The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.
—Sir William Osler
Despite the extraordinary scientific and technological advances in modern medicine, the core skills and sine qua non for the delivery of quality pediatric health care remain those of skillful communication and building and maintaining therapeutic and caring relationships with children, adolescents, and their families. The quality of the relationship with the child and family affects all aspects of patient care—the diagnostic process, treatment decisions, adherence with recommendations, and both patient and physician satisfaction.
Evidence-based studies show a direct association between the physician’s competency with communication and relationship building and healthcare quality and outcomes. Good communication between physicians and their patients improves the physician’s diagnostic acumen and promotes more efficient, accurate, and supportive interviews. Most physicians agree that good communication with their patients is a desirable goal.
In this chapter, we briefly consider the evidence for enhancing physician-patient communication, the concepts of patient-centered and relationship-centered care, interpersonal and communication skills, a framework for enhancing attention to values in healthcare interactions, and several evidence-based models for communication and relational skills. We examine specific strategies and techniques for communicating and building relationships with children and families throughout the pediatric interview. The overlay of children’s understanding of illness and the related developmental stages of childhood are presented.
Why Learn Communication Skills?
In one of the earliest research studies on physician-patient communication, pediatrician Barbara Korsch described communication lapses in the care of children in an emergency department. The central tenet of her groundbreaking paper, that communication is an essential factor in quality of care, is supported by numerous evidence-based studies, including the Institute of Medicine’s 2001 report Crossing the Quality Chasm. Studies show that good communication between physician and patient correlates directly with symptom improvement; better management of chronic conditions; improved efficiency of care, including a significant reduction in diagnostic testing and referrals; increased patient satisfaction and adherence; greater physician satisfaction; and fewer medication errors and malpractice claims. The majority of malpractice claims arise from communication errors.
In pediatrics, effective physician-parent communication is associated with parental satisfaction with care, adherence to treatment recommendations, and enhanced discussion of psychosocial issues. Parents highly value physicians who attend to both their own and their child’s feelings and concerns and who seek to understand their perspective. Greater parent satisfaction with care is positively associated with more active communication between physician and child, adequate attention to parental concerns regarding the child’s illness, and parents’ perceptions of the physicians’ interpersonal sensitivity, partnership building, and ability to provide information.
Kahn and colleagues found that psychosocial issues motivate 65% of primary care pediatric visits, and 85% of mothers with young children indicate they would welcome or not mind being asked about emotional and psychosocial stressors. Studies show that parents are more likely to disclose psychosocial issues when the pediatrician directly questions, shows interest and attention while listening, and shows interest in managing parenting and behavioral concerns.
In 2008, the Committee on Bioethics of the American Academy of Pediatrics published a technical report that reviewed evidence for effective communication in various pediatric situations, provided additional practical suggestions, and, like previous authors, called for greater emphasis on communication with patients and families in pediatric education, practice, and research. Rider, Volkan, and Hafler studied pediatric residents’ attitudes about communication skills and their perceptions of the importance of learning, and confidence in, 15 specific pediatric communication skills. Most residents reported confidence in core communication skills (interviewing, listening, building rapport, and demonstrating caring and empathy), yet half or fewer felt confident about their skills in 7 more advanced communication competencies (ability to discuss end-of-life issues, speaking with children about serious illness, giving bad news, dealing with the “difficult” patient/parent, cultural awareness/sensitivity, understanding psychosocial aspects, and understanding patients’ perspectives).
International guidelines, consensus statements such as the Kalamazoo Consensus Statement, and certification standards reflect the increasing emphasis on interpersonal and communication skills at all levels of medical training. The Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) in the United States, and accreditation organizations internationally, require medical schools and residency programs to teach and assess interpersonal and communication competencies. Licensing and medical specialty boards also require competency in these areas.
Interpersonal and communication competencies in pediatric education continue to evolve. Rider and Keefer provide further definitions of effective communication with diverse patients and families, understanding and responding to emotions, interprofessional communication and working effectively as a leader or member of healthcare teams, and acting as a consultant to other physicians and healthcare professionals.
Patient-Centered and Relationship-Centered Care
Patient-centered care places a focus on the patient’s disease and illness experience. Each patient is acknowledged as a unique individual, and the patient’s and family’s perspectives, culture, personalities, and related factors are relevant to the process of health care. As noted in the Pew-Fetzer Task Force’s document, Health Professions Education and Relationship-Centered Care, “The phrase ‘relationship-centered care’ captures the importance of the interaction among people as the foundation of any therapeutic or healing activity” (p. 11).
With its focus on how physicians and patients relate to each other, relationship-centered care is a natural next step for conceptualizing health care. Beach and colleagues note that the focus on the patient expands to include ways in which both physician and patient relate together and also includes additional relationships around the patient and doctor.
