How to take pediatric history? From patient or parents?

[voxveritatisetlucis]

I have been doing a pediatric surgery mini rotation within my main rotation within my surgery rotation and although it hasn’t been a problem for this rotation, I’m sure it will for peds. Should you talk to the kid or parent? I always feel a bit stupid trying to talk to the kid especially when they’re <7 or so because it doesn’t really make sense because most are poor historians. But then some residents probably say you need to talk to the kid more. Also on peds hospitalist, how is it possible to round efficiently if you’re talking to the kid since they’re probably giving inaccurate info


Also can you even do good on peds if you’re not naturally good with kids?

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[stellarartois]

When I was on peds rotation, I think I talked to both the parents and the kids. Of course, if the kids are like infants, you can't really communicate with them and you have to rely on the parents.

I think as a peds hospitalist, you can talk to the kid first and then come back later or contact the parents for more information.

I mean as long as the kids don't hate you, I don't think being good with kids matter that much. I feel like none of them really like being in the hospital and being examined by some strangers. I remember some of the patients crying just because I placed my stethoscope on them. It is what it is.

 

[voxveritatisetlucis]

When I was on peds rotation, I think I talked to both the parents and the kids. Of course, if the kids are like infants, you can't really communicate with them and you have to rely on the parents.

I think as a peds hospitalist, you can talk to the kid first and then come back later or contact the parents for more information.

I mean as long as the kids don't hate you, I don't think being good with kids matter that much. I feel like none of them really like being in the hospital and being examined by some strangers. I remember some of the patients crying just because I placed my stethoscope on them. It is what it is.

Ya that’s true but I know for our rotation, we need to do like 4 evaluative encounters with patients and I bet the residents will give us bad scores if we aren’t super friendly with the kids. It’s kind of hard to explain but I feel that some ppl are just bad for kids.

 

[TelemarketingEnigma]

Depends on the age of the child. It’s possible to both engage the child and direct most of your information gathering towards the parent. It’s not easy for sure, and I don’t expect a medical student to be super good at (just willing to try!)

Some helpful things you can do:
- make sure to greet the child when you enter the room. Take a moment to be friendly/kind/comforting as the situation requires before getting down to business
- for kids that can talk, direct the simple subjective questions to them (does your belly hurt? Can you point to where it hurts?). You can always look to the parents for confirmation after the kid gives their answer. For more complicated questions like past medical history etc, direct that at the parent.
- for teenagers, interview them pretty directly with glances to the parent as needed for confirmation/additional information.
- focus on the kid during your physical exam. Explain what you’re doing in kid friendly language. To get honors, you’re actually required to make a joke about looking for Mickey Mouse/a puppy/something else silly while doing an otoscope exam.
- get on their level!! I spend a lot of time squatting on the floor with my little patients

As far as inpatient peds rounding goes, there is quite often a parent in the room with the kid to give you info, or you’ll ask the nurse who has been caring for them. Tbh peds rounding is way more efficient than rounding on adults imo cause there’s simpler problems to talk about and if there’s no parent around for a small kid, then you’re mostly just doing a physical exam and brief chat with the kid, then calling the parent later.

 

[SurfingDoctor]

Kids will always tell you if something hurts and where.

Parents/caregivers will tell you time frames and associated symptoms/history.

Nurses will tell you the details.

The chart tells you everything.

Also, if you’re not good with kids, it mostly means you didn’t try to be. Its pretty simple. If they are wearing a SpongeBob shirt, there’s a decent chance, they like SpongeBob. Ask them about it and get them to tell you about their favorite episode, even if you haven’t seen it. Everyone, from kids to adults, like to tell you about the things they like. It’s really not that hard. The trainees who don’t want to engage do so intentionally.

 

[voxveritatisetlucis]

Mickey Mouse/a puppy/something else silly while doing an otoscope exam.

See this is where I think I’ll have the most difficulty because my overall demeanor doesn’t really fit and I fear the parents/residents would be uncomfortable lol

 

[voxveritatisetlucis]

Thank you all for the detailed replies btw, I appreciate it!

 

[DO2015CA]

See this is where I think I’ll have the most difficulty because my overall demeanor doesn’t really fit and I fear the parents/residents would be uncomfortable lol

Change your demeanor. Like you do with different types of adult patients. Talking to people across adult age spectrum and cultural backgrounds dictates your demeanor to change. It’s a skill you need to work on regardless if you never see a child again

 

[cj_cregg]

Great advice above. Obviously level of involvement for kids will depend on age.

For toddlers I don't ask many questions, but I do a lot of playing around with exam equipment and "can you listen to my heart first?" to get them comfortable with the exam and so they can see the otoscope doesn't hurt, etc.

