Talking with Parents

Barbara Korsch

I. Description. It has been documented consistently for the last five decades that the doctor-patient relationship and communication are the strongest predictors of the outcome of a medical visit. The therapeutic alliance is achieved in large measure during the interview. Rapport building; engaging the patient; eliciting psychosocial and personal aspects of the patient’s experiences; supporting the parents in their roles as parents; and including the child, grandparent, and significant others—all of these are essential to establish a therapeutic relationship.

In many communities today, the clinician is faced with cultural and language barriers that complicate the interview. There are no easy solutions for this problem. For language problems, a skilled professional interpreter (preferably not a family member) is the only desirable approach. In the presence of an interpreter, it is essential that the physician maintain eye contact with the patient, continue to address the patient and family directly, and not discuss problems with the interpreter instead of the patient or caretaker (avoid saying “tell her that” or “ask him what”). Cultural sensitivities also pose unique challenges to effective healthcare and require the clinician to employ all his skills for assessing not only the individual patient’s perceptions, value systems, and health beliefs, but also those that are prevalent in his or her culture. This holds especially true when offering advice and counsel.

Although there are no techniques that work for all patients or all clinicians, there are some basics that virtually always strengthen the therapeutic alliance (Table 1-1), which has become even more important in the era of the electronic medical record (EMR) and assistive technology in the examination room.

II. Optimal communication with parents.

A. Listening. Letting the parent know that you are listening is basic. Body language—sitting down, looking at the parent, leaning forward, and showing appropriate concern—is effective in conveying a listening attitude and does not require extra time in the interview. Responding to nonverbal expressions of parent affect is also essential. For example, if the mother’s face falls when the clinician suggests the use of a pacifier for a colicky baby, the responsive clinician needs to inquire, “You do not seem to like that idea. Is there any special reason why you do not want your baby to use the pacifier?” He or she may find out that the mother had difficulty in weaning her firstborn from the pacifier or that she finds pacifiers disgusting. When screening, behavioral checklists have been used (see Appendices A and B); the parental responses can provide the topics for discussion.
B. Facilitating the dialogue. The parent’s story should be facilitated by appropriate empathetic responses, such as, “Tell me more about that” or “I can see that it did not work out so well for you,” or “That must be hard for you.” The clinician should avoid interruptions, subject changes, and judgmental comments and not prematurely pursue other diagnostic hypotheses, which can derail the parent’s narrative. Attentive listening during the opening of an interview promotes communication and rarely takes more than a couple of minutes. Yet it has also been shown that, on average, physicians interrupt the patients within a few seconds or minutes. The reason is conflicting agendas: patients want to tell their story, and clinicians want to pursue their medical task (diagnosis, prescription, or therapeutic recommendation). There are other strategies to facilitate a successful pediatric visit.
C. Elicit the parent’s concerns early in the interview. “What worried you especially when you brought John in to see us today? Why did that worry you?”

D. Elicit the parent’s expectations for the visit and acknowledge them. “What had you hoped we might be able to do for your child today? What would you like to have us explain to you today?” These inquiries may reveal unrealistic expectations for specific therapies or magical cures. At other times, such questions make the clinician’s job simple if what the family desires is reassurance. Once the parent’s expectations have been
acknowledged, the clinician, the parents, and the child can set an agenda for the visit, which synthesizes the parent’s concerns and biomedical issues. It is only after this opening—after listening attentively to the parent—that the clinician can afford to pursue his or her line of questions and fact finding. The first phase of the interaction has taken care of urgent concerns, relaxed the parent, and made her or him realize that the clinician is interested. The parent will now be a better historian and partner in the task-oriented portion of the interview. Experience shows that the above suggestions will make the interview more effective and so lead to earlier closure, which is becoming more and more important these days, will the economic pressures and changes in healthcare delivery systems.

Table 1-1. How to enhance the therapeutic alliance

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