Relationship-centered care in the clinician-patient relationship includes the following concepts: relationships are the medium of care; relationships are therapeutic; both patients and physicians are active participants; and partnership and respect for patients’ participation in decision-making are valued. In addition, the physician’s capacity for self-awareness and self-reflection is an important component of relationship-centered care and includes an awareness of ideas, feelings, and values that influence the relationship, being “present” for self and others, and paying attention to one’s own behavior. The relationship-centered clinician understands that the way in which they participate in an interaction with patients essentially shapes the course and outcome of care.
Interpersonal and Communication Skills
The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients.
—Francis W. Peabody (1927)
Medicine has traditionally defined interpersonal and communication skills as a set of specific behaviors or tasks. Dyche, Duffy and colleagues, and Rider describe how interpersonal and communication skills are distinct, even though they are considered components of the same competency for all physicians to master. Communication skills are behavioral and task-oriented (eg, making eye contact, greeting each person in the room). Alone, these behaviors can neither build nor maintain a therapeutic relationship. Rider notes that the ability to form a deeper level of relationship and connection with patients and families goes beyond developing a set of communication behaviors with which to carry out the interview.
Interpersonal skills are relationship and process oriented and include a focus on humanistic qualities and the effects of communication on others. Examples of interpersonal skills include empathy, with an accurate understanding of patients’ and families’ emotions, caring, and emotional responsiveness; and as Rider and Keefer note, the capacity to provide a sustainable relationship that includes authenticity and honesty and allows repair when mistakes are made.
Values as the Foundation of Care
Browning notes that all healthcare interactions between patients and healthcare professionals, and among healthcare teams and colleagues, occur within a broader moral universe of human standards that include personal integrity, professionalism, and the everyday ethics of practice. Attention to core values and skilled communication are vital to the practice of high-quality, safe, compassionate healthcare. Excellent relationships and communication, grounded by attention to values and patient engagement, improve health outcomes, patient safety, and patient and clinician satisfaction. The International Charter for Human Values in Healthcare delineates core values fundamental to all healthcare interactions, and provides a framework of values that is used to inform clinical practice, training, research, and organizational change efforts.
Rider, Kurtz, Slade, and colleagues describe the development of the Charter and the identification of 5 categories of core values—Compassion, Respect for Persons, Commitment to Integrity and Ethical Practice, Commitment to Excellence, and Justice in Healthcare—that are central to every healthcare interaction. Attention to values along with skilled communication not only inform everyday practice, but can help guide and support physicians’ and other clinicians’ approaches to unexpected, difficult situations such as conversations about end-of-life decisions.
The late pediatrician Steven Z. Miller, a long-time advocate of compassionate clinical care, developed with Hilary Schmidt a conceptual framework to encourage the infusion of humanism into every patient encounter and into the medical culture as a whole. Their “habit of humanism” includes the following:
Identifying the multiple perspectives in each encounter (ie, that of the patient, family member or other support person, and physician).
Reflecting on possible conflicts that could help or hinder forming a relationship with the patient.
Choosing to act altruistically (ie, supporting the patient’s perspective above all, even if it conflicts with the physician’s agenda or personal interest).
FRAMEWORKS FOR INTERPERSONAL AND COMMUNICATION SKILLS AND RELATIONSHIP ABILITIES
The pediatric encounter is unique in medicine. Communicating with children and their families is complex, routinely involves the physician-parent-child triad and other family members, and is influenced by the developmental and cognitive stage of the child. The interaction dynamics of physician-parent-child communication are particularly challenging when the child and the parent have different needs.
In addition to covering medical issues, anticipatory guidance, and parent education, the pediatric interview often includes psychosocial and developmental concerns. Increasingly, more children are seen for behavioral, developmental, and psychosocial problems, especially in primary care. The varied needs and perspectives of both children and family members and the complexity of issues require physician flexibility and the ability to adjust interview and physical examination techniques as needed.
A variety of communication models or frameworks exist and can be learned and/or adapted for pediatric care. These frameworks are evidence based and include specific communication competencies associated with improved health outcomes. The conceptual frameworks for interpersonal and communication skills presented here can be used or adapted for clinical practice, teaching, and assessment.
Expanded Definitions of Interpersonal and Communication Skills Competencies
Rider and Keefer used an expert consensus group model with an international group of medical education leaders to further define and expand the original ACGME interpersonal and communication skills competencies. The international expert consensus group’s expanded competencies that address the physician-patient relationship are presented in Table 3-1.
TABLE 3-1INTERPERSONAL AND COMMUNICATION SKILLS COMPETENCIES: EXPANDED DEFINITIONS ||Download (.pdf) TABLE 3-1INTERPERSONAL AND COMMUNICATION SKILLS COMPETENCIES: EXPANDED DEFINITIONS
|Expanded Competencies and Subcompetencies |
1. Create and sustain a relationship that is therapeutic for patients and supportive of their families.
(a) Be “present,” paying attention to the patient, caring for the patient, and working collaboratively and from strengths.
(b) Accept and explore the patient’s feelings, including negative feelings.
