Teaching paediatric emergency medicine

28.2 Teaching paediatric emergency medicine



Colin Parker




Essentials



1 Effective communication skills and healthy attitudes are prerequisites for good paediatric emergency medicine practice, and their teaching should take precedence over teaching knowledge and skills.

2 Self preservation skills should also be taught.

3 Clinical experience is essential in gaining perspective on clinical knowledge.

4 There are unlimited methods for acquiring new knowledge; part of teaching new trainees is educating them about how to use available media and methods to best effect.


Introduction


Despite the massive explosion in the availability of information, doctors will never be replaced by computers. Paediatric emergency medicine (PEM) has elements of science, particularly with the steady growth of evidence-based medicine, but also relies heavily on the practical application of experience. Perhaps the emergent aspects of PEM, such as trauma resuscitation, have a more formulaic basis; however, clear and effective communication from the team leader is of paramount importance in a challenging resuscitation.


The bulk of PEM does not consist of emergent interventions, but rather risk stratification, and trading information with parents of children who may or may not be very unwell. Parents bring their children for reassurance, explanation, and occasionally some form of treatment. They want to feel that they have been taken seriously, and that someone cares about the well-being of their child. In short, they want to feel better after seeing the doctor.


The practice of PEM requires a set of skills, knowledge and attitudes broadly similar to those required for the practice of clinical medicine generally, but with the added requirement of having to communicate effectively under the pressures of time and emotional stress. Because doctors’ attitudes are so enmeshed with ability to communicate, it is important to teach the correct attitudes before teaching skills and knowledge. Doctors with healthy attitudes will be driven to continually expand their knowledge and skills, and will seek out any available resources to improve the way they care for their patients.



Desirable attitudes in PEM


With the success of immunisation programmes and, to a lesser extent, injury prevention strategies, there seems to be a changing spectrum of illness in children presenting to emergency departments (EDs), with fewer critically unwell children, medicalisation of behavioural issues, and children with a functional component to their ‘dis-ease’. In addition, the public perception of the wonders of modern medicine results in high expectations, which are sometimes difficult for clinicians to meet. The best protection is to approach with healthy attitudes:


• humility;

• caring;

• empathy and compassion;

• non-judgemental approach;

• honesty and integrity;

• advocacy and healthy paternalism;

• self-monitoring and awareness of cognitive errors in medicine.




Humility


Growth in the acquisition of medical knowledge can be likened to exploring a forest: initially it is hard to see the wood for the trees; as one gets to know the landscape, one can develop an appreciation for the large valley in which the forest sits. By the third postgraduate year doctors are familiar with the whole valley. Most then travel up to the crest and realise that the valley is but a small part of the countryside, and there is in fact a vast body of knowledge which they may never know and never discover. While knowledge itself is a valuable asset, a high knowledge-to-confidence ratio is perhaps more desirable.



Caring


Many communication difficulties can be overcome by having and projecting a caring attitude. With children especially, parents may not care what the doctor knows, until they know that the doctor cares. Doctors’ own biases and personality differences can sometimes make this caring seem a difficult task. Projecting a caring attitude initially usually results in a positive feedback which sets the scene for genuine caring to supervene.



Empathy and compassion


Doctors who are themselves parents find it easier to imagine the emotional strain of having a sick child. This tension may sometimes be expressed in fiercely protective terms by a worried parent, in the same way that patients themselves often forego the social graces when they are unwell. It is important not to take this personally, and try to imagine how the parents are feeling.



Non-judgemental approach


There is a common perception among some ED staff that some children should not have been brought to the hospital because ‘it’s not an emergency’. They may blame the referring clinician, the parent or the patient. Everyone who brings their child to an ED has crossed some threshold of anxiety about the perceived illness, and every one of them has considered not coming to the ED. Most of them do not have significant knowledge of health-related matters. There is no place for a judgemental approach, which will not help the child or prevent a future ED visit.



Honesty and integrity


It is important to teach our colleagues humility. Doctors are often humbled by questions they cannot answer and mistakes they may have made. Appropriate teaching to junior colleagues should suggest that answers to parents should be ‘I don’t know but I will try to find out’ and to colleagues ‘that’s a good idea, I forgot to check that’.



Advocacy and healthy paternalism


Planning a course of action requires a collaboration between the clinician and the patient or parent. This collaboration needs to walk the fine line between patient/parent autonomy and the benefit of the unique knowledge and perspective of the health professional. In this regard, doctors need to act as advocates for the child and gently steer the collaborative decision towards one that leads to the best outcome for the patient and family.



Self-monitoring and awareness of cognitive errors


Most clinical presentations have a differential diagnosis. Healthy self-doubt and consideration of potentially bad outcomes are useful safeguards. Doctors process and synthesise available information in various ways, subject to a number of errors of cognition. These include diagnosis momentum, where doctors accept the perceptions of other clinicians and allow a diagnostic label to stick, without making an independent assessment. Or doctors may be affected by anchoring, where they decide on a particular diagnosis relatively early on in the assessment process, and reject subsequent information that does not fit. When there is some diagnostic uncertainty, the simple act of discussing the case with a colleague can often provide clarity from this cognitive fog. The main stumbling-block is the clinical maturity required to recognise feelings of uncertainty, and to act on those feelings.

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Teaching paediatric emergency medicine

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