British Jorirnol of Medical Education 1975,9, 158-161
Parental attitudes to a clinical examination in paediatrics TIMOTHY L. CHAMBERS’ University of Leeds
Department of Paediatrics and Child Health,
K e y words
PAEDIATRICS/ ‘educ *EDUCATION. MEDICAL *EDUCATIONAL MEASUREMENT *PARENTS ‘ATTITUDE PHYSICIAN-PATIENT RELATIONS PARENTCHILD RELATIONS TIMEFACTORS BOREDOM ANXIETY MOTIVATION
‘Children sweeten labours, but they make mis€or- had persistent illness or handicap. Obviously tunes more bitter.’ the invigilators tended to ask those parents -Francis Bacon whom they knew, and thus were most likely to come. The examination lasted from 9.00 a.m. to Recently, the form and conduct of the clinical 5.00 p.m. on two consecutive days. There were examination has been critically scrutinized breaks for coffee, lunch, and tea. Travelling (Stokes, 1973). The central role that patients expenses for parent and child were paid, or play at present has been discussed and alterna- else transport provided. Each child received an tives to them (audiovisual aids, trained non- honorarium of 50 pence per day. patients) considered. At present, we rely Present study heavily on the goodwill of patients and their parents for the smooth running of the paedia- The parents (15 mothers and 1 father) OE 8 tric clinical examination. It, therefore, seemed children who participated at Seacroft and 8 at appropriate to inquire if they were satisfied Leeds General Infirmary were interviewed two with the present form of the examination and, months after the examination. This interview if not, where improvements might be made. was conducted in the homes of 11, and after an out-patient visit to their own clinician (not Organization of examination the author) for 4. The other child had been I n June 1974, 69 candidates presented for readmitted and the mother seen on the ward. the University of Leeds final examination The author is involved in the clinical care of 6 (MB ChB). The paediatric clinical formed part of the children - all a t Seacroft. The interview of the examination in medicine. Each candi- was not structured, but was introduced as a date had one long case (30 minutes with piece of consumer research to start a conversapatient and parent, and 15 minutes subsequent tion. The aim was to discover how much indiscussion with the examiner) and as many convenience had been caused, whether they or short cases that could be fitted into a final 15 the child had been upset or worried by the minutes. There were two paediatric clinical proceedings, and how the organization could examination centres, Seacroft Hospital and be improved. Leeds General Infirmary. The arrangements at Initial approach each centre were supervised by two different invigilators and the choice of patients left to For 12 parents, the request to attend the them. The children whose parents were seen examination was by letter. This asked that the for this study were mainly out-patients and child should attend the hospital to take part in the clinical final examination. Dates and times were given and transport arrangements out’Requests for reprints to Dr Timothy L. Chambers, lined. Nine parents were satisfied with the inDepartment of Renal Medicine, St. James’s Hospital, formation given in this letter. One child had Leeds LS9 7TF. ~~~
~
158
Parental attitirdcs
10
a clinical examination in paedicilrics
attended the clinical four times previously and her mother knew what was involved. Three parents would have liked a more detailed explanation of what was to happen: one thought that the object was a special examination of her child, and the other two worried about their children being used as a ‘demonstration’ or for ‘show’, and would have appreciated knowing exactly how many students would see their child and for how long. All the mothers assumed - correctly -that they would be able to stay with their child during the day, though this was not stated in the letter. The parents of in-patients were approached on the ward and their agreement secured. Any queries were answered at this time and they all felt that the information given was adequate. All the parents had told their children about the clinical examination soon after they had received the letter. Fourteen children were said not to have worried about what was to happen; the other two associated hospitals with enernata or needles and were relieved to be spared their usual ordeals. Opinions about the organization Ten parents made their own travelling arrangements (7 by car and 3 by bus). The other four had taxis provided. Two children were inpatients; their parents visited early and stayed all day. The Seacroft children were asked to arrive at 8.30 a.m. This meant an early start and most were travelling by 7.15 a.m. (One family overslept and the arrival of the taxi caused pandemonium.) The Infirmary is more central and parents were thus able to set out later. All but one of the parents were satisfied with the transport arrangements. The only unhappy mother was kept waiting 90 minutes for a taxi at the end of the day, which meant that she had been away from home nearly 13 hours. Three parents were surprised to have travelling expenses reimbursed. Everybody at the Infirmary was offered a free lunch on the ward. Parents of in-patients ate there; the others (4) went out for lunch to give the children a change and a treat. One mother used this as an occasion to protest about the quality of hospital food. Seacroft is more isolated and, though they were not offered lunch on the ward, no parents left the
