BMJ  2006;333:1330-1332 (23 December), doi:10.1136/bmj.333.7582.1330

Cultural studies

Daisy the Doctor, Dr Dose, Dr Grizzly, Dr Amelia Bedelia, and colleagues

¹ Leeds Teaching Hospitals, Leeds LS1 3EX, ² Stepping Hill Hospital, Stockport SK2 7JE

Introduction

The way children perceive the world is shaped by different factors. They can be strongly influenced from an early age. Many carers and teachers read books to children, and these might be their first encounter with a new subject. This can create certain expectations before children can have their own experiences.

Books for small children about "going to the doctor" are popular, and many adults will use them to help their youngsters cope with any related anxiety. They are common in children's wards and waiting areas for clinics and surgeries. By the time many children see a doctor they may have already looked at a book about doctors.

To our knowledge, there are no previous studies on books for children about doctors and hospitals and whether they present an accurate view. We looked at a series of books to investigate the image of doctors, their attitudes, and their jobs.

Methods

We selected 14 books written in English. The selection process was based on common factors for choosing children's books: colourful and appealing look (figs 1 and 2); reasonable price (<£8 (12; $15)); and easily available.

Details of books for children about doctors included in the study Kottke J. A day with a doctor. Danbury, CT: Children's Press, 2000. Karr K. At the doctor's. London: Collins, 1995. Beylon C. At the hospital. Mineola, NY: Dover Publications, 2003. Joyce M. Busy hospital. London: Ladybird, 2005. Parish H. Calling Doctor Amelia Bedelia. New York: HarperCollins, 2004. Brooks F. Daisy the doctor. London: Usborne, 2004. Ross M. Doctor Daisy. London: Ladybird, 2002. Bourgeois P. Franklin goes to the hospital. New York: Scholastic, 2000. Civardi A. Going to the doctor. London: Usborne First Experience, 2000. Marx DF. Hello, doctor. Markham, ON: Children's Press, 2001. Ahlberg A. Miss Dose the doctors' daughter. London: Puffin Books, 1988. Cole J. My friend the doctor. New York: HarperCollins, 2005. Berenstain S, Berenstain J. The Berenstain bears go to the doctors. New House, Random House/First Time Books, 1981. Adamson J, Adamson G. Topsy and Tim go to the doctor. London: Ladybird, 2003.

View larger version (105K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 1 My Friend the Doctor by Joanna Cole

 

View larger version (110K): [in this window] [in a new window] [PowerPoint Slide for Teaching]   Fig 2 The Berenstain Bears Go to the Doctor by Stan and Jan Berenstain

 
Over a period of three months we browsed shelves in book shops and the internet using the search words "doctors" and "hospital." Half of the books had English publishers, and the others were either Canadian or American. Eleven books were first published from 2000 onwards and three were older (1981-95). We read the stories and studied their 366 illustrations, focusing on the 154 images of the 21 doctors in the books. We looked at different factors to assess how well they reflected reality.

Results

The doctors' looks
There are three common features to the doctors' appearance: a white coat, a stethoscope, and a permanent smile. Only two doctors do not wear a white coat. One third of coats have pens sticking out of the pocket, and one is usually red. All doctors appear with a stethoscope, and most carry it all the time. Doctors are smiling in 126 out of the 154 pictures, even when they are performing examinations or talking. We attempted to examine each other's ears while smiling for a prolonged period of time and found it rather uncomfortable.

Twelve doctors are female, including two bears (Dr Bear and Dr Grizzly), and nine are male, including Dr Potts the dog. Of the humans, all but three are white.

None of the female doctors has hair long enough to touch their shoulders, and only two of the female doctors are blonde. We consider it inappropriate to comment on this fact. Clothes are very conservative. Only one male doctor does not wear a tie, and most female doctors wear flat shoes and skirts just below the knee. One third wear glasses, a high proportion compared with just two out of the 58 patients pictured. Most doctors look young, and only three might be middle aged. One general practitioner wears an indirect mirror on her forehead throughout the whole story but never uses it.

The doctors' role
Most doctors in these books are general practitioners, the others being an occupational health doctor, two emergency medicine physicians, one anaesthetist, and two surgeons. In one story the doctor is initially a general practitioner but then acts as a radiologist and subsequently a surgeon. We assume this is a "hospital at night scheme."

All the doctors seemed busy. Their hands are never at rest or they just hold an object such as a clipboard. One of the doctors complains that she saw 15 patients in 2 hours 20 minutes. We feel that a clinic of that size should be manageable provided that all cases are simple. They spend a long time talking to the patients and playing with the small children. They often allow the children to play with the instruments.

