GP Tutor Dr Michael Poplawski describes his tried and tested methods for ensuring child examinations don’t end up being too scary or emotional – for the patient or the clinician
You are mid-consultation and, in the adjacent consultation room, a two-year-old is screaming blue murder through the paper-thin GP surgery walls. You exchange awkward stares with the patient in front of you as they say, ‘I hope that child is ok’ to which you nod and try to move on.
Is there a way that we can ensure consultations with paediatric patients don’t end up being so distressing?
There are three techniques I have been teaching my medical students and junior doctors that I supervise that can help reduce the risk of children having a tantrum because they are upset or frightened, especially during the examination stage. These do require a bit of effort and potentially a mindset change, but the rewards are often worth it.
1. Remember the parent is your patient just as much as the child
When dealing with pre-school or early years school children, in particular, it is the parent that brings the child in, so it is the parent that you really need to win over. I do this by focusing exclusively on the parent for the first part of the consultation. Having a box of toys or books lying around is a good way to keep kids preoccupied. Completely exhaust the history including concerns and expectations before you start doing any of the examination. If the parent feels at ease and feels they have been listened to, their shoulders start to drop, they start to relax. Children can sense that the parent is relaxed, which in turn increases your chance of having a peaceful consult.
2. Address the child directly, even if they are pre-verbal
This is by far the trickiest, yet by far most effective way to have a good consultation. Once I have finished the history, I will always address the child directly (who, at this stage, is hopefully sitting on the parent’s lap) and say: ‘Ok [insert first name here], I’ve just been having a chat with your mummy/daddy and they have been telling me you’ve been a bit poorly, is that right? Sorry to hear about that. Is it ok if we check you over today?’
It’s hilarious sometimes to see the stares of bewilderment on the parents’ and medical students’ faces when I speak like this to 9 to 12-month-olds. However, I personally believe kids understand a lot more than they can verbalise, and by addressing them directly in a calm and soft manner I am trying to let them know, I mean no harm.
At this point the order is: temperature check, front of chest with capillary refill time and assessing for work of breathing, then back auscultation, bilateral ear exam and finishing off with ‘the stick’ – the throat examination.
Before I do any of those tests, I show the child what I will do on myself first. I pretend to check my own temperature, I listen to my own heart, I stick the otoscope into my ear and let them have a look and so forth. I don’t always show them my own throat, because I’ve noticed children can sometimes feel scared by that.
3. Be very clear about the worst part of the consultation – the throat exam.
This is the worst part of the examination and you need to speak again with the parent at this stage. Children will often forget that you poked a wooden stick into their mouths and made them gag, but if you don’t prepare the parents in advance, they will never come back to you.
The script is: ‘Mum/Dad, I need to examine your child’s throat now with the stick, is that going to be ok? We know that kids hate this because we make them gag, but this is the only way to see the tonsils and make sure there’s isn’t any pus on them. You need to hold them in place and I will be as quick as possible’.
You really need the parents on board with this examination, particularly when you have a stick biter. Typically, around the age of two, children will start to bite down on your stick and will try to prevent you from going any further. If you back down at this point, you will never see those tonsils. But with a parent who fully understands the importance of this check and is helping you by holding the child in place, you can wiggle the stick from side to side while pushing forward and until the child gags. At that point you have exactly one second to see what you need to and then back out! Don’t forget to accompany all this with plenty of ‘sorrys’ and ‘I know that was awful’.
I would say these tips work more than 90% of the time. Once my medical students start adapting these three techniques, it’s so satisfying to see them come into my room smiling rather than completely shaken and frazzled and asking: ‘Do you want mind having a look at this child? I couldn’t really examine them.’
Finally, some children are indeed completely inconsolable and you will have no choice but to work out how to undertake your assessment with a potentially more limited examination, lots of safety netting (making clear the reasons parents needs to bring their children back such as ongoing fevers, shortness of breath and so forth) and maybe even referring the patient to another colleague for them to have a go!
Dr Michael Poplawski is a GP in Greater Manchester, and a GP Tutor. Access his YouTube channel at www.youtube.com/c/gponthemove