1 S9
hospital. They were directed to a Mothers’ and Visitors’ Unit where snacks and meals may be bought. Malfunctioning machines there brought the most vehement criticism of the whole examination upon the author’s head! Three mothers were enterprising enough to use the staff canteen and had no such complaints. The duration of lunch (30 minutes) was long enough for all except the examiners and invigilators. who found one hour to be rushed. Most parents thought that the length of time they spent at the examination was enough. They all admitted to being tired by the end of the full day -particularly if a bus journey in the rush hour lay ahead. The mother who had attended before definitely preferred a half day session. The children were also said to have been able to cope with a full day but were tired at the end - which €or some was 7.00 p.m. Still, as one father pointed out, 50 pence is a great sweetener. Parents’ feelings about the examination A new experience All the parents (15) who had not been before were interested by the examination. They had not realized that this was the way students were tested, but they all felt that contact with a patient should be taken into account in the assessment of competence to practise medicine. Six parents felt that they learned more about their child’s condition: for three of these, the source of information was an examiner. One mother was told €or the first time that her child with overflow incontinence of urine would eventually achieve some control and expressed great relief a t this news. Another father realized that his son’s problems (encopresis and enuresis) were compounded by difficuIties at school (this came out during the candidates’ discussions with the examiners) and was thus able to approach the boy more sympathetically. The other four met mothers whose children had similar conditions and were able to exchange ideas. No parent felt that the whole exercise was a waste of time. Monotony Only four of the 14 parents who stayed all day admitted to being bored. Most had brought games to play with the children and otherwise
160
Timothy L. Chambers
spent the time talking to other mothers. One mother fiad been on nursing night duty and cap-napped during her stay. Another rediscovered her talents for feeding babies. The main irritation was the examiners needing a ready supply of short cases; this meant that most children had to stay near their beds for most of the time. Each child was used twice in the whole day as a long case. The parents all felt that this was sufficient for their children though two enjoyed themselves enough to want more candidates. All seemed satisfied with the diversions supplied for the children on the ward, and were unstinting in their praise for the nursing staff; the extra work involved for them was commented on by most. The short intervals for coffee and tea were appreciated for the break in routine as well as for sustenance.
Parents’ worries All the parents were asked if, as a result of the examination, they thought that (a) their child was more seriously ill than they had appreciated before, or (b) their child had a condition they had not known about. Ten said that neither applied to them. One mother of a 3year-old paraplegic girl with a high meningomyelocele was upset by the term ‘handicapped’ being applied to her daughter. She resarded her condition as a delay in development rather than a disability. This patient also demonstrated how far the clinical examination is removed from reality. Her mother persistently drew attention to her right arm being painful after a fall. No attention was paid to this symptom - which was causing considerable anxiety - by candidates, examiners, or invigilator. The following day an x-ray revealed a fracture of the humerus. Two children were said by the candidates to have heart murmurs which were unknown to the mothers. This, predictably, caused consternation. One murmur was inaudible to the examiners and the mother suitably relieved. The other was associated with anaemia of renal failure and thought to be functional, thus had not been mentioned. The misapprehension this caused only came to light at the end of the examination when the mother chanced to meet the house physician who had looked after the child, and had told him. She was reassured about the benign
nature of the murmur, but might well have gone home very worried. A mother who was a nurse heard her 6-year-old daughter referred to as a ‘spastic’ (she had had a sacral meningocele repaired and retained a mild neurological deficit). With her professional knowledge, she knew this to be untrue, but pointed out that unqualified use of such a term might well have upset another parent. One mother was ver! amused to hear her son’s rash (4th week of Henoch-Schonlein purpura) ascribed to measles. She was surprised that a qualifying student was unable to describe the characteristics of a measles rash. Another candidate thought this boy had rickets: nobody corrected this in front of the mother.
