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Clinical teaching in paediatrics: understanding perceptions, motives and concerns
  1. R E Klaber1,
  2. I Pollock2
  1. 1
    Academic Centre for Medical Education, Division of Medical Education, UCL Medical School, London, UK
  2. 2
    Barnet+Chase Farm NHS Trust, UK
  1. Robert E Klaber, 51 Dalmeny Road, Tufnell Park, London N7 0DY, UK; bobklaber{at}doctors.org.uk

Abstract

Background: Children and young people are used as cases and standardised patients in clinical exams and teaching courses. Consultation with them suggests that education and training are areas they feel they should actively participate in.

Aims: To examine the perceptions, motives and concerns of children and young people participating in exam-focused clinical teaching, and to compare these views with those of their parents, trainees and tutors.

Methods: Consultation and a pilot study were used to design an anonymised questionnaire with 5-point Likert scales and free text answers. This was sent to 112 children and young people, their parents, and tutors and trainees attending a clinical teaching course. Results were analysed using the Mann–Whitney U test.

Results: 71% of the questionnaires sent to children and young people and their parents were completed. For children and young people the major reasons for taking part were the enjoyment of helping people to learn (92% agreement) and wanting to “give something back” (85% agreement). Parents put significantly more emphasis on giving something back than anything else. Tutors and trainees felt the chance for children and young people to earn pocket money was their most important motivation. The major problem highlighted was that it is tiring being repeatedly examined. All children and young people and their parents said that they would participate in future clinical teaching.

Conclusions: This study demonstrates that in the context of well-planned, structured clinical teaching, most children and young people are primarily motivated to participate to help educate doctors.

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The aim of this study was to find out the views of children and young people, their parents, and trainees and tutors as to why children and their families participate as teaching subjects in teaching courses. Consultation with children and young people suggests that they feel they should actively participate in education and training.1

The primary objective was to explore possible reasons for attending teaching courses, as well as the perceived advantages and disadvantages of participating as a teaching subject. Secondary objectives were to investigate the occurrence of and reasons for any unpleasant events that children and young people might have encountered while being teaching subjects. In addition, views on how to improve the experience for the children and young people were sought from all participants via free text answers.

Clinical exams are used across the world as the main method of assessing clinical examination and communication skills in medical students and doctors. In preparation for these exams, a number of teaching courses use patients so that the trainees can practice their clinical examination and communication skills. Within paediatrics, courses and exams are dependent on children and their families participating as teaching subjects.

While some studies have looked at parental attitudes to the participation of their children in clinical trials and research,2 3 there has been little exploration of the role of children in clinical teaching or exams.

Over 30 years ago, Chambers investigated parental attitudes to a UK-based clinical examination in paediatrics. He reported that most parents had an interest in the proceedings and felt that attending was a satisfactory method of expressing their gratitude for the care their children had received.4 Similar findings were reported from the Royal Australasian College of Physicians clinical examination in paediatrics in 1995.5

Another study involved a survey undertaken in Sri Lanka during the MBBS exam in paediatrics.6 A total of 116 “bystanders” (almost all mothers) were asked about their views on the exam. While acknowledging that a clinical examination was a good way of assessing the student’s professional competence, over half claimed that informed consent had not been obtained for the participation of their children, and almost a quarter were concerned by the number of students examining their child. The survey also briefly asked 34 children about their experiences. Of these, 92% had received no explanation of the nature of the exam and 17% complained that they were examined for too long.

This study is important because it examines, for the first time, the views of parents and children and young people, as well as those of the tutors and trainees, as to why families participate as teaching subjects for clinical teaching courses, both at DCH (Diploma of Child Health) and MRCPCH (Membership of the Royal College of Paediatrics and Child Health) level.

Box 1 Key aspects of the questionnaire

  • Non-validated, but designed through literature review, consultation and pilot study

  • Identical version of questionnaire used for all four groups

  • Demographic information collected, Likert scales and free text responses requested

  • Small demand on participant’s time (5–10 min)

  • Clear and concise language (in English), on a single sheet of paper

  • Sent with covering letter and instructions with an example of how to fill in the questionnaire

  • Literacy issues considered during follow-up phone call

  • Consent was obtained by the active completion and returning of the questionnaire

The importance of asking children for their views, and trying to involve them more closely in educational and training activities within paediatrics, is increasingly acknowledged.1 7 In their study “Coming out of the Shadows”, RCPCH and The National Children’s Bureau talked to 74 children and young people between the ages of 3 and 17 to find out how they thought they could be involved in the work of the College. One of the main suggestions was that children and young people should be directly involved in improving the training, examination and continuing professional development of communication skills for paediatric doctors.1

METHODS

With little previous research in this area, there was no possibility of using formerly validated questionnaires, so a process of literature review and consultation was used to develop an unvalidated questionnaire8 of both Likert scales911 and free text questions. A pilot study, involving doctors, families and children on the paediatric wards, was run and further amendments made in light of feedback and results (box 1).