For younger school age kids I ask them what grade they're in, what's your favorite thing and your least favorite thing about kindergarten, what are you going to dress up as for Halloween, did you get any cool birthday/Christmas presents, etc and some simple questions about any symptoms or concerns they may have, but most more detailed questions I direct to the parents.

Teens you can basically talk to like an adult and mostly address them during the visit, although obviously parents may need to add/confirm stuff, and some shyer kids may want parents to answer all the questions lol.

 

[TelemarketingEnigma]

See this is where I think I’ll have the most difficulty because my overall demeanor doesn’t really fit and I fear the parents/residents would be uncomfortable lol

To be clear I was joking about that specific comment being required, but it is a time honored tradition among pediatricians (my pediatrician did it to me, I do it to my patients…)

You don’t have to have the best jokes, the bare minimum is to not look like you’re scared of the child

 

[EthylMethylMan]

See this is where I think I’ll have the most difficulty because my overall demeanor doesn’t really fit and I fear the parents/residents would be uncomfortable lol

You could rehearse a few canned lines in the mirror to make sure you don’t seem too awkward. You could also candidly ask some of the residents or your classmates how they think you could improve in that regard. At the end of the day, I think most parents will appreciate the effort of trying to make their kid comfortable, even if it doesn’t completely land.

I definitely got better with pediatric patients after having my own kids. So if you wanna have a few of those lil guys before your peds rotation that might help.

 

[cj_cregg]

To be clear I was joking about that specific comment being required, but it is a time honored tradition among pediatricians (my pediatrician did it to me, I do it to my patients…)

You don’t have to have the best jokes, the bare minimum is to not look like you’re scared of the child

I like listening to their belly with the stethoscope to see if I can tell what they had for breakfast this morning. For some reason I never get it right.

 

[DO2015CA]

I like listening to their belly with the stethoscope to see if I can tell what they had for breakfast this morning. For some reason I never get it right.

The answer is always chicken nuggies

 

[Goro]

I have been doing a pediatric surgery mini rotation within my main rotation within my surgery rotation and although it hasn’t been a problem for this rotation, I’m sure it will for peds. Should you talk to the kid or parent? I always feel a bit stupid trying to talk to the kid especially when they’re <7 or so because it doesn’t really make sense because most are poor historians. But then some residents probably say you need to talk to the kid more. Also on peds hospitalist, how is it possible to round efficiently if you’re talking to the kid since they’re probably giving inaccurate info


Also can you even do good on peds if you’re not naturally good with kids?

Didn't you learn about this in your preclinical years? My kids sure do.

 

[DOcSto]

I’m on peds this month. Granted, it’s only outpatient and my preceptor is chill, but I do a mix of talking to both the kid and the parent. In the 6/7+ crew and the adolescents I’ve seen, the parent seems to provide more to the hx than the kid does and vice versa. It varies from encounter to encounter who gets me the info I need the clearest.

 

[LunaOri]

For most kids, letting them know “I’m not the kind of doctor who gives shots” eases their fear.

 

[TelemarketingEnigma]

I like listening to their belly with the stethoscope to see if I can tell what they had for breakfast this morning. For some reason I never get it right.

a classic!!

Also a big fan of listening to their knee/arm/head and wondering why I can’t hear a heartbeat and asking them where I’m supposed to put it

 

[voxveritatisetlucis]

You could rehearse a few canned lines in the mirror to make sure you don’t seem too awkward. You could also candidly ask some of the residents or your classmates how they think you could improve in that regard. At the end of the day, I think most parents will appreciate the effort of trying to make their kid comfortable, even if it doesn’t completely land.

I definitely got better with pediatric patients after having my own kids. So if you wanna have a few of those lil guys before your peds rotation that might help.

Well lately I can’t even get a second date so I’ll probably need an alternative

 

[voxveritatisetlucis]

a classic!!

Also a big fan of listening to their knee/arm/head and wondering why I can’t hear a heartbeat and asking them where I’m supposed to put it

What about otoscope exam. That was always the toughest when I was on family med and saw a few peds patients

 

[voxveritatisetlucis]

Didn't you learn about this in your preclinical years? My kids sure do.

Not really. All of our standard patients are adults and they never have us do a pediatric history/physical

 

[TelemarketingEnigma]

What about otoscope exam. That was always the toughest when I was on family med and saw a few peds patients

For little kids who might be afraid of the otoscope itself I like to boop them with it a few times in less scary places (hand, leg, etc). You can also let them hold it and look at it first.