Worries of children One girl, aged 13 years, was upset at the description of ‘spindly’ being applied to her finger joints: another candidate commented on her ‘pigmentation’ - she felt this word had a racial connotation. None of the candidates was said to be rough, though the child with arthritic hands who was used as a short case would have appreciated a warning from the examiners to student that the joints might be painful. One father told his son (complaining of frequent abdominal palpation) that he would ‘have to put up with it’- as a part of a repayment of ii debt of gratitude to the hospital. Attitudes to candidates The parents were briefed before the examination to answer all the candidates’ questions. but not to volunteer a diagnosis. Two mothers would have appreciated more advice from the invigilators particularly whether details of investigations or drug therapy could be revealed In response to a direct question, three mothers admitted to being frustrated by the candidates‘ wrong line of inquiry-they wanted to pui words into the students’ mouths. One mother cheerfully admitted to doing so. Two parents felt they had given poor information to the candidates and wished they had thought our details such as milestones and immunization timing before they arrived. This particularlj applied to one mother whose child had had many operations, the dates and details of which she had forgotten, but which assumet
-
Parental attitrrdes to a clinical examination in paediatrics
increasing significance to the candidate. All the mothers were aware of the importance that would be attached to the history and were anxious to get it right. Two mothers thought that 30 minutes was too short a time for a long case involving their child: none found it too long. The tense atmosphere, particularly at the start of the day, was commented on by the parents as inhibiting their ability to recall important details. No parent was upset by the candidates. All said that the students made an effort to put them and the children at ease, though as more than one mother observed, it was often the patients or parents who calmed the students. One mother thought that a candidate who saw her child should not have passed the examination (he did). The rest were satisfied that the students who talked to them and examined their children were now doctors. Attitudes to the examiners Most parents felt that some candidates did not do themselves justice in the presentation of their histories to the examiners. One mother noted that the examiners who sat down with the Candidate and involved herself and her child in a discussion usually produced a ‘natural’ performance from the student, in contrast to those who stood round the bed and talked over her. The examiners were generally thought to be fair in their attitudes to the students. Their job was acknowledged to be repetitious and demanding of tact and sympathy. Three mothers spontaneously commented on the responsibility that the examiners held, both to the students, to try and encourage them to overcome nervousness, and to the general public for maintaining medical standards. There were no complaints about the examiners’ approach to parents or children. It was appreciated that a brief short case does not allow time for. pleasantries. One mother admitted to answering for a faltering student; she saw him as a partner in the struggle with ‘authorities’. Motivation When asked why they had come, most parents were unable to give a reason, though they all saw the examination as being of no direct benefit to them or their children. None gave the
161
impression of being motivated by power or of being ‘professionals’ as suggested by Stokes (1973). Two mothers hoped that medical understanding of their childrens’ conditions would be improved (one was retarded, the other had glomerulonephritis which had been undiagnosed for several months). Both parents of one boy defined the situation as one in which they could repay the help that had been given to them by the hospital, and by one individual in particular - the invigilator. This feeling was also expressed in a less forthright way by most other parents. The extreme to which this may be carried was shown by the mother whose daughter had been to clinical examination before. She saw attendance as an obligation consequent to the care and attention her daughter had received - despite the latter’s expressed unhappiness at being the subject of the examination. All parents would bring their children for another clinical examination if asked. The only reservations were about transport and catering arrangements and the duration of stay. There were no complaints about the conduct or form of the examination and two mothers would be happier to come now they knew what was involved. Apart from the child referred to above, the other children questioned all had no hesitation in agreeing to come again. Their parents quickly pointed out that their motivation was primarily financial. Summary A selected group of parents. whose children were patients in a recent clinical examination, declared, with one exception that this experience was not disturbing to them or their child. The overall impression given was of interest in the proceedings and of satisfaction that this was a tangible method of expressing their gratitude for the care their children had received. Complaints were few and related to organization rather than to the examiners or candidates. I would like to thank the parents and children who participated in the examination, and who co-operated in this survey, and M n Christine Jackson and Miss Angela Fergusson for secretarial help.
Reference Stokes, J. F. (1973). The Clinical Examination. Association for the Study of Medical Education.