Participants were recruited from two different London-based teaching courses. The catchment areas for both courses (one for DCH preparation and the other for MRCPCH preparation) were similar mixed-affluence urban areas. Participants were identified from the lists of children and families who had already agreed to attend the courses. All were clear that they were attending an exam-focused teaching course and not the exam itself. They were approached by means of a postal questionnaire, with a covering explanatory letter, sent out to their home address shortly after the course had finished. Trainees (candidates about to sit the relevant exam) and tutors (consultant or specialist registrar teachers) were those who had applied to be on the course and those who had agreed to teach; they were verbally asked to fill in a questionnaire during the feedback sessions at the end of the courses.

With a relatively small sample size, there would only be sufficient power to detect significant difference where there were markedly contrasting results, and thus there may be some difficulty in detecting benefit or harm. It is for this reason that free text answers to questions such as “Have you encountered a bad experience for any of the children helping on the course?” and “Are there any other reasons why a child may take part in the course?” have an important role.

Quantitative data from the 5-point Likert scales gave non-parametric interval values to attitudes expressed.12 Differences in the results between both questions and sample groups were analysed using the Mann–Whitney U test on SPSS. Free text answers were grouped by theme but not formally analysed and so cannot be considered as formal qualitative data. However, they did have a role as a “safety net” to identify issues not explored by the quantitative questions.

Ethics approval for the study was granted from the Institute of Child Health/Great Ormond Street Research Ethics Committee (REC).

RESULTS

Of 112 questionnaires sent, 80 (71%) were completed and returned, of which 26 (74% response rate) were from children and young people and 54 (68% response rate) from parents. This compares favourably with most other postal surveys.13 The children and young people ranged from 10 to 17 years of age, and had a wide range of chronic medical conditions. Over half of the children had attended five or more previous courses. In total, 78% of tutors and 100% of trainees completed questionnaires at the end of each course. There were no significant differences in the answers from each of the two courses, so results were kept combined. The responses from each of the four groups are detailed in tables 1–4 with summaries of agreement and disagreement percentages and rank, as well as mean rank clearly displayed.

Table 1 Children’s responses (percentages and means)
Table 2 Parents’ responses (percentages and means)
Table 3 Tutors’ responses (percentages and means)
Table 4 Trainees’ responses (percentages and means)

In considering the reasons for taking part in medical courses, tutors (96% agreement) and trainees (87% agreement) felt that the chance to earn some pocket money was the key motivating factor for children and young people (p<0.001 compared with all other possibilities).14 For children and young people the major motivations cited were the enjoyment of helping people to learn (92% agreement) and wanting to “give something back” (85% agreement), although neither of these were statistically different from the pocket money question (73% agreement). Overall, 85% of children and young people disagreed with the statement that they attended the course because their parents told them to do so. Parents put significantly more emphasis on wanting to “give something back” (85% agreement) than anything else (p<0.005). Both children and young people (77% agreement) and parents (59% agreement) felt attending was a good opportunity to learn about their condition. Free text comments putting forward other reasons for attendance included “raising awareness of their condition”, “the opportunity to get regular check-ups”, “to learn to feel comfortable with doctors” and “as doctors saved her life, to help others learn to save other lives”.

When considering the problems of children and young people taking part in medical courses, the major factor highlighted by all groups was that being repeatedly examined is tiring (children were examined intermittently over a period of 60–150 min depending on age). Interestingly, tutors (96% agreement) and trainees (90% agreement) were significantly more concerned about this than parents (35% agreement) and the children and young people themselves (43% agreement) (p<0.001). Other concerns of the children and young people were difficulty discussing personal issues (24% agreement) and the fact that they didn’t like being back at hospital (23% agreement). Most of the free text suggestions referred to sometimes getting tired and bored, as well as logistical difficulties parking at the hospital. One 13-year-old girl wrote that “some of the doctors can be a bit heavy handed”.

All groups placed an extremely high value on the participation of the children and young people for the trainee doctors (96%–100% agreement). All children and young people and parents said that they would return and help again and, of all 167 responders, only one tutor said that they would not recommend others to help. Most respondents from the four groups agreed that the trainees treat the children and young people well (85%–93% agreement). Other important comments were made in the free text boxes. One child complained that a trainee had been too rough, while one mentioned “sometimes feeling like an object”. A 12-year-old girl wanted to remind trainees “not to forget that children have feelings and are not just for prodding around”.

Comparing the children and young people with the parents, the only statistically significant differences were that the children put more emphasis on the enjoyment gained in helping people to learn (p<0.05) and, perhaps not surprisingly, parents were more concerned than the children about time missed from school (p<0.05).

DISCUSSION

These findings demonstrate that children and young people and their parents are primarily motivated to attend medical teaching courses in order to help educate doctors. Contrary to the expectations of tutors and trainees, pocket money was not the main reason for agreeing to take part. Although some children agreed that it was tiring being examined repeatedly, this concern was considerably overplayed by tutors and trainees alike. Overall, all four groups placed heavy emphasis on the educational value to the trainees and the feeling that the children were treated well, and indicated that they would recommend participation to others.

