Definitions of Interpersonal and Communication Skills

The ACGME has set forth three main elements of the communication and interpersonal skills competency that postgraduate residents should demonstrate.¹ Also, a consensus statement known as the Kalamazoo statement and the Kalamazoo report was developed by leaders in medical education.² Although these documents were designed to apply generally across all medical specialties, the focus of this chapter will be the application to pediatrics.

There are three elements of the ACGME Interpersonal and Communication Skills competency that physicians should master, and each will be discussed in depth.

1. “Create and sustain a therapeutic and ethically sound relationship with patients and their families.”¹ There are several concrete behaviors that help develop therapeutic and ethical relationships. First, it is important to always focus your complete attention on the patient and family (being “in the moment”) during conversations. Second, it is essential to explore and understand the patient or parent’s ideas, concerns, values, and feelings, even if they are negative or unpleasant, because this demonstrates respect for the autonomy of the patient. Third, the relationship is strengthened when there are openness and honesty that allow for the admission and repair of mistakes and the expression of authentic sorrow.^1,2 Finally, an approach that recognizes and honors diversity is another skill that allows a physician to foster a therapeutic relationship. By the year 2020, 44.5% of American children 0 to 19 years of age will belong to a racial or ethnic minority group.⁴ Given these changing demographics, cultural competence is vital for developing successful relationships with families. The pediatrician must be aware of the many potential barriers to quality health care that a racial or ethnic minority family may confront, not only to understand how these may affect patients’ care, but also to advocate for them. These barriers may include poverty; geographic factors; racism and other forms of prejudice; nonnative languages, including cultural variations in verbal and nonverbal communication; low-literacy; and culturally based beliefs surrounding illness, health, and death.⁴

The relationship with the pediatric patient is unique because it involves connecting not only with the child but also with the immediate family, other caregivers, and/or extended family. This situation brings its own challenges and rewards. The relationship with a family is often dynamic as family members enter or leave the family circle. It may also involve the challenging task of working with members of the family who are in conflict with one another or working with a family in crisis. On a positive note, it can be very rewarding to help a family engage their strengths or overcome their weaknesses in support of their child (e.g., ceasing tobacco use in a family that includes a child with asthma).

2. “Use effective listening skills to facilitate the relationship. Elicit and provide information using effective non-verbal, explanatory, questioning, and writing skills. Respond promptly to patient’s queries and requests.”¹ This competency element may be, in part, accomplished using the model of child- and parent-centered interviewing. This model allows the patient/parent to lead the discussion to the concerns that are most important in his/her eyes. Rather than following the doctor’s agenda, it allows the patient to tell his/her own story. The parent is acknowledged as being the expert on his/her own child. The pediatrician is charged with finding an appropriate balance between centering the interview on the child or the parent, depending on the child’s level of development and ability to participate. This style requires several key skills. Active listening involves hearing the patient’s words in such a way that the patient feels understood. This may be accomplished by nonverbal cues and positive body language such as good eye contact, nodding, and leaning forward. Verbal skills include reflecting a patient’s words back to him/her, paraphrasing back to the patient in your own words what you think has been said, and therapeutic pauses. Other verbal skills that facilitate the dialogue include using open-ended and closed-ended questions appropriately, asking for clarification when needed, and avoiding interrupting the speaker.¹

Understanding the perspective of the family is also an important skill. Identify in a nonjudgmental way the emotions and feeling that you hear conveyed by the words, tone, or body language of the parent/child, and acknowledge this verbally to the speaker. For example, “You sound frustrated” (sad, angry, etc). Often bringing highly charged emotions out in the open both validates the speaker and subsequently diffuses the negativity of the situation so that you may move forward with the interview more productively.

The importance of effective communication of information back to the family cannot be overlooked. A correct diagnosis is in vain if the family is unable or unwilling to follow the treatment plan. Ensure that an agreement with the family is reached. The pediatrician should use language that is understandable, ask the parent to repeat what he/she heard, and ask for questions. Finally, the pediatrician should provide support in the form of appropriate follow-up care.^1–3

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.”¹ Excellent patient care depends on the cooperation and clear communication of the entire health-care team. Elements of a highly effective team include respect, honesty, and integrity. Respectful treatment includes being truthful and responsible, following through on commitments, honoring the expertise of other health-care professionals, being open to learning from others, and being collaborative in patient care.

Acknowledge and respect the unique contributions that each professional makes to the health-care team. In interactions with colleagues, the pediatrician should be proactive in communication and take full responsibility for being understood by others. Resolve conflicts quickly and directly by discussing the issue with the relevant parties, instead of with other staff or parents. Advocate for a consensus treatment plan that takes into account all subspecialists, ancillary health-care providers, or support personnel involved. Parents who get the same message from all of their providers view their child’s care as coming from a coordinated team, as opposed to receiving care piecemeal from a variety of individuals. Give and be open to receiving honest, constructive feedback from other health-care providers,¹ and agree to make adjustments to a plan with the team to provide the best and most integrated care possible.