(c) Provide a sustainable relationship that allows for repair when mistakes are made, and includes authenticity, honesty, and admission of and sorrow for mistakes.
(d) Communicate with the patient’s family honestly and supportively. In some cases (eg, pediatrics and geriatrics), the doctor-patient relationship is imbedded in and extends to the family; in other circumstances, the doctor’s relationship with the family may be separate from that with the patient.
2. Use effective listening skills to facilitate relationship. Elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills. Respond promptly to patients’ queries and requests.
(a) Demonstrate effective listening by hearing and understanding in a way that the patient feels heard and understood. Use nonverbal cues such as nodding, pausing, and maintaining eye contact, and verbal skills including back-tracking, reflecting, and mirroring.
(b) Recognize the patient’s preferred (or current) mode of communication and selectively choose the most effective mode of communication for the situation. Assess patient’s understanding of problem and desire for more information; explain using words that are easy for the patient to understand.
(c) Understand the patient’s perspective, including the patient’s individual concerns, beliefs, and expectations; respect the patient’s cultural and ethnic beliefs, practices, and language.
(d) Create an atmosphere of mutuality and respect through patient participation and involvement in decision-making.
Include patient in choices and decisions to the extent he or she desires.
Collaboratively set agenda for encounters.
Negotiate mutually acceptable plans in partnership with patient.
3. Work effectively with others as a member or leader of the healthcare team or other professional group. In all areas of communication and interaction, show respect and empathy toward colleagues and learners.
The Four Habits Model, described by Frankel and Stein, organizes communication tasks into 4 interrelated groups of skills and provides techniques for performing these “habits” as well as the benefits of each (Tables 3-2 and 3-3). The Four Habits Model was originally created for use within Kaiser Permanente and was derived from a blend of clinical experience and empirical literature.
TABLE 3-2THE FOUR HABITS MODEL ||Download (.pdf) TABLE 3-2THE FOUR HABITS MODEL
|Habit ||Skills ||Techniques and Examples ||Benefits |
|Invest in the Beginning ||Create rapport quickly || |
Introduce self to everyone in the room.
Refer to the patient by last name and title (eg, Mr. or Ms.) until a relationship has been established.
Make a social comment or ask a nonmedical question to put the patient at ease.
Convey familiarity by commenting on prior visit or problem.
Consider the patient’s cultural background and use appropriate gestures, eye contact, and body language.
Establishes a welcoming atmosphere
Allows faster access to real reason for visit
Increases diagnostic accuracy
Requires less work
Minimizes “Oh by the way …” at the end of the visit.
Facilitates negotiating an agenda
Decreases potential for conflict
|Elicit the patient’s concerns || |
Start with open-ended questions:
“What would you like help with today?”
“I understand that you’re here for… . Could you tell me more about that?”
Speak directly with the patient when using an interpretor.
|Plan the visit with the patient || |
Repeat concerns back to check understanding.
Let the patient know what to expect: “How about if we start with talking more about ___, then I’ll do an exam, and then we’ll go over possible ways to treat this? Sound OK?”
Prioritize when necessary: “Let’s make sure we talk about ___ and ___. It sounds like you also want to make sure we cover ___. If we can’t get to the other concerns, let’s …”
|Elicit the Patient’s Perspective ||Ask for the patient’s ideas || |
Assess the patient’s point of view:
“What do you think might be causing your symptoms?”
“What concerns you most about this problem?”
“What have you done to treat your illness so far?”
Ask about ideas from loved ones or from community.
Express respect toward alternative healing practices.
Allows the patient to provide important diagnostic clues
Uncovers hidden concerns
Reveals use of alternative treatments or requests for tests
Improves diagnosis of depression and anxiety
|Elicit specific requests || |
|Explore the impact on the patient’s life || |
|Demonstrate Empathy ||Be open to the patient’s emotions || || |
Adds depth and meaning to the visit
Builds trust, leading to better diagnostic information, adherence, and outcomes
Makes limit-setting or saying “no” easier
|Make an empathetic statement || |
|Convey empathy nonverbally || |
|Invest in the End ||Deliver diagnostic information || || |
Increases potential for collaboration
Influences health outcomes
Reduces return calls and visits
Enhances confidence and trust
|Provide education || |
Explain rationale for tests and treatments in plain language
Review possible side effects and expected course of recovery.
Discuss options that are consistent with the patient’s lifestyle, cultural values, and beliefs.
Provide written materials in the patient’s preferred language when possible.
|Involve the patient in making decisions || |
Discuss treatment goals to ensure mutual understanding and agreement.
Assess the patient’s ability and motivation to carry out plan.
Explore barriers: “What do you think would help overcome any problems you might have with the treatment plan?”
|Complete the visit || |
Summarize visit and review next steps.
Verify comprehension by asking the patient to repeat instructions.
Ask: “What questions do you have about what we discussed today?”
Give the patient a written summary of the visit, including relevant Web sites.
Close the visit in a positive way: “It’s been nice seeing you. Thanks for coming in.”
