Chapter 3. Communication

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 Osler1

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 health care 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, and several evidence-based frameworks 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,2 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.3 Studies show that good communication between physician and patient correlates directly with symptom improvement,4,5 better management of chronic conditions,6 improved efficiency of care including a significant reduction in diagnostic testing and referrals,7 increased patient satisfaction8 and adherence,9 greater physician satisfaction,10 and fewer medication errors11 and malpractice claims.12 The majority of malpractice claims arise from communication errors.13

In pediatrics, effective physician-parent communication is associated with parental satisfaction with care, adherence to treatment recommendations,9,14 and enhanced discussion of psychosocial issues.15 Parents highly value physicians who attend to both their and their child’s feelings and concerns16 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,17 and parents’ perceptions of the physicians’ interpersonal sensitivity, partnership building, and ability to provide information.16

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.18 Studies show that parents are more likely to disclose psychosocial issues when the pediatrician directly questions, shows interest and attention while listening,19 and interest in managing parenting and behavioral concerns.20 A useful resource on psychosocial pediatrics can be found at http://www.cehl.org/providers.shtml.

International guidelines, consensus statements,21,22 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 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.23 Licensing and medical specialty boards also require competency in these areas.

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: “The phrase ‘relationship-centered care’ captures the importance of the interaction among people as the foundation of any therapeutic or healing activity.”24(p11)

With its focus on how physicians and patients relate to each other, relationship-centered care is a natural next step for conceptualizing health care. The focus on the patient expands to include ways in which both physician and patient relate together and additional relationships around the patient and doctor.25

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 is 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.25

Communication Skills and Relationships

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 child and 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.26 The varied needs and perspectives of both children and family members and the complexity of issues require physician flexibility and ability to adjust interview and physical examination techniques as modeled in Box 3-1.

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.27

—Francis W. Peabody

Medicine has traditionally defined interpersonal and communication skills as a set of specific behaviors or tasks. Alone, these behaviors can neither build nor maintain a therapeutic relationship. 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.28

The late pediatrician Steven Z. Miller, a long-time advocate of compassionate clinical care, developed with Hilary and Schmidt29 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” include

1. 1. Identifying the multiple perspectives in each encounter (ie, that of the patient, family member or other support person, and physician).

   2. Reflecting on possible conflicts that could help or hinder forming a relationship with the patient.

   3. Choosing to act altruistically (ie, supporting the patient’s perspective above all, even if it conflicts with the physician’s agenda or personal interest).

A variety of communication models or frameworks exist and can be learned.23 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 ACGME Competencies

Rider and Keefer30 used an expert consensus group model with an international group of medical education leaders to further define and expand the 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.

The Four Habits Model

The Four Habits Model31,32 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.

Kalamazoo Consensus Statement

The Kalamazoo Consensus Statement,21 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 (Table 3-3).21,23

Similarly, the Academic Pediatric Association (formerly the Ambulatory Pediatric Association), with help from 300 pediatric experts, developed guidelines for education in pediatric residencies.33 These guidelines include core communication skills that were developed, in part, from the Kalamazoo Consensus Statement framework.

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 use these frameworks as a guide to examining techniques and strategies for working with children and their family members.

Building Relationships

Building and sustaining relationships with children and their family members remains an ongoing task within all clinical encounters. Components that underlie an effective physician-parent-child relationship include getting to know the patient and parent as individuals, interest in the child as a person, 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, respect, empathy, and understanding the role of play and children’s different developmental stages.34

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.35 Studies show that direct communication between physician and child contributes to improved relationships, treatment adherence, satisfaction with care, and better health outcomes.36,37

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.38

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. Give advice and explain treatment plans to the child in words he or she can understand.34 As you utilize these and similar strategies, you role model for parents the direct inclusion of the child.

Listening Skills

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.”39(p143)

—Rachel Remen

Effective listening skills facilitate relationships30 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.

Nonverbal Communication

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 nonverbal cues such as nodding, pausing, maintaining eye contact, and posture to show attentiveness and concern. Congruence between words, tone, and body language is important for effective communication.34 Strategies for nonverbal communication that promote relationship building are presented in Table 3-4.

Invest in the Beginning

The Four Habits Model identifies three 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 three essential elements for communication in medical encounters: build a relationship, open the discussion, and gather information (Table 3-3).

Opening the Interview

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, one 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.34

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.34

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. One 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.40

The short time allowed for many office visits and the issues a parent desires to discuss 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. We can invite the child and parent to return for subsequent visits if concerns remain.

The words we 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 than if the physician says, “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.”41
• 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, 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 three 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.32 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 (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. .”

Even young children reveal clues to their concerns and perspective through their questions and comments:

After a three-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.”42

Demonstrate Empathy and Compassion

Empathy helps 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.43,44 Empathy also has been shown to increase both patient45 and physician satisfaction.46

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.34 The ability to convey empathy 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.47 What we say may promote empathic discussion, or miss it, or actually end it.48 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.

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.34

Establish a Partnership

Tuckett and colleagues describe the clinical encounter as a “meeting between experts.”49 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.21,34

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.

Children’s Concepts of Illness

Children’s understanding of illness50,51 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.

Approaches to Children

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.52 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).

Children and Play

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.34,53

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.54

—Morris Green

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 two-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. Competency I: interpersonal and communication skills. In: Rider EA, Nawotniak RH, Smith GD. A Practical Guide to Teaching and Assessing the ACGME Core Competencies. Marblehead, MA: HCPro, 2007; and from Rider EA. Communication and relationships with children and parents. In: Novack DH, Clark W, Saizow R, Daetwyler C, eds. Doc.com: an interactive learning resource for healthcare communication. 2006. Available at: http://webcampus.drexelmed.edu/doccom/user/. Accessed February 9, 2008.