Parental attitudes to a clinical examination in paediatrics TIMOTHY L. CHAMBERS’ University of Leeds
Department of Paediatrics and Child Health,
K e y words
PAEDIATRICS/ ‘educ *EDUCATION. MEDICAL *EDUCATIONAL MEASUREMENT *PARENTS ‘ATTITUDE PHYSICIAN-PATIENT RELATIONS PARENTCHILD RELATIONS TIMEFACTORS BOREDOM ANXIETY MOTIVATION
‘Children sweeten labours, but they make mis€or- had persistent illness or handicap. Obviously tunes more bitter.’ the invigilators tended to ask those parents -Francis Bacon whom they knew, and thus were most likely to come. The examination lasted from 9.00 a.m. to Recently, the form and conduct of the clinical 5.00 p.m. on two consecutive days. There were examination has been critically scrutinized breaks for coffee, lunch, and tea. Travelling (Stokes, 1973). The central role that patients expenses for parent and child were paid, or play at present has been discussed and alterna- else transport provided. Each child received an tives to them (audiovisual aids, trained non- honorarium of 50 pence per day. patients) considered. At present, we rely Present study heavily on the goodwill of patients and their parents for the smooth running of the paedia- The parents (15 mothers and 1 father) OE 8 tric clinical examination. It, therefore, seemed children who participated at Seacroft and 8 at appropriate to inquire if they were satisfied Leeds General Infirmary were interviewed two with the present form of the examination and, months after the examination. This interview if not, where improvements might be made. was conducted in the homes of 11, and after an out-patient visit to their own clinician (not Organization of examination the author) for 4. The other child had been I n June 1974, 69 candidates presented for readmitted and the mother seen on the ward. the University of Leeds final examination The author is involved in the clinical care of 6 (MB ChB). The paediatric clinical formed part of the children - all a t Seacroft. The interview of the examination in medicine. Each candi- was not structured, but was introduced as a date had one long case (30 minutes with piece of consumer research to start a conversapatient and parent, and 15 minutes subsequent tion. The aim was to discover how much indiscussion with the examiner) and as many convenience had been caused, whether they or short cases that could be fitted into a final 15 the child had been upset or worried by the minutes. There were two paediatric clinical proceedings, and how the organization could examination centres, Seacroft Hospital and be improved. Leeds General Infirmary. The arrangements at Initial approach each centre were supervised by two different invigilators and the choice of patients left to For 12 parents, the request to attend the them. The children whose parents were seen examination was by letter. This asked that the for this study were mainly out-patients and child should attend the hospital to take part in the clinical final examination. Dates and times were given and transport arrangements out’Requests for reprints to Dr Timothy L. Chambers, lined. Nine parents were satisfied with the inDepartment of Renal Medicine, St. James’s Hospital, formation given in this letter. One child had Leeds LS9 7TF. ~~~
~
158
Parental attitirdcs
10
a clinical examination in paedicilrics
attended the clinical four times previously and her mother knew what was involved. Three parents would have liked a more detailed explanation of what was to happen: one thought that the object was a special examination of her child, and the other two worried about their children being used as a ‘demonstration’ or for ‘show’, and would have appreciated knowing exactly how many students would see their child and for how long. All the mothers assumed - correctly -that they would be able to stay with their child during the day, though this was not stated in the letter. The parents of in-patients were approached on the ward and their agreement secured. Any queries were answered at this time and they all felt that the information given was adequate. All the parents had told their children about the clinical examination soon after they had received the letter. Fourteen children were said not to have worried about what was to happen; the other two associated hospitals with enernata or needles and were relieved to be spared their usual ordeals. Opinions about the organization Ten parents made their own travelling arrangements (7 by car and 3 by bus). The other four had taxis provided. Two children were inpatients; their parents visited early and stayed all day. The Seacroft children were asked to arrive at 8.30 a.m. This meant an early start and most were travelling by 7.15 a.m. (One family overslept and the arrival of the taxi caused pandemonium.) The Infirmary is more central and parents were thus able to set out later. All but one of the parents were satisfied with the transport arrangements. The only unhappy mother was kept waiting 90 minutes for a taxi at the end of the day, which meant that she had been away from home nearly 13 hours. Three parents were surprised to have travelling expenses reimbursed. Everybody at the Infirmary was offered a free lunch on the ward. Parents of in-patients ate there; the others (4) went out for lunch to give the children a change and a treat. One mother used this as an occasion to protest about the quality of hospital food. Seacroft is more isolated and, though they were not offered lunch on the ward, no parents left the