TABLE 3-3A COMPARISON OF THE COMMUNICATION AND RELATIONSHIP COMPETENCIES OF THE FOUR HABITS MODEL AND THE KALAMAZOO CONSENSUS STATEMENT FRAMEWORK ||Download (.pdf) TABLE 3-3A COMPARISON OF THE COMMUNICATION AND RELATIONSHIP COMPETENCIES OF THE FOUR HABITS MODEL AND THE KALAMAZOO CONSENSUS STATEMENT FRAMEWORK
|The Four Habits Model ||Kalamazoo Consensus Statement Framework |
Habit 1. Invest in the Beginning
1. Build a relationship (throughout interview)
Greet and show interest in patient as a person
Use words that show care and concern throughout the interview
Use tone, pace, eye contact, and posture that show care and concern
2. Open the discussion
3. Gather information
Habit 2. Elicit the Patient’s Perspective
4. Understand the patient’s perspective
Ask about life events, circumstances, other people that might affect health
Elicit patient’s beliefs, concerns, and expectations about illness and treatment
Respond explicitly to patient statements about ideas, feelings, and values
Habit 3. Demonstrate Empathy
Be open to the patient’s emotions
Make an empathic statement
Convey empathy nonverbally
1. Build a relationship
4. Understand the patient’s perspective
Habit 4. Invest in the End
5. Share information
6. Reach agreement
7. Provide closure
Kalamazoo Consensus Statement
The Kalamazoo Consensus Statement, developed by a group of 21 medical education leaders and communication experts from the United States and Canada, identifies 7 evidence-based “essential elements” of effective physician-patient communication and provides tasks for each element. The essential elements are (1) build a relationship, (2) open the discussion, (3) gather information, (4) understand the patient’s perspective, (5) share information, (6) reach agreement, and (7) provide closure. The framework considers building a relationship an ongoing task throughout each encounter (see Table 3-3).
Similarly, the Academic Pediatric Association, with help from 300 pediatric experts, developed guidelines for education in pediatric residencies. These guidelines include core communication skills that were developed, in part, from the Kalamazoo Consensus Statement framework.
COMMUNICATION SKILLS AND RELATIONSHIP STRATEGIES IN THE PEDIATRIC ENCOUNTER
The models for communication and relationship skills presented in the previous section can be used or adapted for clinical practice with children and their families. The combined components of the Four Habits Model and the Kalamazoo Consensus Statement framework are presented in Table 3-3. The components of these frameworks overlap significantly because they stem from the same literature. We can use these frameworks as a guide to examining techniques and strategies for working with children and their family members.
Building Relationships with Children and Families
Building and sustaining relationships and building a therapeutic alliance with children and their family members remain ongoing tasks within all clinical encounters. Components that underlie an effective physician-parent-child relationship include getting to know the patient and parent as individuals, expressing interest in the child as a person, giving attention to the child’s and family’s values, and understanding the way each family member experiences the child’s illness. Other important components of effective relationships include listening skills, nonverbal communication, and understanding the role of play and children’s different developmental stages. As noted by Rider, Kurtz, Slade, and colleagues, awareness of and attention to core values such as compassion, respect, integrity, excellence, and justice remain essential in healthcare interactions.
The Child’s Participation
Children understand more about concepts of health and illness than previously thought and can provide unique and valuable information about themselves. When appropriate, children should be involved in decisions about their own health care. Studies show that direct communication between physician and child contributes to improved relationships, treatment adherence, satisfaction with care, and better health outcomes.
Physicians can collaborate with parents to help children have a voice in medical encounters. Differing communication needs of the child and parents sometimes present a challenge to relationship-centered care in pediatrics. Physicians can facilitate the child’s participation and at the same time address parents’ needs and call on parents’ expertise and knowledge of their child.
Strategies that enhance the child’s participation in the pediatric encounter include addressing the child by name, inviting the child to state the problem, and encouraging the child to participate in the conversation both verbally, by directing questions to the child, and nonverbally, by using eye contact, nodding, and smiling. Physicians should give advice and explain treatment plans to the child in words he or she can understand. Utilizing these and similar strategies allows physicans to model for parents the direct inclusion of the child.
I suspect that the most basic and powerful way to connect to another person is to listen. Just listen. Perhaps the most important thing we ever give each other is our attention. And especially if it’s given from the heart…. We connect through listening.
—Rachel Remen, MD
Effective listening skills facilitate relationships and promote collaboration between physician and patient. Listening inattentively or without mindfulness may lead to suboptimal diagnostic and treatment decisions.
Active listening enables the physician to hear and address the concerns of children and their families. Listening includes being “present” and attending fully. Physicians demonstrate effective listening by reflecting, summarizing, and checking whatever seems unusual in the context of the patient’s story so that the patient can correct or add information that completes the picture. Patients appreciate the physician’s attempts to understand.
