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COMMUNICATING WITH CHILDREN, ADOLESCENTS AND MORE THAN ONE PATIENT AT A TIME

 CHILDREN  
When communicating with children, it is vital to remember that the child is the patient but the parent is a key person in any transaction.  Serious illness in children is overwhelming for all parents, and even minor illness can be frightening.  There are a number of good texts which discuss communication and behaviour issues in children and families. A thorough understanding of the psychological processes through which children pass is essential reading so that doctors can tailor their explanations to the level of the child’s understanding.  Family systems therapy offers a useful way into exploring family dynamics and is well within the repertoire of the GP.  (Asen and Thompson,  1993)

 Key core skills

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.

 Key issue-specific skills

reassurance, interviewing more than one person at a time, (see under Adolescence),humour and fun.

 Suggested teaching methods

Discussion

Discuss and list the skills and behaviours which might be most helpful when consulting with children and their parents.

·        lay out of the consulting room, toys and books and drawing materials are all important

·        establish how comfortable the child is when she first comes in with a parent and her family

·        put aside time at the beginning of the consultation to build rapport

·        listen to and involve the parents

·        use clear and appropriate language appropriate to the child’s age

·        find out where the child is most comfortable - on the parent’s knee or on the floor playing with toys particularly during the examination

·        pay attention to proximity between you and the child - many children like you to be at their level

·        use an unstructured, open and collaborative approach - build in play during the interview

·        take children seriously and don’t be patronising

·        offer support and praise

·        engender confidence and responsibility

·        be gentle and led by the child  and the parent’s pace

·        offer a clear follow up plan

 Roleplay            

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. 

Video review

Video 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.  (Kurtz, 1989) 

Patient centred exercises

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.

 Presenting 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.

 Other sources    

*Speirs (1992)  Talking with children in Talking with patients. ed. Myerscough P.  Oxford Medical Publications Oxford

*Lloyd and Bor (1996) Guidelines in communication with young children in, Communication skills for medicine  Churchill Livingstone New York

Lewis 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        

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.

 Key core skills

Listening, building rapport, acceptance, support, understanding the patient’s perspective, sensitivity when examining.

 Key issue-specific skills

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.

Suggested teaching methods    

Discussion

Flip charting the difficulties that learners have with adolescents is a constructive exercise.  The following points will probably come up: 

·        the patient who won’t talk

·        when should a doctor interview an adolescent on her own;  is it legal?

·        confidentiality problems

·        conflict in the interview;  how to avoid giving a lecture

·        “he reminds me of my teenage son”

·        “I don’t understand their language - I don’t know haw to talk to them”.

 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.
 

CONSULTING WITH  TWO OR MORE PEOPLE AT A TIME          

Remember:

·         that the interactions are more complicated than you and two or more patients “separately”

·         body language and position is important

·         take each person seriously and show equal respect

·         establish the “ground rules” with both patients by negotiating them at the beginning

·         there will probably be more than two agendas - two patients, their joint agenda and possibly yours!

·         there will be two or more patients’ illness frameworks to take into consideration

·         there will be two sets of cues to pick up

·         pay equal attention to both patients and try to divide the time “fairly”

·         don’t take sides or compete

·         negotiate interviewing each patient separately if that is what they wish

·         keep the boundaries safe

·         Confidentiality is important;  you may know things about one person that the other party doesn’t know.

 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.

 Patient-centred exercises

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 comes up.

Roleplay

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. 

Real 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.

 Other sources

*Asen E., Thompson P.  (1993)  Family solutions in Family Practice  Quay Publishing

*Wrate  (1992) Talking to adolescents in “Talking  with patients.”  Myerscough P.  Oxford Medical Publications

      * Lloyd and Bor (1996) Guidelines on communication with children and young people in “Communication skills for medicine”  Churchill Livingstone  New York            

 

 

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