Pediatric History
Starting Off
go to the patient and meet them where they are, then bring them in.
the sooner you start releiving their anxiety, the better.
start making friends in the waiting room.
be able to say hello in every language
Introductions
It is good to stay towards caution and to use titles (Mr. Pickles)
"Why don't you start off by telling me why you've come to see me, and how you think I can help?"
Let them finish their opening statement - no interruptions!
- don't let your agenda take precedence over theirs.
Involve the child from the beginning.
If parents start listing all the problems especially behavioural), interrupt and say "i know you have many concerns. let's start by telling me all the great things about your son/daughter..."
History of Presenting Illness
baggage = hidden agendas
often the hidden stuff is the number one issue
- parental guilt, which can be over simple things
- fear that this is something serious or fatal
- bring it up and
- look, I don't know about you, but most parents of a child with this thing are worried this is something very bad.
- wait for them to nod.
- I see you've been worried about this.
- who do you know that's had a [brain tumour]?
- mental health concerns (depression is the second most frequent thing that affects people, after the common cold)
- substance abuse
- domestic violence
sometimes investigations can be very scary and are not worth doing.
I don't know about you, but...
good introduction for a hot topic. It is very disarming
end the interview
therapeutic contract at the end
come up with specifics for behaviour
- "I want you to call me at 9:15 on Friday to report." then write it in your schedule in their presence.
- reporting back is one of the most important elements. you want to see how much progress you can make in a few days.
Taking a history is as much therapeutic as it is diagnostic.
at regular intervals, interject empathy, affirmation, and support.
It can be good to throw in some curve balls to get them thinking.
Parents want to know they are being listened to.
They want to know you'll give them time.
- pull up a chair - they'll know you're interested in staying for a while.
- body language - keep your eye level below theirs
- try at all costs to avoid interruptions
be cautious when writing notes
it can interfere with learning in a major way
try writing all the notes at the end of the interview
be on time whenever possible
learn about cultural profiles of the people you'll be seeing
They want doctors who exaplin things to them in words they understand.
Are the parents smiling when they leave?
one of the biggest mistakes you can make is to assume a nodding head mean people understand.
often the most important part of the interview is the last 2-3 minutes.
- ask the parent to reiterate what's been said and what the plan is for their child to get better.
disease is a pathological process, while illness is how the patient feels. these are frequently discordant
as medical training unfolds, doctors talk more about disease and less about illness.
medicine is like pplaying a muscial instument - you are always getting better.
Dr Harry Gordon - "doctor's mission is to relieve anxiety"
Henry Kemp, always ask 3 questions when meeting people
- how do they look?
- what do they do?
- what do they say?
prediatricians frequently see the whole family.
a kid crying in the clinic is a major failure.
anxiety is more contagious than chicken pox. it is transmitted through touch.
conflict resolution
- lower your voice
- get them into a quiet space
- say "i can see you're upset. tell me about what's happening."
breaking bad news
- doctor, was the tumour malignant?
- yes it was
- thank you very much.
means the conversation is done.
we learn remarkably little from the examination - the history is where to spend most of your time.