Effective use of nonverbal communication helps to promote an environment of trust and support. Nonverbal communication includes body language as well as tone, pace, and pitch of speaking. To focus the interview on the patient as well as the illness, the physician must demonstrate, nonverbally, that what the patient and parents have to say is important. Use of nonverbal cues such as nodding, pausing, maintaining eye contact, and posture show attentiveness and concern. Congruence between words, tone, and body language is important for effective communication. Strategies for nonverbal communication that promote relationship building are presented in Table 3-4.
TABLE 3-4STRATEGIES FOR NONVERBAL COMMUNICATION THAT PROMOTE RELATIONSHIP BUILDING ||Download (.pdf) TABLE 3-4STRATEGIES FOR NONVERBAL COMMUNICATION THAT PROMOTE RELATIONSHIP BUILDING
|Nonverbal Communication Strategies |
Acknowledge and briefly interact with the child at the beginning of the visit.
Establish eye contact with the infant and child from across the room. Talk with the parent and acknowledge and smile at the child, while the child becomes more comfortable with your presence. This strategy brings the child into the interaction nonverbally.
Adapt your own pace, tone, and posture in response to the child and parent. Tone and pace of speech sometimes communicate feelings more effectively than the words themselves.
Be present, appear unhurried, and convey interest and caring.
During the physical examination, respect the child’s personal distance. If your face is too close to an infant’s face, she may look away and cry. Toddlers often avoid unfamiliar people in their personal space. A good strategy is to look away when you are close (eg, listening to heart and lungs). Approach school-aged children calmly and respectfully.
Adults appear large to small children. Make yourself appear less threatening by sitting at the child’s eye level while the child remains in the parent’s lap, or having the child sit on the examination table with the parent nearby.
Avoid interruptions of patient visits. This includes interruptions from phone calls and beepers, reading the chart, or using the computer while listening to or talking with the child and family.
The Four Habits Model identifies 3 tasks to accomplish at the beginning of the interview: create rapport quickly, elicit the patient’s concerns, and plan the visit with the patient. The Kalamazoo Consensus Statement identifies similar tasks in its first 3 essential elements for communication in medical encounters: build a relationship, open the discussion, and gather information (see Table 3-3).
Rapport begins from the opening moments of the interview and includes mutual interest and respect among the physician, child, and parents. The pediatric visit often includes a variety of individuals (eg, siblings, 1 or both parents, or other caregivers). Open the interview with an inclusive greeting and introduction, acknowledge everyone in the room, use their names, and find out how they are related to the patient. Greet and welcome the child. Even with infants, the physician can smile and interact with the infant for several seconds. This also gives the physician a moment to assess the child.
Address and acknowledge siblings in the room: “I see your baby brother came today. Does he make lots of noise?” “Sometimes babies do funny things!” Siblings can be disruptive if they feel displaced by a new baby or another sibling, so your early interaction with a patient’s sibling may have an important calming effect on the entire visit. Your role modeling also engages and assists the parents.
Elicit Concerns and Plan the Visit
Important components of investing in the beginning of the interview include planning the visit and setting an agenda with the parents and patient. Dyche and Swiderski’s study showed that physicians who solicited an agenda from their patients and allowed them to complete a statement of concerns were able to report their patients’ problems more accurately, while failure to ask the patients’ agenda correlated with a 24% reduction in physician understanding.
In today’s healthcare environments, the short time allowed for many office visits and time a parent needs to discuss issues may prove incompatible. Prioritizing concerns, both parents’ and physician’s, and being explicit about the time allowed for a visit, conveys respect to the patient and saves time. The physician can invite the child and parent to return for subsequent visits if concerns remain.
The words physicians use are important. For example, a parent will experience the words “I wish we had time to talk about your concerns about your child’s sleep today. Let’s make a follow-up appointment to talk further” differently from the words “I don’t have time to deal with all these problems now.” The following questions may help to plan the visit.
Agenda-setting questions: “What is concerning you today?” “Anything else?” “I see you have a list; is there anything else you would like us to talk about today?” “Your child was scheduled for a 10-minute visit. I want to make sure I’ve heard all of your concerns, and then we can decide together what we can accomplish today.”
Prioritizing questions: “What is most important for us to address today?” “What is at the top of your list?” The physician may need to take the lead in efficiently negotiating and prioritizing both the physician’s agenda and the parents. “Let’s make sure we discuss A and B; if we don’t get to C, we can talk by phone or set up another visit.”
Understand the Patient’s and Family’s Perspective
Effective communication requires an understanding of the patient in his or her world context. Understanding the patient’s and family’s perspectives includes understanding their individual concerns, beliefs, values, and expectations about diagnosis and treatment, and also depends on the child’s developmental stage. Inherent is respect for the patient’s and family’s cultural and ethnic beliefs.
The Four Habits Model identifies 3 skills to elicit the patient’s perspective: assessing patient attribution, identifying the patient’s requests for care, and exploring the impact of the patient’s symptoms on his or her life and well-being. The Kalamazoo Consensus Statement adds asking about life events, circumstances, and other people that might affect health, and responding explicitly to the patient’s statements about ideas, feelings, and values (see Table 3-3).
