CHAPTER 2

Talking With Parents

Geeta Grover, MD, FAAP

Communication is the foundation of the therapeutic relationship between physicians, patients, and patients’ families. Effective communication in the pediatric setting involves the exchange of information between physicians, parents, and children. In addition, observing the interaction between parents and children gives physicians an opportunity to assess parenting skills and the dynamics of the parent-child relationship. The communication needs of parents and children are quite different, which makes the exchange of information challenging. Parental concerns should be addressed in a sensitive, empathetic, and nonjudgmental manner. A nonthreatening, pleasant demeanor and age-appropriate language help facilitate communication with children (see Chapter 3).

Pediatrics encompasses not only the traditional medical model of diagnosis and treatment of disease but also maintenance of the health and well-being of children through longitudinal care and the establishment of ongoing relationships between physicians and families. Personal relationships between physicians and families create an atmosphere in which information can be exchanged openly. The pediatrician’s role in such relationships is to not only diagnose and treat but also to listen, advise, guide, and teach.

The doctor-patient relationship is truly a privilege. Patients entrust physicians with their innermost thoughts and feelings, allow them to touch private parts of their bodies, and trust them to perform invasive procedures or administer medications. Mutual respect is essential for the development of a healthy relationship between physicians, parents, and children. Through practice and continued awareness of interpersonal abilities, the physician can develop good communication skills. All physicians eventually develop their own personal interviewing and examination style. What seems awkward and difficult at first soon becomes routine and even enjoyable as the physician becomes more comfortable with patients and their families.

Parental Concerns

Parents’ preconceived ideas and concerns about their children’s illnesses can greatly influence the exchange of information between physicians and parents. At health maintenance or well-child visits, it is important for the pediatrician to address parents’ nonmedical and psychosocial concerns, such as their children’s development, nutrition, and growth. Often these questions stem from discussions with other parents or, increasingly, from information received from various online and media resources (see Chapter 7). Although such concerns may seem trivial to the pediatrician, they may be extremely important to parents. In addition to addressing the needs of the child, the health maintenance visit also affords the pediatrician an opportunity to assess and address parental needs. Parental depression, substance abuse, family violence, or marital discord all can have profound effects on children’s health and development. Similarly, the conditions in which children and their families live, learn, work, and play can affect both physical and emotional health. Collectively, these conditions are known as the social determinants of health (see Chapter 141).

When evaluating children brought in for illness, it is important to ask parents what concerns them most. Parental fears may be much different from medical concerns. Failure to give parents the opportunity to ask questions or to address these concerns in a sensitive manner may result in dissatisfaction and poor communication.

The Pediatric Interview

Pediatric interviews are conducted in a variety of settings for many different reasons. The first interaction between the physician and parent or parents may be during the prenatal interview before the birth of the child, in the hospital following the delivery, or in the doctor’s office during the well-baby visit. Later, the physician may see a child in the office for regular health maintenance visits or in the office, emergency department (ED), or hospital for an acute illness.

The specific clinical situation dictates the information that must be gathered and the appropriate interviewing techniques. During the prenatal visit, the physician should discuss common concerns and anxieties about the new baby with the prospective parent or parents. In addition, the prenatal visit affords the parent or parents an opportunity to interview physicians and evaluate their offices and staff.

In the emergency setting, the physician must elicit pertinent information necessary to make decisions about management within a short period. Lack of a long-term relationship can make communication in the ED particularly challenging. The physician should mostly use focused, closed-ended questions in this setting. For the periodic health maintenance visit, however, the use of broad, open-ended questions is more appropriate, and closed-ended questions should be used only as necessary for clarification.

Communication Guidelines

Professionalism encompasses technical, intellectual, and humanistic competencies. Clinicians are increasingly seeing conditions that may not be treatable; however, that does not mean the clinician cannot provide healing. Whereas “treatment” focuses on cure, “healing” is about building relationships with patients and helping them optimize emotional and physical health so that they may continue to pursue what has meaning and value for them.

Overall principles that are applicable regardless of the setting include interacting with the child and family in a professional yet sensitive and nonjudgmental manner. Common courtesies, such as knocking before entering the room, dressing and behaving in a professional manner, introducing oneself, and addressing parents and children by their preferred names, are always appreciated and welcomed. Taking a few moments to socialize with families develops a more personal relationship that may allow more open conversation about sensitive and emotional issues.

Family-centered care is an approach to health care in which the physician realizes the vital role that families play in ensuring the health and well-being of children. Physicians who practice family-centered care convey respect for parents’ insight into and understanding of their children’s behavior and needs, and actively seek out their observations and incorporate their family preferences into the care plan as much as possible. Benefits of family-centered care include a stronger alliance between the physician and family; increased patient, family, and professional satisfaction; and decreased health care costs. Since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, the electronic medical record (EMR) is increasingly affecting the practice of medicine (see Chapter 6). Although the EMR has the potential to improve patient understanding of health information as well as to improve sharing of medical information, without conscious effort to adjust clinical speaking and documentation practices, this new model of practice may also negatively affect patient-centered communication. Some behaviors that facilitate patient-centered communication with the EMR include screen-sharing, cessation of typing during sensitive discussions, and maintaining eye contact or continuing to speak while typing. In this digital age, physicians are learning to listen, talk, think, and type simultaneously.