1 S9
hospital. They were directed to a Mothers’ and Visitors’ Unit where snacks and meals may be bought. Malfunctioning machines there brought the most vehement criticism of the whole examination upon the author’s head! Three mothers were enterprising enough to use the staff canteen and had no such complaints. The duration of lunch (30 minutes) was long enough for all except the examiners and invigilators. who found one hour to be rushed. Most parents thought that the length of time they spent at the examination was enough. They all admitted to being tired by the end of the full day -particularly if a bus journey in the rush hour lay ahead. The mother who had attended before definitely preferred a half day session. The children were also said to have been able to cope with a full day but were tired at the end - which €or some was 7.00 p.m. Still, as one father pointed out, 50 pence is a great sweetener. Parents’ feelings about the examination A new experience All the parents (15) who had not been before were interested by the examination. They had not realized that this was the way students were tested, but they all felt that contact with a patient should be taken into account in the assessment of competence to practise medicine. Six parents felt that they learned more about their child’s condition: for three of these, the source of information was an examiner. One mother was told €or the first time that her child with overflow incontinence of urine would eventually achieve some control and expressed great relief a t this news. Another father realized that his son’s problems (encopresis and enuresis) were compounded by difficuIties at school (this came out during the candidates’ discussions with the examiners) and was thus able to approach the boy more sympathetically. The other four met mothers whose children had similar conditions and were able to exchange ideas. No parent felt that the whole exercise was a waste of time. Monotony Only four of the 14 parents who stayed all day admitted to being bored. Most had brought games to play with the children and otherwise
160
Timothy L. Chambers
spent the time talking to other mothers. One mother fiad been on nursing night duty and cap-napped during her stay. Another rediscovered her talents for feeding babies. The main irritation was the examiners needing a ready supply of short cases; this meant that most children had to stay near their beds for most of the time. Each child was used twice in the whole day as a long case. The parents all felt that this was sufficient for their children though two enjoyed themselves enough to want more candidates. All seemed satisfied with the diversions supplied for the children on the ward, and were unstinting in their praise for the nursing staff; the extra work involved for them was commented on by most. The short intervals for coffee and tea were appreciated for the break in routine as well as for sustenance.
Parents’ worries All the parents were asked if, as a result of the examination, they thought that (a) their child was more seriously ill than they had appreciated before, or (b) their child had a condition they had not known about. Ten said that neither applied to them. One mother of a 3year-old paraplegic girl with a high meningomyelocele was upset by the term ‘handicapped’ being applied to her daughter. She resarded her condition as a delay in development rather than a disability. This patient also demonstrated how far the clinical examination is removed from reality. Her mother persistently drew attention to her right arm being painful after a fall. No attention was paid to this symptom - which was causing considerable anxiety - by candidates, examiners, or invigilator. The following day an x-ray revealed a fracture of the humerus. Two children were said by the candidates to have heart murmurs which were unknown to the mothers. This, predictably, caused consternation. One murmur was inaudible to the examiners and the mother suitably relieved. The other was associated with anaemia of renal failure and thought to be functional, thus had not been mentioned. The misapprehension this caused only came to light at the end of the examination when the mother chanced to meet the house physician who had looked after the child, and had told him. She was reassured about the benign
nature of the murmur, but might well have gone home very worried. A mother who was a nurse heard her 6-year-old daughter referred to as a ‘spastic’ (she had had a sacral meningocele repaired and retained a mild neurological deficit). With her professional knowledge, she knew this to be untrue, but pointed out that unqualified use of such a term might well have upset another parent. One mother was ver! amused to hear her son’s rash (4th week of Henoch-Schonlein purpura) ascribed to measles. She was surprised that a qualifying student was unable to describe the characteristics of a measles rash. Another candidate thought this boy had rickets: nobody corrected this in front of the mother.