Listen to the patient’s or family’s story, identify their major concerns, and ask about their understanding of the causes of illness and possible treatment. “What concerns you the most about your child’s illness?” “What do you think has caused the problem?”
Elicit expectations about illness and treatment. Find out what the patient and family want: “How were you hoping I might help?” Explore the impact of the illness on the patient and family, considering their physical, emotional, and social well-being. How do they experience the child’s illness? Respond explicitly to the patient’s and parents’ expressed thoughts and feelings: “You seem worried about….”
As noted by Rider (2002), even young children reveal clues about their concerns and perspectives through their questions and comments:
After a 3-year-old well-child visit, Sarah’s mother shares that Sarah has seemed anxious and worried since the 9/11 terrorist attacks. We talk further. I kneel down to Sarah’s eye level and tell her, “Your mommy is safe, your daddy is safe, and you are safe.” She looks at me with big, attentive eyes and I know I have connected. With solemn seriousness, she slowly pulls her lollipop out of her mouth and says, with great emphasis, “And my kitty cat.” “Yes, your kitty cat is safe too.”
Demonstrate Empathy and Compassion
Demonstrating empathy and compassion help the child and family to feel validated and understood. Evidence-based studies support the positive value of empathy in health care and suggest an association between the physician’s caring and empathy and the effectiveness and appropriateness of care. Conveying empathy increases diagnostic accuracy and patient adherence, yet remains time efficient. Empathy also has been shown to increase both patient and physician satisfaction.
Conveying empathy requires the physician to perceive the patient’s emotions and experience and then respond to them in ways that the patient and family feel understood. Much of empathic communication is subtle and subject to cultural differences, particularly in its nonverbal components. Because of this subtlety, empathy may be lost if the physician is preoccupied with the cognitive work of organizing complex data about diagnosis and treatment, and the patient is preoccupied with confusion, worry, or perceived social rules for medical visits. The ability to convey empathy and compassion in countless diverse and complex medical interview situations requires a mindful approach to interactions, listening to feedback, and continuing practice.
The words we use with patients help us to recognize patient clues and to elicit and respond to the patient’s emotions. What we say may promote empathic discussion, or miss it, or actually end it. By exercising basic empathic skills, physicians can attend to connectedness and relationship and remain empathic in spite of obstacles. Possessing a toolbox of strategies to promote empathic communication promotes the physician’s efficiency and enhances satisfaction. Strategies and words to use to convey empathy and to handle emotions are presented in Table 3-5.
TABLE 3-5STRATEGIES THAT CONVEY EMPATHY AND FACILITATE HANDLING EMOTIONS ||Download (.pdf) TABLE 3-5STRATEGIES THAT CONVEY EMPATHY AND FACILITATE HANDLING EMOTIONS
|Strategy ||Content and Words to Use |
|Elicit emotions || |
Recognize when the child or parent has emotions that are present but not directly expressed in words. The child may hide behind the examination table or cling to a parent. A parent may appear distracted or skeptical.
Invite exploration of unexpressed feelings.
With the child we can ask, “Are you worried?” “How are you doing right now?” “Anything else?”
With the parent, we can ask, “What are you most concerned about?” “What has this been like for you?” “Can you tell me more?” or note, “You look skeptical.”
Explicitly acknowledge and accept feelings: “You seem worried by this; you’ve been through a lot.”
Accept children’s expressions of upset or grief. Crying usually brings relief and can be helpful to the child. Avoid overreacting to tears or trying to distract children from their feelings. Ignore temper tantrums.
|Respond to the child’s and parent’s emotions || |
“I can see that this is bothering you.”
“That sounds really hard.”
“It seems like that might feel …”
“You must feel proud about that. That’s great!”
“You were really brave. Good for you!”
“It’s okay to cry. No one likes to have a shot.”
“I am here to help you in any way I can.”
“Most people feel overwhelmed when this happens.”
“You must have been up all night too (with your child). I imagine you are tired.”
|Reflect content and check in with child and parent || |
“It sounds like you think … Did I leave anything out?”
“What I am hearing is … Do I have it right?”
“I want to make sure I understand what you have shared with me.”
“Are you worried about having a shot?”
“You sound sad (or unhappy, skeptical, etc).”
Invest in the End of the Visit
Investing in the end of the visit includes sharing information and providing education, partnering with the child and family members, and including them in choices and decisions to the extent they desire. The physician also works with the child and parents to reach agreement on plans and to complete the visit by summarizing, clarifying follow-up plans, and providing closure.
Share Information and Provide Education
Determine the patient’s and family’s understanding of the issues and their desire for additional information: “Is there a particular issue you would like information on now?” “What is your understanding of why your child is receiving this medication?” Consider the child’s developmental and cognitive perspective, and use this knowledge when sharing information. Provide education for both child and parents, including the rationale for diagnostic tests and treatment options, expectations, and resources.
