Health: Mummy, take care what you say to the doctor: Heather Welford reports on how prejudice can prevent children from getting the best treatment

YOU'RE 10 years old. You've been referred to paediatric outpatient clinic by your GP with a chronic ear infection, and you turn up with your father or mother. Does it matter whether the doctor you're about to see likes your parents? And could his feelings about them affect how well you are treated? Surprisingly, the answer to both questions is yes.

In a pilot survey of 25 hospital doctors by Roy Meadow, a paediatrician at St James's University Hospital, Leeds, all considered that the health care a child received was likely to be worse if the parents were perceived as 'difficult' or 'unlikeable'. Follow-up appointments were less likely to be made, and the time spent with the family at outpatient clinics was likely to be shorter.

Professor Meadow then surveyed 200 medical and nursing staff in the Leeds area, all of whom dealt with children as inpatients and outpatients. Exactly what, he wanted to know, made parents difficult or unlikeable?

Refreshingly, he says, medical staff were honest, self-aware and self-

critical. Several wrote at length about their feelings towards parents. 'It was heartening that doctors didn't feel they had to be seen as perfect,' he says. 'They expressed misgivings, and sometimes guilt, about their prejudices.'

And prejudices there were. Parents can easily get off on the wrong foot, for example, if more than one adult accompanies the child into the consulting room. 'Hangers on', as one respondent described them, such as friends or grandmothers, are regarded as particularly irritating.

Is this feeling a reaction to being outnumbered in some sort of clinical power game? Professor Meadow thinks not. 'I still find it difficult, sometimes, to deal with more than one adult in a consultation. It's probably more a question of wondering who to direct your questions to, and finding your way through sometimes contradictory information.'

Parents should watch their language, too. Doctors' toes curl at 'kiddiespeak' and at dinky-darling euphemisms for the genitalia ('twinkie') - and they don't like over-use of the words 'little' or 'tiny'. Professor Meadow says he's reminded of one doctor quoting a mother who described a problem thus: 'He draws up his little legs, doctor, and his little face is all screwed up when he passes his little motion.'

It sounds as though much of this negative feeling stems from a clash of cultures. They like you better if you are like them. In fact, half the doctors admitted to difficulty if the parents were 'much more clever' or 'much less clever' than they were.

It is not just brainpower that counts. Money talks, too. Parents with a lot of spare cash should not make it too obvious. More than 40 per cent of medical staff did not like parents being much wealthier than they were; but it made little difference to attitudes if the parents were poorer.

Asian parents posed problems as well, though this was mainly because of communication difficulties and a shortage of interpreters. 'It's a national scandal that the health service has yet to organise a proper interpreter service,' says Professor Meadow. West Indian parents had no language problems but, according to the survey, their 'laid-back attitude' and casual appointment- keeping irritated about a third of doctors.

Nursing staff were far less frank about their feelings towards parents. 'We were disappointed with this,' says Professor Meadow. 'Fewer of the questionnaires were returned, and of those that were, many seemed to be written as idealised, exam-paper answers.' Some senior nurses had considered the survey 'improper' and had told junior colleagues to ignore it. Nurses, it seems, are less willing to admit to anything but a squeaky-clean professionalism in their reactions to patients.

Predictably, most doctors feel irritated and even extremely angry with parents who are aggressive - whether with the child or the doctor. It is understandable, too, that most doctors find it more awkward to talk to parents if the child has a condition that is untreatable or poorly understood. Coping with these feelings, rather than denying them, is the way forward, according to Professor Meadow; more emphasis is needed in training on communication skills, he argues.

An American study, published in 1988, found that paediatricians were 'greatly positively influenced' by a myriad of factors, including whether the mother used a car safety seat, and whether she stopped smoking in pregnancy. Doctors were also keen on the mother appearing well satisfied with the care offered - and the older the doctor was, the more he needed his ego massaging in this way.

Doctors are not always good at making themselves likeable to parents, it should be added. Ronald Illingworth, former professor of child health at Sheffield University, once reported: 'Scores of mothers have expressed their irritation to me at being told they are just over-anxious, imagining things, or fussing about nothing.'

Some doctors assume an air of jovial informality, and set parents' teeth on edge by addressing them as 'Mum' or 'Dad' ('come in and sit down here, Mum'). Yet it is a brave soul who dares reply: 'Mrs X to you, doctor', whether to a fresh-faced house officer or a wrinkled consultant.

Doctors should also bear in mind that a parent may be feeling particularly vulnerable, and even guilty, if a child is ill or having behavioural problems; these feelings may well account for an aggressive attitude and communication difficulties. Professor Illingworth's recommendation to colleagues is: 'Never appear to criticise a mother for her child's difficult behaviour.' Mothers do their best in the face of much conflicting advice, he points out.

Professor Meadow suggests that parents write down their questions before meeting the doctor. With regard to taking an adult companion to the consultation, he says: 'It's very reasonable to see the doctor in pairs, but it would help if you agreed beforehand which one of you is to do most of the talking.'