Some good ideas seem to be elegant in their simplicity. The Teddy Bear Hospital is one of these.
I spent a day with medical students on placement with the Newcastle University Department of Rural Health in Tamworth finding out about how they use this intervention to reduce children’s anxiety around encounters with doctors, other health professionals and health services and its role in their professional and personal development.
Tamworth is a small city in the centre of the southern rural district of New England. UDRH is here because of well-reported and documented concerns about the health of people in rural and remote Australia and the problems and challenges around the provision of health services (for example, Walker et al., 2008) Paliadelis et al., 2012). Students from a wide range of health professions: trainee nurses, nutritionists and dieticians, physiotherapists, radiologists, occupational therapist, pharmacists and speech pathologists as well as medical students, do a rural rotation under the aegis of UDRH. These rotations include placements that aim to expose them to the needs and issues faced in rural communities, engage them in supporting the rural health workforce and disadvantaged communities and to give them a taste of the career and lifestyle opportunities available outside metropolitan Australia.
The Teddy Bear Hospital (TBH) is just one of around 30 community projects in which healthcare students are engaged in the Tamworth area.
The Teddy Bear’s Hospital
In essence, TBHs involve medical students running ‘hospitals’ for teddy bears. Children bring their ‘sick’ toys to the ‘hospital’ (which might be in a school, community setting or in the Medical School) take them into a ‘consultation’ with a student doctor and get some treatment and advice.
The TBH is thought to have originated in Norway in late 1990s (Thambapillai, 2009). Although the ways that TBHs are organised and delivered vary from place to place, they seem to share the common aim of providing a fun encounter in which doctor-patient interaction is role-played around a teddy to contribute to a reduction in children’s anxieties about doctors, medicine and healthcare.
There are several good descriptions of TBHs available via the web (for example, at Edinburgh and Southampton in the UK, Otago and Dunedin in New Zealand and Michigan in the USA). Many TBHs in Medical Schools in Europe seem to follow the lead and operate in association with the European Medical Students’ Association (EMSA).
Nowendoc and Woolbrook
In Tamworth, I tagged along with four medical students, Stuart, Vanessa, Emily and Cate who were staffing the TBH in two rural communities in New England: Nowendoc and Woolbrook.
They were giving up their time voluntarily to be Teddy Bear Doctors. It’s quite a commitment taking these students out for whole days at a time over the course their rotation. They need to be reliable because the ‘hospital’ can’t operate without them and the scheme needs to retain the goodwill and commitment of the schools that they visit. UDRH has linked the project with its extensive engagement in community development as well as the work of a local community nurse (who is the link with the schools that we visited, accompanied the students and introduced the sessions).
We visited two schools – at Nowendoc and Woolbrook. These are two tiny rural communities in bush farming lands. The school at Nowendoc has 6 pupils spanning the age and ability range for primary education. There is one full-time teacher. Woolbrook is a bit bigger. The village is home to around 200 people and the school enrolls around 13 pupils. It’s not quite as remote as Nowendoc but the road to Tamworth (where the nearest main health services are) is winding, rough and only relatively recently sealed.
The distance from major health services and the impracticality of providing full-time, on- hand access to healthcare workers was very evident. People also told me about the impact of recent drought and economic and social change on farming – the major source of income and as importantly, way of life in these areas. I could see the links with the strong evidence that people in rural and remote areas are especially vulnerable to accident and injury, acute illness as well as high levels of stress and anxiety and mental ill-health as a consequence (Phillips, 2009; Tonna et al., 2009).
However, I recognize you don’t get to really understand these problems and challenges from a fleeting visit to a school. What I was struck by the strength of the school identities and place in these communities. Both were lively, vibrant places full of action and colour and life. Their embeddness in their communities was evident too – from the drawings and other images and artifacts that decorated the space to materials and resources reflecting local life, customs and traditions. I hope that can get a sense of some of this from the photographs in the slideshow below.
The Tamworth ‘Hospital’
At each school the medical students carefully set up the ‘clinic’ in a space away from the main classroom. They would lay out their equipment including the bandages and plasters, sphygmomanometers and XRay scanner and various bits of paperwork – the medical record forms, xray photographs and certificates of attendance for the bears’ ‘parents’. Children buzzed around. Although not permitted to come to the clinic before opening time some streaked by stealing glances into the room; others hung about conspicuously clutching armfuls of teddy and other soft toys.
