GPs write this so often in patients’ records that by the time we’ve written Pat… the software has completed the phrase. It’s almost certainly the commonest concluding remark of a consultation, especially one involving a parent of a sick child or someone worried about a symptom that they had associated with something serious like cancer. We spend a lot of time learning about communication in medical school and afterwards in our GP training (believe it or not), and I am still learning.
Maisy’s ears look fine, her throat is a little pink, her glands are a little enlarged, her chest is clear and her tummy feels fine, and her temperature is just a little bit up at 37.8 It looks like she’s got a viral infection and I expect she will be like this for another two or three days before she gets better
I watched Keris, the trainee GP describe her examination findings to three-year-old Maisy’s mum. Keris looked kind, friendly and concerned as she faced Maisy’s mum, consciously ignoring the computer screen next to her. Maisy looked tired and pale and sat on her mother’s lap with her head leaning against her chest. Her mum looked tired and worried. Keris noticed this,
“Was there anything else you were worried about?”
“No not really, thank you. I suppose, well you’ve checked her and you’ve said she’s going to be OK”
“If she gets any worse, or you’re worried, you can always call us again and we can see her if necessary”
“Thanks, and thanks for seeing us so quickly” Maisy and her mum left and Keris turned to finish typing up her consultation. She began to type, “Pat …”
We looked at each other, was Maisy’s mum really reassured? Was reassurance what she wanted or needed?
A series of studies looking at parents of sick children suggested that what parents want is not only reassurance – that there are no signs of serious illness and their children will be OK, but reassurance that they have done the right thing at the right time, by asking for medical advice. Beyond reassurance, the articles suggest that what parents want and need is confidence in the doctor and confidence in their own abilities.
In one study, parents
felt excluded from the apparent mystique of the professional’s assessment. The commonest example was seeking advice about a chld’s cough when they feared infection “on the chest” because the child’s chest sounded, and even felt, “rattly”. However the doctor would pronounce the lungs “clear” on examination despite apparent evidence to the contrary. Parents would then find it difficult to question the doctor’s authority and were left feeling silly for worrying or still perplexed by the problem.
The significance of this is highlighted by another study about parents experience of criticism when presenting with sick children,
Parents reported being made to feel stupid or silly in these negative encounters with health care professionals, usually doctors. They felt that they had been criticised, even when no directly critical comments were made the criticism was communicated through the attitude or manner of the doctor concerned.
Being made to feel stupid or silly makes parents feel of guilty or ashamed, for example that they’ve wasted health-professionals’ time or that they are bad parents. The consequence of this felt or enacted criticism was that parents tended to feel more anxious about their abilities to recognise and manage their childrens’ illnesses. Thinking back on my own experience as an inexperienced A&E doctor and an exhausted GP, particularly before I had children of my own, I have no doubts that I left parents feeling bad about wasting my time. My intention, in a rather careless, ignorant or callous way, was to try to make sure they didn’t come back with a similar problem in future. My role was conflicted between my duty to my patients and my duty to stem the tide of demand. These pressures are even higher now as a result of cuts to NHS funding at the same time as rising demand and increasing emphasis on individual responsibility. Parents feel in a double bind, expected to find the ‘Goldilocks zone’ where their child is sick enough to warrant medical advice, but not so sick that they’ve left it too late, whatever the illness. Signs on buses and A&E (Emergency) departments warning parents and patients not to waste healthcare professionals’ time highlight the ignorance of government advisers, suggesting, “You won’t get any sympathy here if you’re child isn’t seriously ill”. GP and educator, John Launer has asked, rhetorically, “What is an emergency [anyway]?
Doctors who make parents feel bad about bringing in sick children may believe they are avoiding patient dependency especially when the parents don’t come back. But,
Parents leave such encounters without the capacity to manage the situation, still anxious about their child’s illness and therefore may need to seek advice again.
And so, still anxious, they present elsewhere where they are less likely to see the same health professional again or where they think they are less likely to be criticised. It has been suggested that because of their position of authority, doctors are more likely to be perceived as critical than nurses. I’ve met gentle doctors and fierce nurses, but in general this rings true.
What should we do?
We should start by acknowledging, explicitly if possible, that parents are,
strongly influenced by a sense of responsibilty to act as competent parents and the fear of overwhelming guilt should they fail to do so. (Kai)
So we should reassure them, not only that their child is OK, but that they are not wasting our time and we understand their concerns. GPs are taught to explore parents ideas, concerns and expectations, but while these shouldn’t be pre-empted, it helps to know that in one study, parents of children coughing worried that their children might die, by choking to death or that they might develop long-term damage like asthma. Almost all parents have experienced a child who has been listless, feverish, coughing and miserable all night only to perk-up as soon as they get to the GP or hospital and wonder how or why they did that.
