«Mr Dreher, how do you gain the trust of young patients?»
Just a few minutes ago, Thomas Dreher was standing in the operating theatre, now he appears punctually and in a good mood in the hospital canteen and says: «We have time.» In fact, a whole four hours will pass before we say goodbye.
Taking the time he needs is a key issue for him as a paediatrician, as he will explain in a moment. For the interview, we take a seat at the conference table in his functional, small office, with a children's hospital hidden object book leaning against the wall behind us and a skeleton looking over our shoulders from the right.
Mr Dreher, I recently took my daughter to the paediatrician for a vaccination. We were both quite startled when he suddenly gave her a jab without warning. How do you approach a child with a syringe?
You have to deal with children as patients differently than with adults - but you don't treat children more gently by scaring them. Fortunately, I very rarely work with injections, but I always prepare the child for what is to come. The most important thing to prepare a child for pain is to create a calm and trusting treatment situation.
How do you do that?
The crucial thing is that I, as a doctor, am calm myself. I need the necessary time to do this.
And you have them?
As head physician, I naturally have many different tasks. But I also have more freedom to organise my time in this position. Even in the past, I was very reluctant to cut back on time for patients - now I try not to do so at all. Here in Zurich, I can take more time for patients and their parents than before in Germany. That was one of the reasons why I decided to take the job.
How do you deal with a child who comes to you in an emergency after an accident?
I try to make direct contact with him in a warm, cordial way. That way I can create a basis for explaining to him that perhaps something needs to be done.
How do you do that specifically?
That depends on your age. With younger people, if it was a minor accident, you can make contact in a humorous way. For example, you can ask: «What cool trick did you do with the skateboard?» This will ease the situation. Or you can tell them that you have also had a similar accident or injury.
And with older children?
The slightly older ones, from the age of twelve, are more reflective. They want less jokes about their accident and more warm-hearted information and the certainty that further treatment will be accompanied by little or preferably no pain. You have to be able to assess the situation correctly: Am I dealing with a rather anxious child? Or is it a child who is still making jokes even with a broken arm? You have to be able to assess the situation in a relatively short space of time.
Did the encounter with the children also go wrong?
Sure, that happens. The assessment of the situation has to be made within seconds or fractions of a second, which can't always work. There are situations in which the mood changes immediately and the child starts to cry when the doctor enters the room. Children realise early on that the people who come in now, that the ...
... are hostile to them?
(laughs) Not in a hostile way, but I do believe that there is a natural aversion to doctors and medical treatment. There's even a name for it: Iatrophobia. According to research findings, we are probably conditioned very early on.
How early?
With the first vaccination. After that, further vaccinations are regularly added, and so at some point children associate the arrival of a person in a white coat with pain. There is therefore a trend in paediatrics to do away with the white coat. Not all hospitals allow this, but it would be nice if paediatrics could do without it altogether.
What do you do to relax difficult situations with paediatric patients?
The most important thing is not to pretend. Children have a very good sense of when someone is trying to pretend. For the doctor, this means always remaining natural and accepting when things don't work out. There are situations where you have to say: «We'll discuss this again later.» Incidentally, many parents are surprised that I primarily address the child. But I don't let myself be put off, even though I know that talking to them afterwards will be the bigger challenge.
Do you need to reassure the parents rather than the child?
This is often the case. In this situation, the parents feel the extreme responsibility they have for their child. It would be terrible if that wasn't the case.
How much can and should children be trusted and expected to do?
It depends on age, but not only: I notice time and again that children of the same age differ greatly in how much they understand and how much they want to participate in decision-making. But once a child has understood the context, they can of course participate in decision-making.
In which cases do you need a decision?
In trauma surgery, the case is usually clear-cut. In orthopaedics, however, there are elective operations, i.e. procedures that are performed to prevent problems that may arise in the future, for example in the case of a hip maturation disorder. This is often difficult: you may have children who have no complaints at all and you have to explain to them that they need an operation to prevent pain in the future.
Do the parents understand that?
Yes, they usually inform themselves independently and many seek a second opinion. However, it is crucial that the child also understands why an intervention is necessary. You get a completely different relationship of trust with patients if you respect their autonomy. I believe this is a very central point in paediatric medicine: preserving autonomy and respecting the individual.
What do you want from parents who take their child to the doctor?
They should also behave as authentically as possible. I expect them to be open and honest, to address fears and other feelings - because then you can tackle them together. Many parents don't want to show weakness and are afraid that I won't understand them or that I won't have time to deal with their concerns. That is absolutely not the case.
