Children's ages

Tomorrow's Doctors2 states that “medical graduates should be able to communicate clearly, sensitively and effectively with individuals and groups regardless of their age”. The diverse age range of our patient population imposes particular demands on students, who have to learn to relate to children of a different ages in addition to the inherent challenges of dealing with adolescent patients. This requires a portfolio of skills in communication and examination and repeated practice to achieve this goal.

Triangulation of consultations

Paediatrics differs from adult specialties in that one of the key aims of paediatric undergraduate attachments is to equip students with the skills to triangulate their consultation to relate to children and their families/carers. This can appear as a ‘softer’ learning objective for students who are often used to a checklist approach to learning skills. The students have to refine their skills in relating to more than one person and experience the challenges that this can sometimes create and develop strategies accordingly. The paediatric outpatient clinic is therefore perceived as a different, and potentially threatening, learning environment by students.

Facilities

The outpatient rooms need to be sufficiently large to accommodate children and their families and to provide sufficient space for medical students to actively participate in the consultation. Students put great store on seeing patients by themselves so, importantly, there must be a supportive environment conducive to learning with additional space for students to carry out some initial consultations.3

Alternative venues

Participation in clinical experiences leads to the development of practitioner confidence. Inpatient encounters are valuable but with reduced patient stays there is a need to widen and enhance all available learning opportunities for our undergraduate students.

The wider community affords opportunities to deal with a broad range of commonly seen child healthcare issues and placements should reflect the changing pattern of healthcare.2 It is necessary to identify the venues which provide students with the opportunity to develop the core knowledge and skills as outlined in their paediatric curriculum.

Student access to sufficient numbers of children may be facilitated by using alternative venues such as:

• ▶ Community placements – general practitioners, special schools, mainstream schools and nurseries

• ▶ Other clinical specialties – orthopaedics, dermatology, surgical day case unit, radiology department

• ▶ Home visits – with specialist or community based nurses

• ▶ Child development centres

• ▶ Allied health professionals – physiotherapy/occupational therapy/speech therapy, dietetics, orthotics

• ▶ Waiting rooms

• ▶ Ward ‘play rooms’.

Some venues have often been overlooked or underutilised and are untapped resources for teaching.

Educational concepts

The teaching and learning opportunities provided should include a holistic approach to child health. This will involve exploring common issues including core clinical problems, child health surveillance, and also exposure to neonatal and adolescent medicine.4 In addition to this, there should be some insight into the role of community based teams; this may be under the auspices of clinical nurse specialists or community based nursing teams or by visits to educational institutions such as special schools or nurseries. By seeing children in a wide range of settings, students will be more aware of the impact of social factors on children's (and parental) health and their access to health services. A variety of educational strategies may be used to aid student learning, but these are not always widely known or appreciated and opportunities for staff development for teaching may not be able to compete with other demands on a clinician's time.

• ▶ Empowering learners: Simple introductory materials and face-to-face inductions can help students to be independent learners in an unfamiliar environment. They can orient students to the venue by providing a site plan, a list of staff members and a rough timetable of weekly activities indicating the learning opportunities available. Many students have an inkling of which career path they wish to follow and it is important to offer subspecialty experience, where available, to them during their child health attachment. For example, they could be provided with a list of visiting specialists (eg, cardiologists, paediatric surgeons and endocrinologists) or spend time in the radiology suite observing paediatric imaging and procedures.

• ▶ Prelearning: Learning is likely to be facilitated when students come to any new clinical teaching venue having been briefed about what to expect and having prepared themselves for the range of clinical cases they may encounter. Study guides are a good way of introducing students to the clinical problems expected and to direct their initial thoughts about the learning issues they present.5 In an outcome-based approach, a wide variety of learning outcomes may be identified in the experiences available and can be actively identified by tutors. For instance:

  • ▷ Examination skills

  • ▷ Multi-professional care – reinforced by a visit to diabetic clinic, for example

  • ▷ Data interpretation

  • ▷ Diagnostic and management decisions

  • ▷ Counselling/communication skills.

