. Communication

Communication

Elizabeth A. Rider

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.

FRAMEWORKS FOR INTERPERSONAL AND COMMUNICATION SKILLS AND RELATIONSHIP ABILITIES

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. 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.

Box 3-1. Using Developmentally Based Communication during the Two-Year-Old Well-Child Visit

The Examination

The language of play and metaphor creates relationships and enables physicians to examine young children.

“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.

Table 3-1. Interpersonal and Communication Skills Competencies: Expanded Definitions

Create and sustain a relationship that is therapeutic for patients and supportive of their families.

Be “present,” paying attention to the patient, caring for the patient, and working collaboratively and from strengths.

Accept and explore the patient’s feelings, including negative feelings.

Provide a sustainable relationship that allows for repair when mistakes are made and includes authenticity, honesty, admission of and sorrow for mistakes.

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.

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