For really squirmy little ones where it’s important to get a good look, learning how to have a parent hold the child so you can get the access you need is important. I like to phrase it as having mom/dad give them a BIG HUG while I take a peek. But there’s specific positioning you ideally want - seated on parent lap with their feet between parents legs + one parent arm around their torso (keeping arms still) + the other hand holding their head still usually works well

Use the largest speculum available that will comfortably fit in the kids ear. Don’t mess around with those teeny tiny speculums meant for newborn ears on bigger kids - it will be harder for you to get a good look and so you’ll probably take longer, the kid will squirm more, and no one will be happy

Practice practice practice. Because I knew I needed to get better at ear exams before residency, I did a whole peds ENT clinic rotation expressly for that purpose.

 

[cj_cregg]

What about otoscope exam. That was always the toughest when I was on family med and saw a few peds patients

I also boop them on arms/legs, then tummy, then getting closer to the ear with the otoscope to make it less scary. Also very fun to put your finger over the tip and show them how it glows. Now can you make your finger glow? (And now they know the otoscope isn't sharp/painful.) Now can I see if your ears glow?

But also some kids are just gonna cry about it and you have to just work through it. Especially likely if they're anxious already, autistic/sensory issues type things, or have an ear infection. If they're losing it when you are just approaching them for the exam none of this will probably be worth your time lol.

 

[VA Hopeful Dr]

Didn't you learn about this in your preclinical years? My kids sure do.

You can't train people in a classroom to be comfortable around kids if they aren't used to dealing with them. It just takes practice.

 

[Goro]

You can't train people in a classroom to be comfortable around kids if they aren't used to dealing with them. It just takes practice.

For us it's not a classroom event, as we use live kids...ie, volunteer children of the faculty and staff. Juice, crackers and fruit make wonderful bribes.

 

[VA Hopeful Dr]

For us it's not a classroom event, as we use live kids...ie, volunteer children of the faculty and staff. Juice, crackers and fruit make wonderful bribes.

Without knowing the exact set up I can't comment much, I just know that I hated standardized patients and didn't get all that much from it personally.

 

[RangerBob]

I don't consider myself great with kids. But being genuine helps (it's easy to be confident/not scared if you're being yourself).

I like the idea of listening to their belly to see what they had for breakfast. Letting them put your stethoscope on so they hear your heartbeat (or their parents') was something I used to do too.

They love the neuro exam-reflexes are always fun. Of course show them how you use the hammer on yourself and feign an exaggerated 4+ reflex.

I always told them I had to look for butterflies or birds in their head for the otoscope. Or see if their brain was still there (that only works for a more mature kid who understands you're teasing them--little kids will worry their brain could fall out. So know your audience!)

I learned that the little stuffed "stethoscope buddies" are horrible. Babies and young ones like to grab them and put them in their mouth. And you can't disinfect them. So I lost them. Just grab stickers/whatever from the clinic and ask the kids if they like them.

Also just watch a few episodes of Bluey. Not only does it give you something to talk to kids about, but the dad in the show is actually really great at interacting with kids/playing with them. You can learn a lot from them.

Learn a few really popular kids shows as well, and learn a few characters. As others pointed out, ask about the characters on their T-shirts, jackets/etc.

Talk directly to the kid--they may be shy, but they certainly won't open up to you if you ignore them. Mom/dad will chime in as needed. Basically treat them with the respect Mister Rogers did.

90% of peds was just being authentic with the kids and building rapport. 10% was reviewing labs/immunizations/looking at the kid to understand "sick or not sick." If you're a pediatrician it's more than that, but as a med student most peds visits were well-child checks and those are simply and can be a lot of fun.

 

[Dral]

There are some resources online about peds I'm sure. You just have to learn as many as you can (some good ones in this thread). You'll start to see concepts of dealing with peds patients. Just work on using ones you learn and coming up with your own.

A big part of it is just pretending you're a kid yourself. How would you feel around a doctor? How would you feel about that piece of equipment? How would you feel about being in a new scary place?

A big part of it is trying your best to ease those concerns/fears. Peds 101 is getting down on their level. If you're in clinic, you kneel down and get to their level. Don't be the towering scary doctor hovering above them.

Carry stickers in your white coat pocket. Sticker bribes/rewards always help. It doesn't seem like much to us, but there is a sociological/psychological part of letting a kid pick out what sticker THEY want. They get to control at least something during a time when they might feel they are not in control of anything.

Blowing up a glove to make a balloon is another one I can think of off the top of my head.

Also, I hate to have to go here, but you should be talking to every kid you can to tease out if anything bad is happening to them. It's not something you ask directly of course, but you should be looking at body language and trying to pick up on other cues. We're responsible as health care providers to be protectors of the peds population in that regard. Not at least engaging them, even if they may not be a good historian, is a disservice.