whether it be treatment, referral, or wait-and-see. Negotiating a treatment plan with a child will increase its chances of success.
Attention needs to be paid to some special circumstances (Avril Washington, personal communication, 2007). There may be a discrepancy between the child's chronological age and developmental age. If so, it is the developmental age that determines the best communicative style and content. If English is the parent's second language, there can be a danger that the child becomes a translator or advocate for the parent, with the potential consequence that the child's needs and interests get lost in the muddle of who is saying what for whom. Getting a paid interpreter for a 10-minute consultation could be unfeasible, but it may be possible to ensure that another member of the family attends who is older than the index child, and can appropriately act as interpreter.
With a chronically unwell parent, the child may at times have to act as carer for the parent. Sometimes this may be the underlying reason for the child presenting with problems. The GP may be in a privileged position through having detailed knowledge of the parent's medical history, which can help to negotiate this particular minefield: the danger is that the child's needs may be subordinated to the parent's. Organisations for young carers may be very helpful in this circumstance.
The papers by Cahill and Papageorgiou set the skills of triadic consultation in a scientific context, but it is still an art that has to be learned, and which should be more actively taught from the first year of medical school and throughout any medical career that involves seeing children.
- © British Journal of General Practice, 2007.