The doctors perform jobs that are traditionally done by other healthcare workers. They carry out seven paediatric check ups, involving weighing and measuring the children. They give the injections in five out of six immunisations. We assume that the nurses were probably on their break.

The doctors are generally appreciated by their patients. One gets a thank you card and another a present of ice cream. The patients all seem pleased about the service, and there are several mentions about the doctor being "friendly" and "nice." Most patients leave with a smile.

The doctors' tools
Stethoscope—This is a permanent feature, and it appears in 125 of the total images. It is surprising to find that two thirds of the doctors carry it with the rigid arms around the neck. We assessed how plausible this might be. The earpieces pressed into the back of the head, the pressure over both carotids made us feel dizzy, and the distal end kept hitting the genitals. There is a great variety in the looks of the stethoscope. Some of them are quite unusual. Stethoscopes are used on 16 patients but applied only once on each of them. The places are variable: the axilla (three), shoulder (three), or the epigastrium (two).

Auriscope—This is popular too. It is used 10 times for both ears and eyes. On six occasions the auriscope is used as a torch to look at the throat and on two occasions the earpiece is still attached to it. This would result in an illuminated area of 4 mm². When the auriscope is used it barely touches the ear, and in only one illustration does the doctor pull the ear back.

Tongue depressor—Doctors examining the patients' throats use a tongue depressor and a light but the doctors' eyes always appear much higher than the children's mouths, making a successful examination unlikely.

Thermometer—This is seen nine times. All are mercury and glass. We are concerned about health and safety issues.

X rays—We see a few examples. Interestingly one shows a foot next to a banana and another proves that "the child was brave inside." We are unaware of these advanced techniques.

The doctors' office
We see a total of 12 waiting rooms; only five look child friendly. The rest are crowded and dull. Patients waiting look upset or worried. At the general practitioner's, the staff is reduced to four nurses and three receptionists. Their attitude is always helpful. Unlike reality, the nurses' role seems to be limited to following the doctors' instructions. The desks display different items; the most common are telephones and tins with pens or tongue depressors. There are two family pictures.

Only two doctors have computers. These surgeries are in obvious need of some modernisation. Half of the offices have a framed picture that looks like a medical certificate.

The doctors' skills
The doctors' managerial skills seem good. There is no indication of waiting times. Seven of the stories start at home, and all patients seem to get an appointment immediately. The general practitioners deal with various minor complaints such as colds and coughs, minor trauma, skin problems, one fractured shell of a tortoise, and check ups.

The doctors do not hesitate in their diagnosis. In terms of treatment, six patients with colds, coughs, or sore throats receive a prescription for "medicine"; a child with earache gets a prescription for "antibiotics and painkillers." Half of all patients leave with a prescription; this seems high for such minor complaints.

The occupational heath doctor checks the hearts of three people (a fireman, a police woman, and a builder) during Healthy Heart Day. She describes the noises she can hear ("ba-doum, ba-doum") as a "very healthy heart." We believe this assessment to be appropriate.

We are concerned about the ALS (advanced life support) skills of the hospital doctors. Two patients on monitors seem to be in ventricular tachycardia or ventricular fibrillation, but they receive no special attention. It could be a technical problem, however, considering that the patients don't look clinically compromised.

In general, examination skills are variable. Most doctors seem highly incompetent during ear, nose, and throat (see above) and abdominal examinations. Three doctors feel abdomens with the tips of their fingers (as if playing the piano).

Conclusions

In general, the image of doctors is kind, professional, and reassuring. They look young, tidy, and conservative. Many wear glasses, carry pens, or display their degrees on the walls to provide them with an aura of cleverness. They seem popular among their patients and they receive compliments, but no complaints. They are not particularly good at physical examination, but they are excellent diagnosticians. All their patients seem to get better, too. ALS skills are poor. Most doctors seem busy but never stressed. They seem focused in their work, and they look permanently happy. None of the stories suggests that doctors are under any pressure from management targets.

Some of the situations portrayed in many of these books look unrealistic. A young reader might expect to get an immediate appointment, a holistic approach, a long consultation, and a prescription. This could result in a big disappointment. Still, the presentation of the doctor as a friendly and capable person might successfully allay a child's anxiety before a visit to the doctor's.

What is already known on this topic Books about going to the doctor are common in children's literature and are used by parents to relieve children's anxiety when they visit a doctor What this study adds The image of doctors in books for children is positive but might lead to unrealistic expectations

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We thank our children Paula (8 years) and Martin (3 years) for their invaluable comments during the research for this study.

Contributors: ML conceived the study, analysed the data, wrote the manuscript, and is guarantor. JAA analysed the data and edited the manuscript.

Funding: None.

Competing interests: None declared.

Ethical approval: Not required.

(Accepted 28 October 2006)

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