Wednesday, 27 April 2016

When a dilemma presents, take a five year old for a pint

Because most interactions involving a parent and clinician are harmonious, it can be perplexing to find ourselves at odds with a parent or carer.  If there is a difference of opinion about what the best management plan is, I try very hard to find a way to address the parent’s agenda.  It is also important to remember that the best interests of the child should always come first.  Of course, the best interests of the child may be very different to the child's agenda.  The GMC 0-18 guidance (1) says that we need to consider both.

Including the child’s agenda is difficult and at all ages it is easy to allow the fact that children and young people either can’t or won’t articulate their wishes in a useful way to lead to their wants being lost in the course of problem solving.

The fact is that as clinicians, we must always act in the best interests of the child.  This is more complicated than it sounds.  Sometimes that means compromising our plan to help a parent, even when we don’t necessarily agree with their health beliefs.  Sometimes it can mean that we have to insist on a course of action that the parent disagrees with.  If we are faced with the second scenario, we must make every effort to help the parent or carer to understand the reasons for this determination.

I don’t like conflict.  It makes it difficult to think logically and clearly.  It is so much easier to be sure when all parties are in agreement.  The ability to doubt yourself is an essential part of being a good decision maker.  However, facing outright opposition to what feels like the best plan can lead to poor decision making, especially if you like to keep people happy.  So when a conflict cannot be resolved, I take a mental step back and ask the child.  I am not talking about asking the child in front of their parent.  I need to get them on their own and take them for a pint.

Next time you find yourself in a conflict over what to do, try this thought experiment:

Imagine that the child involved is now an adult, able to fully understand all the dilemmas involved.  They have read their medical records and want to talk to you about the thing.  You meet them as an adult and sit down over a pint – beer or tea, it doesn’t matter too much.  (This is a thought experiment so the medical regulatory body can’t strike you off the register.)  So now you can explain to them adult to adultwithout a third party involved, why you did what you did .  The agenda of the parent or carer will still be a factor, but the only person that you have to convince is the (now adult) patient.

So how will that go?  Will you be able to tell them that you acted in their best interests?  Will you be able to tell them that you did what you thought that they would want?  If the outcome of the thought experiment is a clear conscience then at least you have fully tried to act in the best interest of the child.  Whether you make the right choice or not is always a retrospective decision.

Often, the best interests of the child are clear in which case I put all my efforts into resolving conflict.  When there is uncertainty or the conflict clouds my judgement, I find that this thought experiment helps.

 Interestingly this thought experiment has always had a pleasant side effect on me.  Afterwards I feel much more relaxed.  I think it is something to with the fact that I have always got on really well with these children turned adults and they have been very understanding.  It’s also nice to have refreshment, even if imaginary.  Of course if I am at work, it has to a pint of tea but sometimes I do this while walking home, in which case I enjoy a pint of Woodfordes (2).  Nothing beats it.

Edward Snelson

Disclaimer – no-one should ever take a five year old for a pint of beer.  I am so heretical that I was once discontinued by the Pope.


  1. General Medical Council 0-18 Guidance 
  2. Woodfordes Wherry Ale, Woodbastwick, Norfolk

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