The impact of the physician’s words is often powerful, and patients and worried parents may be easily frightened by careless word choices, especially about prognosis. Share diagnostic and treatment information gently, and use words that are easy for the child and family to understand. Intersperse the telling of information with asking about understanding and impact. Patients value these demonstrations of respect and consideration.
Establish a Partnership with the Child and Family
Tuckett and colleagues describe the clinical encounter as a “meeting between experts.” The patient is an expert in describing his or her problems, experience of disease, and preferences. The physician is an expert in disease identification and management and in sorting the patient’s issues into a format that provides therapeutic direction.
Studies show that involving the patient and parents in making decisions corresponds with improved outcomes. Invite active child and family collaboration throughout the encounter, with attention to involving them in decision making to the extent they wish. Most patients prefer information and discussion, and some prefer mutual or joint decisions. Strategies for partnering with patients include inviting the child and parents to help establish the agenda for the visit, checking for mutual understanding of information about diagnosis and treatment, exploring barriers, and collaborating in negotiation about mutually acceptable diagnostic and treatment plans.
Provide Closure for the Visit
Ask if the patient has additional questions or concerns, summarize what was discussed, and clarify any follow-up plans. Complete the visit by acknowledging the patient and reassuring the patient of ongoing care.
COMMUNICATING WITH CHILDREN AT DIFFERENT DEVELOPMENTAL STAGES
Children’s Concepts of Illness
Children’s understanding of illness and their cognitive, social, and emotional abilities vary by developmental stage. Understanding children’s perspectives at different ages helps the pediatrician to communicate more effectively and accurately. During the pediatric visit, the physician can educate parents about child development and support good parenting. Table 3-6 presents information about children’s cognitive development and their concepts of illness at different developmental stages.
TABLE 3-6CHILDREN’S COGNITIVE DEVELOPMENT AND CONCEPTS OF ILLNESS AT DIFFERENT AGES ||Download (.pdf) TABLE 3-6CHILDREN’S COGNITIVE DEVELOPMENT AND CONCEPTS OF ILLNESS AT DIFFERENT AGES
| ||Preschool Children (3–5 Years) ||School-Aged Children (6–12 Years) ||Adolescents (≥ 13 Years) |
|Cognitive development ||Magical thinking; circular reasoning ||Begins to think relationally and to generalize ||Capable of cognitive problem solving and decision making |
|Sees 1 or 2 aspects at a time; may ignore the whole of the situation ||Emergence of clear differentiation between self and others ||Can think abstractly and hypothetically |
|Does not differentiate well between self and outside world; lives in the immediate environment ||Begins to integrate variables in causal relationships ||Uses generalization to fill in gaps in knowledge |
|Child’s concept of the cause of illness ||Does not spontaneously conceptualize the internal parts of the body ||Can distinguish what is internal and external to self ||Integrates multiple factors/causes in understanding illness; imagines alternative possibilities |
|Illness results from wrongdoing; medical procedures are seen as a punishment ||Cause of illness is a person, object, or action outside of the child: “You get a cold from not wearing a hat;” “You breathe too much air in your nose.” ||Cause of illness lies in internal physiologic organ or process; may have additional psychological cause |
|Illness is caused by external concrete phenomenon: contagion, magic, “from the sun,” “from outside” ||Cause of illness is the presence of “germs” ||Understands illness as internal systems that dysfunction and cause external symptoms: “A virus gets into the bloodstream and causes a cold.” |
Approaches to Children at Different Stages
Both child and family members have different needs based on the child’s developmental stage. Each developmental stage requires different interviewing, examination, and counseling approaches. Placement of the child in the room, relationship-building strategies, play and interaction techniques, and history taking are important variables to consider (Table 3-7).