Although there are disadvantages in using an unvalidated questionnaire, the process of consultation and the pilot study produced a clear and simple tool able to collect information from four different groups. Based on the authors’ experiences of the levels of understanding of children of that age, the questionnaire was sent only to children aged 10 years and over, although the parental views of those under the age of 10 were included in the parent group data. A good overall response rate of 71% was achieved. Due to the nature of the two courses, with patients involved in small-group case-based and scenario teaching, there were only relatively small numbers in each group. Taking data across two different teaching programmes both increased sample sizes and produced a broader outlook. The results from the two courses were very similar, although there was some heterogeneity with the MRCPCH course using more teenage children than its DCH counterpart.

Despite the excellent response rate,13 it is important to consider the impact on the results of the nine children and 23 parents who were non-responders. Other studies have gone back to their non-responder group and demonstrated a bias in the results caused by different core characteristics of the responders and the non-responders.15 16 Reviewing the original data, there were no significant differences between the non-responders and the responders in terms of the age of the child, condition or number of attendances. Within the context of a self-selecting group (namely those who voluntarily attend a teaching course), the non-responders might be more likely to be perfectly happy with their experience on the course, or on the other hand, they may be a group who have less enthusiasm for the course than the responders. Follow-up interview would be needed to ascertain this.

Another question was whether the children and parents filled in their questionnaires together. Despite being sent separately at different times, it may well be the case that the answers were conferred. This needs to be considered when comparing the answers given by the different groups as it could produce a type 2 error, where an apparent difference is not detected. Similar difficulties with a trainee or tutor conferring with a colleague may have occurred.

In the context of this type of exam-focused teaching, the children who attended, although “real” patients known to the clinicians organising the courses, were in effect taking on the role of “standardised patients”. The benefit of this structured approach to a clinical teaching course, and even more so for an exam, is a degree of consistency and standardisation of clinical findings and communication from one group of learners/candidates to the next. Children have been used as standardised patients for over 20 years,17 although in a review of the literature Tsai18 explains that only very few studies have reported on this subject. In the five reports that described the contents of the stations in paediatric objective structured clinical examinations (OSCEs),1923 younger children, with consistent, stable findings, were asked to be actual patients in basic clinical examinations, while older children were coached to act out simulated roles. Of these reports, both Joorabchi19 22 studies demonstrated reliability and construct validity in the standardised patient examination stations, although, other than mentioning that they enjoyed the session, there is no feedback from the children on their experiences.

A more recent paper looked at the experiences of being a young female adolescent standardised patient in teaching sessions for medical students.24 No adverse effects were recorded and mention is made of the value of using the adolescent standardised patients “out of character” to give feedback to the students.

Summarising this work, Tsai18 has presented a list of tips for the development of paediatric clinical assessments using child standardised patients (box 2), which along with the suggestions from children and young people below, provide exam and course organisers with useful guidance.

Box 2 Tips for the development of paediatric assessments using child standardised patients18

  • Use children as standardised patients only when necessary

  • Avoid using young children

  • Carefully select children as standardised patients

  • Assign appropriate standardised patient roles

  • Carefully keep a database of child standardised patients

  • Limit the number of examinations (<10) per child per session

  • Avoid scheduling a child for a whole day

  • Find substitute standardised patients for switches

  • Avoid using inpatients

  • Always obtain permission from a parent or guardian

  • Arrange for a parent or guardian to accompany a young child

What is already known on this topic

  • Children and young people are used as cases and standardised patients in clinical exams and teaching courses across the world.

  • Parental views suggest attending is a good way of expressing gratitude for previous care given.

What this study adds

  • Children and young people attend clinical teaching courses primarily to help educate doctors and to “give something back”.

  • Children and young people find attending structured clinical teaching enjoyable, valuable to trainees and often beneficial to themselves.

With the further introduction of OSCE examinations and work-based assessments25 within paediatrics, the need for child volunteers as structured patients is likely to grow. It is therefore reassuring that overall the experiences of children and young people and their families attending medical teaching courses are extremely positive. The occasional bad experience of “heavy-handed” examination emphasises the importance of briefing trainees or candidates prior to the course or exam. Suggestions from children and parents to improve future courses and exams included early notice of the dates, smooth administrative and transport arrangements, adequate breaks between sessions, spacious venues, refreshments and a range of activities to help pass the time. Further detailed qualitative research is needed to explore these themes which were brought up in the free text comments. It would also be valuable to consider approaches to measure whether the direct participation of children and young people improves the quality of the education and training of doctors.

REFERENCES

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Footnotes

  • Competing interests: Both authors had a teaching and organisational role on each of the courses, for which they received a fee.

  • Funding: None.

  • Ethics approval: Ethics approval for the study was granted from the Institute of Child Health/Great Ormond Street Research Ethics Committee (REC).

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