Secondly, the experiences of parents of sick children reveals that we need to go beyond learning about ideas, concerns and expectations to understand informal social rules, our role as moral agents, how actual or perceived criticism can lead to guilt or shame, and how to use our own power to empower parents (and other patients).
Thirdly, we need to give explanations that make sense to parents. In the first study, If the doctor told them that,
their child had ‘a virus’ or ‘a bug’ it was confusing, provoking anxiety rather than reassurance, and sometimes anger. Some parents believed that a viral explanation was offered when the doctor was unsure about the diagnosis.
Finally, we need to go beyond reassurance, to give parents and patients confidence in themselves and their ability to cope. One of the reason this is difficult, especially for inexperienced doctors is that first they have to reassure themselves that the child is OK, and have confidence in their own abilities. Sometimes when we think we’re reassuring patients, we’re really just trying to reassure ourselves, like Keris above. My own experience and that of other older doctors is that trainees these days have more anxiety-provoking assessments, but less confidence-building experience than they used to. We also need to think critically about patient choice and information – the twin obsessions of policy makers, because they are only means to the ends of patient reassurance and confidence. Used carelessly, too much choice and information and can worsen parents’ anxiety and undermine confidence.
One of the most effective ways I learn is by watching my colleagues and trainees work and by inviting them to watch me. When experienced surgeon Atul Gawande noted that even the most experienced sports-stars benefit from a coach he invited a colleague to watch him at work and was amazed by how much he could learn. I’m in a fortunate position of teaching trainees when I work, but I’m now making time for my experienced colleagues to watch one another.
Even though I’ve been a GP for 14 years, I still find this useful. Just as parents share stories, which often take the form of moral tales, about their experiences with sick children and medical professionals, by sharing stores about how we struggle to be better doctors, we realise we’re struggling with the same issues. To be a good GP – or indeed any healthcare professional, is difficult because it’s bound up with sensitive relationships. We need to articulate this to policy makers who think our work can be automated or industrialised and we need to support one another and know that we can help each other change.
Why do mother’s consult when their children cough? http://www.ncbi.nlm.nih.gov/pubmed/8359610 1983
What worries parents when their preschool children are acutely ill, and why: a qualitative study http://www.ncbi.nlm.nih.gov/pubmed/8892420 1996
Parents’ difficulties and information needs in coping with acute illness in preschool children: a qualitative study http://www.bmj.com/content/313/7063/987 1996
The role of felt or enacted criticism in understanding parent’s help seeking in acute childhood illness at home: a grounded theory study. http://www.ncbi.nlm.nih.gov/pubmed/22137590
Safety netting – a guide for professionals and parents of sick kids from GP Paedtips
Shame. How it affects patients and their relationships with health care professionals. https://abetternhs.wordpress.com/2012/11/16/shame/
What is an emergency? John Launer
Conversations inviting change. John Launer
Thanks Jonny this is great I will share it with my trainees.
I have 2 fresh ST1s who are particularly grappling with these issues at the moment. When I read the Joe Kai papers when they came out in 1996 I had been a GP for 3 years and had 2 small children (and was very tired all the time!). I could see that most of the acutely unwell children I saw were obviously not seriously ill but also as a parent I could understand the parental concerns but couldn’t really reconcile the two. The papers were a revelation. I started asking mothers (and it is more often mothers) in more detail about their worries I found they often matched those in Kai’s paper and I started to routinely explain about some of the issues raised for example transmitted sounds “the sound is coming from the back of the nose but the lungs act like a sort of amplifier so you can hear or feel it in the chest” It did seem to help and I found these encounters more satisfying and at least some of the patients seem to as well. When confronted with those only interested in numbers based research I quote this as an example of how qualitative as well as quantitative work can change practice.
Thanks Alan, that’s very similar to the language I use, though I have to continually check for clues as to whether it’s credible from the parents’ perspective. It’s a great example of how qualitative research (and reflective practice) can change clinical behaviour, I agree!
Another thought: I use the code “reassurance given” not “patient reassured” I can only be sure that I have sent the message not that I have done it effectively or that it has been received!
Don’t forget that people are also keen at times to reassure the doctor !