• ▶ Structured learning: Log-books can be used to direct student learning to required outcomes or desired learning aspects of a clinical problem. They can also provide a way for students to document what they have seen and learned prior to assessment.5

• ▶ Virtual patients and tutorials: These can be used to supplement the student's clinical experiences. As the clinical problems with which patients present are often unpredictable, virtual patient problems or recorded case presentations or tutorials can be used to provide additional learning material or to augment cases seen.

• ▶ Collaborative learning and multidisciplinary input: Opportunities can be created for students to work together in the clinical setting to solve diagnostic or management problems. Clinical activities with other members of the healthcare team are another way of diversifying learning.

Staff development requirements

As clinical teachers we have opportunities to provide information, to help students learn and to be professional role models.6

We may also have opportunities to assess clinical competence, but this is more difficult to do in the context of the outpatient department (see problem scenario 3 below).

Knowledge of the medical school curriculum and its educational objectives are required to help clinicians focus tuition towards the most student-relevant objectives and should be readily available from the medical school or university website.7

How to facilitate or stimulate student learning, carry out short, focused, on-the-spot assessment of student performance,8 using for example the mini-CEX,9 10 and then give constructive feedback, are all skills required of the clinical tutor. Of these, student assessment is the most difficult to find time to carry out in the context of the outpatient department (OPD), but may be a more feasible option than performing a workplace-based assessment during a frenetic post-take ward round.

The medical school may provide resources for staff development for teaching by offering short courses for attendance or for distance learning.11 However, accessible, practical help for aspects of clinical teaching at the moment of need is also appreciated. The Getting started…12 series of booklets recently commended by the General Medical Council13 provides on-the-spot instruction for effective teaching in a range of clinical teaching venues.

Putting it into practice

What to do during the teaching session (delivery)

• ▶ Identify inter-professional learning opportunities

  • ▷ Nurse-led activities may include: urinalysis, weighing and measuring then plotting growth parameters, blood pressure measurement

  • ▷ Nurse-led clinics – for example, asthma, enuresis, etc

  • ▷ Dietician/therapist teaching.

• ▶ Use any available space – is there a free room for a student to see a patient/family on their own?

What to do when it is over

• ▶ Summarise at the end of the session. Suggest and agree further reading/development to reinforce key points14

• ▶ Ask yourself (and the students!) what went well and what didn't go so well. How could you do this better next time?

Food for thought

Most clinicians will probably be expected to continue to deliver undergraduate teaching while being under increasing pressure to see more and more patients in the OPD setting.

• ▶ Teaching venues: It would be helpful if opportunities in other ambulatory care venues could be made available or if a dedicated ambulatory care teaching space could be provided.

• ▶ Paediatric nurse educators: Could you recruit an experienced nurse or other healthcare professional, with an interest in education, to deliver some teaching? Paediatric nurses have a wealth of experience in caring for children and their families and can offer useful teaching on many clinical domains, in addition to communication skills teaching. They often have longstanding and rich relationships with many children and their families. They can facilitate access for students to these families and also provide students with honest, formative feedback about their performance from this ‘expert patient and parent’ cohort.

• ▶ Volunteer patients: The provision of volunteer ‘real’ patients has proved invaluable in these situations in other centres15 16 and the idea could be extended to provided volunteer ‘real’ families to visit, at home, where students could explore the impact of chronic illness on family life.

• ▶ Adolescent consultations: Use the outpatient setting to highlight the differences between consultations with younger children and with adolescents (see box 1). It is important to stress the fact that consultations with adolescents can provide communication challenges. They may have different priorities, consent and confidentiality issues can arise and sometime their problems can appear insoluble.17

• ▶ Use of interpreters: In response to our increasingly multicultural society, we need to train our future practitioners to have the skills to communicate effectively with non-English speaking patients and their families. The outpatient setting can offer the ideal opportunity for students to gain experience of consultations with the help of a trained interpreter. Ask students to reflect on the consultation:

  • ▷ How did I structure my consultation when the interpreter was present?

  • ▷ To whom did I address my questions?

  • ▷ How did I arrange the seating?

  • ▷ What about my body language?

in addition to directing them to useful references such as How to do it: work with an interpreter,18 which can maximise the learning opportunity.