Worries of children One girl, aged 13 years, was upset at the description of ‘spindly’ being applied to her finger joints: another candidate commented on her ‘pigmentation’ - she felt this word had a racial connotation. None of the candidates was said to be rough, though the child with arthritic hands who was used as a short case would have appreciated a warning from the examiners to student that the joints might be painful. One father told his son (complaining of frequent abdominal palpation) that he would ‘have to put up with it’- as a part of a repayment of ii debt of gratitude to the hospital. Attitudes to candidates The parents were briefed before the examination to answer all the candidates’ questions. but not to volunteer a diagnosis. Two mothers would have appreciated more advice from the invigilators particularly whether details of investigations or drug therapy could be revealed In response to a direct question, three mothers admitted to being frustrated by the candidates‘ wrong line of inquiry-they wanted to pui words into the students’ mouths. One mother cheerfully admitted to doing so. Two parents felt they had given poor information to the candidates and wished they had thought our details such as milestones and immunization timing before they arrived. This particularlj applied to one mother whose child had had many operations, the dates and details of which she had forgotten, but which assumet
-
Parental attitrrdes to a clinical examination in paediatrics
increasing significance to the candidate. All the mothers were aware of the importance that would be attached to the history and were anxious to get it right. Two mothers thought that 30 minutes was too short a time for a long case involving their child: none found it too long. The tense atmosphere, particularly at the start of the day, was commented on by the parents as inhibiting their ability to recall important details. No parent was upset by the candidates. All said that the students made an effort to put them and the children at ease, though as more than one mother observed, it was often the patients or parents who calmed the students. One mother thought that a candidate who saw her child should not have passed the examination (he did). The rest were satisfied that the students who talked to them and examined their children were now doctors. Attitudes to the examiners Most parents felt that some candidates did not do themselves justice in the presentation of their histories to the examiners. One mother noted that the examiners who sat down with the Candidate and involved herself and her child in a discussion usually produced a ‘natural’ performance from the student, in contrast to those who stood round the bed and talked over her. The examiners were generally thought to be fair in their attitudes to the students. Their job was acknowledged to be repetitious and demanding of tact and sympathy. Three mothers spontaneously commented on the responsibility that the examiners held, both to the students, to try and encourage them to overcome nervousness, and to the general public for maintaining medical standards. There were no complaints about the examiners’ approach to parents or children. It was appreciated that a brief short case does not allow time for. pleasantries. One mother admitted to answering for a faltering student; she saw him as a partner in the struggle with ‘authorities’. Motivation When asked why they had come, most parents were unable to give a reason, though they all saw the examination as being of no direct benefit to them or their children. None gave the
161
impression of being motivated by power or of being ‘professionals’ as suggested by Stokes (1973). Two mothers hoped that medical understanding of their childrens’ conditions would be improved (one was retarded, the other had glomerulonephritis which had been undiagnosed for several months). Both parents of one boy defined the situation as one in which they could repay the help that had been given to them by the hospital, and by one individual in particular - the invigilator. This feeling was also expressed in a less forthright way by most other parents. The extreme to which this may be carried was shown by the mother whose daughter had been to clinical examination before. She saw attendance as an obligation consequent to the care and attention her daughter had received - despite the latter’s expressed unhappiness at being the subject of the examination. All parents would bring their children for another clinical examination if asked. The only reservations were about transport and catering arrangements and the duration of stay. There were no complaints about the conduct or form of the examination and two mothers would be happier to come now they knew what was involved. Apart from the child referred to above, the other children questioned all had no hesitation in agreeing to come again. Their parents quickly pointed out that their motivation was primarily financial. Summary A selected group of parents. whose children were patients in a recent clinical examination, declared, with one exception that this experience was not disturbing to them or their child. The overall impression given was of interest in the proceedings and of satisfaction that this was a tangible method of expressing their gratitude for the care their children had received. Complaints were few and related to organization rather than to the examiners or candidates. I would like to thank the parents and children who participated in the examination, and who co-operated in this survey, and M n Christine Jackson and Miss Angela Fergusson for secretarial help.
Reference Stokes, J. F. (1973). The Clinical Examination. Association for the Study of Medical Education.