In each school the clinic was opened with a short introduction from the nurse and then the first patients would come forward to consult with the student doctors. In each, the children got to explain their teddies’ condition – and very frequently injury – to the doctor and they jointly put together a treatment plan (written on a form) and gave the bear an XRay and, again very frequently, copious bandaging. What started as a consultation about a torn ear or loosely stitched leg quickly went much further. Children might talk about the bear’s life history – a fair number had belonged to parents and/or grandparents – discuss its dietary preferences and needs and favourite hobbies, pastimes and so on. I’d characterize engagement as excited and enthusiastic but also serious. A good number of teddies came not once nor twice but three times or more to see the doctor, or different doctors.
This has a wonderful theatricality about it. Everyone was engaged to a great degree in the willing suspension of belief – either to practice medicine, be a patient, or to be patients’ carer and amanuensis. This collective commitment to playing the required roles in the drama radiated both warmth and intensity. It also allowed for some serious discussion about a being a getting being poorly and seeking and being cared for.
It’s easy to see why this would be enjoyable. For children, the TBH represents a fun encounter with medical students. They get to talk about things that interest them with new people who show genuine interest. It’s also an opportunity to bring toys to school and a break from lessons.
For the medical students it’s a day out in the inevitably winning company of children. For all involved it’s a chance to play. But of course there was much more going on here, and it’s the way that these important processes and outcomes are embedded in but do not predominate over the intervention that seems to make it work:
A good deal of important information about health services was imparted to children. This included how to identify health professionals (by their official badges and sometimes uniforms) and clearer ideas about what they do.
Children had an opportunity to practice talking to health professionals. They gave accounts of their bears’ conditions, explained things, expressed thoughts, ideas and concerns and thereby accrued understanding of the processes involved in these interactions and their role in them. I think just practicing saying things, putting thoughts in words, and trying to describe events and answer clinical questions about where it hurts and so on, is incredibly powerful.
They also had an opportunity to experience some of the wider context around clinical encounters. They had to sit in the ‘waiting room’ represented by the rest of the classroom away from the consultations at the tables as they took turns to see the medical students. They saw, touched, and indeed sometimes used for themselves some of machinery of medicine – the XRay machines, stethoscopes and sphygmomanometers. There were many charming moments when children concentrated hard to hear their own heart beat or that of the teddy. They could see that these examinations took place only with an explanation and their consent and with concern for their comfort.
There was quite lot of other health education going on. For example, children talked either on their own behalf or via their teddy about their diet, their lifestyle and so on. The students had an opportunity to explain the implications – to gently prompt around choice and changes in behavior and the importance of being and staying well. Through the negotiation of ‘treatment plans’ it was also very apparent to me that students were often times reminded of the value of cuddles and care in treatment.
I think that reduced anxiety about ‘white coats’ is almost certain to be an outcome of the TBH in Nowendoc and Woolbrook.
From point of view of students there are opportunities to develop and practice communication skills. Opportunities like this for working with children are not easily contrived in the context of medical education and, whether a student goes on to work in Pediatrics or not, there are valuable things to understand and exercise around giving clear explanations, listening, working in ways that are age appropriate and also thinking about the anxieties that any person encountering a healthcare professional might feel.
The medical students also got to see visit rural communities, to acquire a sense of where the bush is and what it’s like. How long it takes to get somewhere and what it looks, smells, ‘tastes’ like. It’s all very well having rural rotations in town and cities located in the countryside but being the country is something different that Stuart, Cate, Emily and Vanessa experienced at first hand.
There were some other things going on too.
Not least, because the schools invited the siblings of pupils to bring patients to the hospitals there was an additional buzz from the presence of infants and mums. They had an opportunity to be in school, to catch up, engage with the teachers and with the nurse.
There was a celebratory ethos about the TBH. As you can see and indeed hear below, in Woolbrook, this culminated in an impromptu concert from the pupils. They wanted to thank the medical students and to show off their considerable musical skills.
A few final thoughts
It was a great day. One that filled me with a sense of well-being: that’s an important reminder that educational process and experience can be positive, pleasant and indeed life affirming.
This experience also further reinforced and clarified some of my thoughts about non-clinical community-based practice and its contribution to medical education.
What is so evident in Nowendoc and Woolbrook, partly because of the size and relative isolation of these communities, is the importance of relationships. While not wanting in any way to downplay the differences between these communities, their needs and experiences and those of larger and/or urban communities, one of things that encounters for medical students which get outside clinical environments do, is to make manifest the importance of relationship between people and between people and places in mediating ways of life and the meaning and possibilities for ‘doing’ and experiencing health. They too can get invested in these through direct experience.
The TBH also represents a very nice example of the potential reciprocal benefits of CBP. In Tamworth the TBH is being used both to provide educational opportunities to medical students and contributing to the health education of children.
I told you it was elegant in its simplicity.
And, finally, the promised musical ending