It is not unusual for a parent to bring their young child to a GP surgery, fearing the worst about their condition and pushing for their child to get treatment when it might not be necessary. When this occurs, it is important to act in the patient’s best interests whilst managing the parent’s expectations.
It can be hard, especially for GP trainees, to know what to do in these situations, but here are some tips to make it a bit easier:
1. Carefully examine the child and actively address any concerns
As always, a careful history is essential. It is easy to obtain a false impression of a child’s health during the short period of a consultation. Many children will perk up in novel surroundings and sustain this throughout the consultation, only to wilt on departure. This can leave the parent frustrated if they perceive that their concerns were not taken seriously and potentially result in a complaint. It is necessary, therefore, to actively address each of the parent’s concerns, involving the parent in your decision-making process and your proposed management plan.
2. Act in the best interests of the child, but consider the wishes of the parent
The GMC offers reassurance in their guidance document Consent that a doctor does not need to provide treatment requested by a patient, or in this case the parent, which they consider not to be in the patient’s best interests. In the case of a child, a doctor’s paramount concern should be the best interests of the child, which would involve avoiding unnecessary investigations simply in order to reassure parental anxiety. However, further guidance on assessing the child’s best interests includes taking into account the views of the parent. Doctors should explore how they can reconcile the wishes of the parent for further investigation, with a less invasive approach they consider appropriate. This could be done by arranging non-invasive preliminary management such as symptom diary, simple non-invasive tests, follow-up or second opinion.
3. Show that you acknowledge the parent knows the child best and really listen to their concerns
A parent spends all day with the child so knows what is normal. Make sure to show that you’re listening to their concerns, for example by reflecting back your perception of the parent’s concerns and by not trivialising their anxiety. Keep an open mind and look for hidden clues. Any reassurance you then provide might be given more weight by the parent.
4. Consider other people who care for the child
You should also discuss the child’s daily routine. If they are tired, is this because it has changed recently? Do they still have a day time nap? Have they just started nursery school? You may wish to consider who else cares for the child. Nursery school teachers are a useful source of information for the parent - it can be immensely reassuring to hear that the child is active and boisterous for the three hours they spend at nursery, which may then account for the tired, sleepy child the parent sees each afternoon.
5. If the parent expresses dissatisfaction or insists on investigations suggest a second opinion either from a GP colleague or a paediatric referral
A second opinion might help with the avoidance of unnecessary procedures, however sometimes, in spite of all efforts by clinicians, some procedures that are not strictly clinically necessary might be undertaken because of clinical uncertainty and the potential benefits to the child of having a reassured parent. It may also allow for a fresh clinical assessment that might pick up aspects you have missed.
Ben, a three year old boy, is presented to the GP by his mother. She says he eats ‘nothing’, is lacking in energy and is not gaining weight. History reveals poor eating habits, with his main intake being sweet food, due to his refusal to eat main meals. His bowel habits are normal and there is no history of vomiting. On examination you are faced with an inquisitive, alert child who looks well. His weight is appropriate for his height and you find nothing abnormal on examination. His mum wants him to have blood tests and be referred to hospital for gastro intestinal investigations as she is convinced he has a bowel disorder.
Ben’s mum has presented three main symptoms: not eating, no energy and not gaining weight. From your history you have already formed an opinion that Ben actually does eat quite well, albeit inappropriate foods. Assess his daily routine to see if there is any reason for the lack of energy. The lack of weight gain is a factual matter that needs to be addressed - hopefully mum will have brought Ben’s personal child health record or ‘red book’. Recent weights have possibly been done on the home bathroom scales rather than at a baby clinic so it is worthwhile weighing Ben in your surgery and then re-weighing him at a follow up consultation.
The ‘not eating’ can be left for the follow up consultation as it is necessary to have an accurate record of Ben’s weight loss or gain before addressing this issue further. If, as you suspect, Ben is actually gaining weight normally you may then wish to tactfully address the eating issues. However, should Ben, to your surprise, actually have lost weight, you should consider changing tack altogether and perhaps consider a paediatric referral.
Hopefully, mum will feel her concerns are being addressed seriously and will be happy to wait the couple of weeks for review before further consideration is given to the need for investigations. Should she be more pushy and be insisting on investigations today, the doctor can feel confident that it is not at that point in Ben’s interests to do so and politely decline, perhaps also offering a second opinion.
Dr Kirsa Morganti and Dr Dan Kremer are medicolegal advisers at Medical Protection