TABLE 3-7APPROACHES TO THE PEDIATRIC INTERVIEW WITH CHILDREN AT DIFFERENT DEVELOPMENTAL STAGES ||Download (.pdf) TABLE 3-7APPROACHES TO THE PEDIATRIC INTERVIEW WITH CHILDREN AT DIFFERENT DEVELOPMENTAL STAGES
| ||Infants (0–15 Months) ||Toddlers (15 Months–2 Years) ||Preschool Children (3–5 Years) ||School-Aged Children (6–12 Years) ||Adolescents (≥ 13 Years) |
|Location of child during interview ||Parent’s lap or arms ||Parent’s lap or arms ||Freely moving about room ||Exam table ||Exam table |
|Exam table ||Freely moving about room ||Exam table ||Chair ||Chair |
|Relationship-building strategies ||Talk with child ||Talk with child ||Talk with child ||Talk with child ||Talk with adolescent |
|Play ||Play ||Playful interaction ||Playful interaction ||Ask about school, relationships with peers, family, feelings, activities |
|Make sounds ||Share books, toys ||Share books, toys ||Share books, toys || |
|Share board books, toys || || || || |
|Play and interaction strategies ||Respond to baby’s sounds, smile ||Pretend-play, guessing games ||Engage in discussion ||Engage in discussion ||Engage in discussion by using nonintrusive questions, listening, reflecting back |
|Play peek-a boo, pat-a-cake, hiding games ||Tell stories ||Make-believe games, hide-and-seek, counting and number games, mimic animals, hand puppets, read ||Make-believe games, improvise, jokes and riddles, magic tricks, guessing games, talk about hobbies, sports |
|Hide and find things |
|Name objects as you give them to baby || |
|Can obtain some history from child ||No ||Minimal; ask older toddler, “Can you put your finger on where it hurts?” ||Yes ||Yes ||Yes |
The use of play is a particularly effective strategy for communicating with young children. Children use play to gain understanding of themselves and others, to learn about the world, and to explore their abilities to cope with its complexities. As you observe young children at play, you will see family-related themes and action plans for helping and healing and for avoiding fears. Children’s play becomes increasingly complex and varied as they grow older. Creating a playful atmosphere helps the physician to complete necessary tasks and enhances enjoyment for both the child and the physician (Table 3-8).
TABLE 3-8USING DEVELOPMENTALLY BASED COMMUNICATION DURING THE 2-YEAR-OLD WELL-CHILD VISIT ||Download (.pdf) TABLE 3-8USING DEVELOPMENTALLY BASED COMMUNICATION DURING THE 2-YEAR-OLD WELL-CHILD VISIT
Using the language of play and metaphor builds relationships and enables physicians to examine young children in ways that create positive experiences.
“No doctor! No doctor!” exclaims my next patient, his small hands pressed tightly over his ears, a determined scowl on his face. Ryan is 2 years old. I smile at him and say, “Hi.” “No doctor!” he replies. After talking with his mother and letting him get used to me, I approach him slowly. He looks at me with big blue eyes beneath his brown, spiking crew cut.
“Would you like to see a pink finger?” I ask as I put my finger on the otoscope light and it lights up pink. I note, playfully, how silly that is. A skeptical smile forms on his face. We play peek-a-boo with the light and I examine his eyes. “Show me the biggest mouth in the world!” I exclaim. Ryan opens his mouth wide. His hands remain tightly clamped over his ears.
“Where is your heart? Is it here?” I ask, pointing to Ryan’s head. He looks at me and points to his chest. “We’d better check,” I note calmly and then exclaim, “I hear it right there!” “Do you have Elmo back here?” I ask as I listen for various Sesame Street characters on his back.
“Do you have birthday cake in your tummy?” I inquire. “Let’s check!” Ryan remains skeptical but allows his mother to lay him on his back on the examination table. I listen to his heart, then quickly search for birthday cake in his abdomen. “Do you have pizza in there? Milk? Goldfish?” He smiles and removes his hands from his ears.
When Ryan sits up again, I pull out the reflex hammer. “Would you like to see my hammer?” I say as I lightly tap it on my nose. “It’s very soft. Let’s check your knees!” Curiosity has the best of him, and he smiles as I check his reflexes.
“Do you have bunny rabbits in your ears?” I ask. “Which ear should we check first?” He points to his right ear. After I look for bunny rabbits in one ear, he turns his head so I can check the other. He’s now relaxed and more comfortable with me. “You’re perfect,” I tell him as we finish the examination.
Ryan’s mother and I talk, and she helps Ryan put on his coat. When he realizes our time is up, he lags, pulling on his mother’s arm so he can remain in the examination room. “More doctor! More doctor!” he exclaims.
Elizabeth A. Rider, MSW, MD
Expertise in interviewing is the key to the pediatrician’s psychotherapeutic effectiveness…. Skill in interviewing involves more than asking the right questions; it also requires an ability to empathize, to observe, and to listen carefully.
—Morris Green, MD
Skillful communication and relationship abilities are essential to the practice of high-quality pediatric care. Effective communication among child, family, and physician consists of a 2-way, relationship-centered process involving flexibility in interaction and relationships rather than simply information exchange.
Numerous studies support the importance of enhancing physician-patient communication and confirm the value of relationship-centered care. Building and sustaining relationships with children and their family members is an ongoing responsibility and is enhanced by the physician’s development of communication and relationship abilities. The physician’s skill in these areas improves with knowledge, reflection, and practice.
Parts of this chapter were adapted from Rider EA. Interpersonal and communication skills. In: Rider EA, Nawotniak RH, eds. A Practical Guide to Teaching and Assessing the ACGME Core Competencies. 2nd ed. Marblehead, MA: HCPro, Inc; 2010:1-137; and from Rider EA. Communication and relationships with children and parents. In: Novack DH, Clark W, Saizow R, Daetwyler C, eds. DocCom: an interactive learning resource for healthcare communication. 2006. Available at: http://webcampus.drexelmed.edu/doccom/user/. Accessed October 10, 2016.
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