How do you deal with parents who disagree with you and justify this with information they have found on the Internet?
There are colleagues who don't appreciate it when parents come to them with information from the internet. I am of the opposite opinion: as doctors, we have to face up to this situation and evaluate information that parents have found on the internet.
How do you convince the parents that you are right?
It's a question of trust. It's part of my duty to keep up to date with my training, but even as a doctor, I don't know everything by heart. And I sometimes say to parents: «You know what - I don't know any better.» Or: «You're right, it could be done better in a different way.» Or if something hasn't gone well, to say: «I think I'd like to do that again. The result is not what I had in mind.»
Have you already done that?
Yes, if I'm not happy with the result of an operation, I tell the parents.
How often has this happened?
This has happened a few times. It happens to everyone who does a lot of surgery. However, I'm not so sure that everyone can admit this.
How do the parents react?
I can't remember any situation in which they said: That's not possible, we don't want you to do that again. My experience is that they show understanding and say: We also want it to be perfect.
Do parents also forgive mistakes?
The question is how you define mistakes. No human being is infallible. Everyone has a complication from time to time, and it happens to everyone that things don't go the way they want them to, especially in a speciality in which operations are performed.
These are statements that you could hardly imagine a doctor making 10 or 15 years ago.
The days when doctors were untouchable are over. The culture of error has improved. Dealing with complications, unexpected outcomes and reflecting on the results of operations in order to draw conclusions for future treatments are now standard practice in many hospitals.
Have you ever realised that your child doesn't want what the parents want? The child doesn't want what the parents want?
Oh yes. That's not uncommon at all.
How do you react to this?
A distinction must be made between things that have a certain urgency and those that are elective, i.e. not absolutely necessary from a medical point of view. Let's take the case of a
15-year-old girl who comes to hospital with her parents because she has a crooked toe. If the parents insist on correcting the toe, but the girl doesn't want to have the operation, then as a practitioner I say with a clear conscience: «I'm not going to correct this toe». This deformity is not so serious that I would disregard the young lady's autonomy. She can decide for herself from the age of 18.
But what if an operation was urgent?
Let's take the case that the girl has a painful hip due to a maturation disorder with previous damage. If she doesn't want to have the operation, but her parents are in favour of it, then the doctor needs to provide information. If she has understood the connection between the painful hip and the prospect of improvement through treatment: Why should she still be of the opposite opinion?
Growing pains are a much-discussed topic. Do they exist?
They definitely exist. They most frequently manifest themselves as pain in the heels, on the back of the thigh, at the base of the patellar ligament or on the shin. However, the question is whether they should be labelled as pain. Ultimately, they are body signals: the bones grow and the soft tissues have to grow with them. During growth spurts, the muscles and ligaments are repeatedly stretched and irritated. However, if pain is defined as a negative phenomenon, the term growing pains is probably inadequate.
How can you see pain in a positive light?
In pain theory, it is said that it helps if pain is positivised - if it has no direct anatomical origin, only occurs in certain situations and does not pose a threat. Let's take growing pains, for example: this requires the assessment of a paediatric orthopaedic surgeon who says: «I can reassure you, this is typical growing pain.» Without this information, the pain can become chronic.
The pain remains because the patient sees it as something negative?
Yes, the positive side of growing pains would be to say: «Yay, I'm growing, I'm getting taller!» And if the child understands where the pain is coming from and that it will go away on its own, it can deal with it better. If you don't constantly brood about it, you are less sensitive to these signals. If, on the other hand, you are afraid and don't understand why it is there, then you perceive pain as negative and therefore worse. This is the case with all types of pain. Otherwise, however, I have to tell children with growing pains and their parents that there is nothing I can do and that the pain will eventually go away on its own.
Do they accept that?
There are parents who go from doctor to doctor when things don't get better for a long time. And sometimes a doctor recommends a treatment that is not actually needed. Many doctors find it difficult to say that they can't help. The classic idea is that the doctor always has a solution at hand and can change things with their skills. But this is not always the case. And especially when it comes to pain in the musculoskeletal system, the following applies: treatment is not always necessary.
Book tip:
Taking your child to the doctor: two paediatricians from Bern have published a lovingly designed picture book that prepares children and parents for their check-ups. With lots of photos, it explains in a child- and adult-friendly way everything that happens at the paediatrician's - or, of course, at the paediatrician's - from weighing and vaccinations to addiction prevention. Sabine Zehnder & Lea Abenhaim: Everything ok? Everything is ok! What I can experience at the paediatrician's ..., Creathera 2019, 24 Fr.
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