Listen to the parents

They may know best

There are two contrasting perspectives on the way patients and their parents use health services. When searching the literature on out of hours and emergency treatment, helpful keywords are “inappropriate” and “misuse.”1 Meanwhile, there is evidence that parents are more effective than professionals in the early diagnosis of a wide range of child health problems.2 3

Three qualitative studies reported in this week's BMJ4 5 6 address these contrasting views, which are at the heart of general practice. Children with trivial complaints, parental anxiety, and out of hours calls make major demands on general practitioners' time. But the antecedents of these calls make demands on the wellbeing of parents, usually mothers, whose hours of work and on call duties can make the commitment of even the most overworked general practitioner seem modest.

The two papers by Kai (pp 987, 983) explore parental concerns about childhood illness and communication difficulties between professionals and parents.4 5 Based on group discussions and one-to-one interviews with parents in a disadvantaged inner city area, his work indicates parents' anxiety, sense of lack of control, and bewilderment at what they see as inconsistent prescribing patterns, unhelpful explanations, and opaque decision making. Kai advocates more information and education for parents. His title, “parents' difficulties,” suggests where the problem might lie. But it takes two to tango, and “empowering” patients means recognising their and their children's special expertise on their own bodies, lives, and environments, as well as getting professionals to relinquish “their monopoly on expert knowledge.”4

Hopton and her colleagues (p 991) show that patients usually have a rationale for actions that may seem to the medical practitioner haphazard, perverse, or plain cussed.6 In their qualitative analysis of service users' accounts of telephoning their general practitioner out of hours they draw, like Kai, on the context as well as the content of the consultation. For those interviewed, a key factor was their prior experience with health services. Hopton et al conclude that educating and informing patients is not enough.

So what should be done? Decision making, differential diagnosis, risk assessment, and living with doubt are part of the good general practitioner's stock in trade.7 But this also goes for patients and parents of young patients. Douglas Black has suggested that there is a false antithesis between “the medical model” and “the social model” of health.8 Whether or not the antithesis is false, these papers show that in some circumstances there remains at best a divergence of view—at worst a yawning gap—between users and providers of general medical services.

This divergence is only rarely examined, though often discussed. While general practitioners tell colleagues their atrocity stories (my favourite is the one of a general practitioner, summoned for a night call because the baby had swallowed a condom, who was later phoned and told he needn't bother as they had found another one), patients tell their friends their stories of failures to diagnose. But the divergence is normally latent rather than manifest. As Philip Strong describes in his elegant essay on the etiquette of the consultation, “As every … doctor was overtly competent, so every … mother was nominally treated as loving, honest, reliable and intelligent: not, of course, capable of passing judgement on medicine, but certainly fulfilling her maternal duty to the child.”9

Parents' views of being “a good mother” can conflict with professional views.10 11 However, in dealing with the content of health behaviour (“inappropriate” consultations) rather than the context of the visit (24 hours a day, seven days a week health surveillance by the mother) there is the risk that a child or a patient may be seen as a “work object,” however compassionately dealt with. A recognition of parents' key role in the health care of their children would go beyond Illingworth's textbook advice that doctors do well to attend to parents' views.12 Parents are the principal health carers of their children and are in a unique position to take an overall view of their health. This week's qualitative papers on general practice indicate the value of low technology interventions such as listening.