The medical visit may be divided into 3 parts: the interview, physical examination, and concluding remarks. Examples of doctor-parent and doctor-child communications for each of these components are provided in Table 2.1.

Interview

The goal of the interview is to ascertain the chief concern, determine appropriate medical history, and gain an understanding of the family’s perspective of the illness or its specific concerns. It is important to address cognitive (ie, informational) and affective (ie, emotional) needs of the family during the interview. The interview usually begins with open-ended questions to give parent and child an opportunity to discuss their concerns and outline their agenda for the visit. Often, the real reason for the visit is not disclosed until the family believes the physician to be trustworthy and honest. Rachel Naomi Remen, MD, coined the term generous listening to describe a technique of receiving and respecting information without judgment or any agenda to analyze it and determine what to do next. Generous listening creates a space of safety that allows parents and children to say what they perceive to be true. After issues have been laid out, closed-ended questions can be used to clarify and further define the information presented. It often becomes necessary to guide the interview, especially when parents have several broad issues on their agenda for that visit and time does not permit discussion of them.

The physician should gently acknowledge parental concerns and define time limitations. These actions allow the physician to focus on the most salient issues of that visit. Additionally, the physician should limit the use of medical jargon (ie, scientific terms) and be aware of nonverbal communication. A sincere, empathic, and compassionate communication style helps parents feel truly understood even if the physician can do little to help the situation. Pauses and periods of silence should be used, especially when discussing emotionally difficult issues, to convey to parents and children that their physician cares enough to listen. Physicians should not underrate their own knowledge; however, they should recognize their limitations and use consultants appropriately. Finally, the physician’s understanding of the chief concern and history should be summarized so that the parent or parents have an opportunity to clarify points of disagreement.

The primary care physician faces increasing demands to address not only the physical but also the psychosocial health needs of patients. Patient-centered care is a comprehensive approach to medical care that encourages communication between the physician, patient, and family. The clinician addresses the immediate pressing medical concerns in the context of each patient’s unique environmental circumstances and underlying psychosocial concerns, both of which may directly or indirectly affect health-related outcomes. Empathy, unconditional positive regard, and genuineness are essential physician characteristics in this collaborative approach.

Motivational interviewing is one such patient-centered, collaborative, and directive interaction style that offers an effective means of addressing these developmental, behavioral, and social concerns within the context of a primary care setting. Motivational interviewing addresses the ambivalence and discrepancies between a person’s current values and behaviors and the person’s future goals. In contrast to more traditional medical approaches that rely primarily on authority and education, motivational interviewing is a collaborative approach that relies on eliciting the patient’s ideas about change. The physician who practices motivational interviewing understands that trying to move beyond a patient’s readiness to change is likely to increase that patient’s resistance to treatment; for example, lecturing to an adolescent who is not yet ready to quit smoking about the dangers of smoking is unlikely to be effective and may even produce more resistance. Motivational interviewing requires that the physician follow the 4 principles listed in Table 2.2. Operationally, open-ended questions (eg, “How do you feel about smoking?”), affirmations (eg, “You are tired of having to monitor your blood sugar every day and stick to your diet.”), and reflective listening (eg, “You are worried about your daughter’s behavior and are concerned that if it persists, she may be expelled from school.”) are important tools of motivational interviewing. In addition, physicians who practice motivational interviewing ask permission before giving advice (eg, “Would it be OK if I shared some information with you?”). Alternatively, the physician may state the facts but let the parent interpret the information (eg, “What does this mean to you?”). Research has also shown motivational interviewing to be an effective tool for use with adolescent patients to increase self-efficacy to enact change (eg, adolescent smoking cessation).

Derived from Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press; 2013.

Physical Examination

Parents keenly observe physicians’ interactions with their children during the examination. It is an important time for the physician to build a therapeutic relationship with the child (see Chapter 3). The transition between the history and physical examination can be made by briefly telling the child and parent what to expect during the examination. The physician should show consideration for the child’s fears. In general, physicians often find it helpful to speak with families at periodic intervals during the examination about their observations. Prolonged periods of silence as the physician listens or palpates may be anxiety provoking for the family. Physicians should explain any procedures that they or their staff are going to perform at a level that is appropriate for parents and children. In addition, the physician should try to avoid exclamations or comments to self during the examination (eg, “Wow, that’s some murmur!”), which may be alarming to the family.

Concluding Remarks

The conclusion of the visit, which is all too easy to rush through, is extremely important. Closure can be provided by summarizing the diagnosis or outlining plans for a follow-up visit. The parent or parent should be asked to participate by acknowledging closure and helping to develop a management plan. Shared decision making and a consumer model are replacing the traditional paternalistic medical model in which the physician decided what should be done and the patient accepted the recommendations without question. In this shared decision making model, it is important to assess parental readiness for knowledge (especially in emotionally difficult situations) and keep family resources and limitations in mind. Discharge instructions should be minimized, the physician should be specific, and the number of diagnoses, medications, and “as needed” instructions (ie, indications for seeking medical advice, such as “return as needed for high fever”) should be limited. When complicated discharge instructions are given, additional physician time may be required to ensure parental understanding. Praising parents on care of their children can boost their self-esteem and confidence and may minimize calls and questions. Parental understanding should be confirmed; parents should be asked to repeat the diagnosis and treatment plan. Simply asking parents if they have understood is not enough because they often say “yes” out of respect for the physician’s time or embarrassment that they have not understood what has been said. For example, the physician could say, “I want to be sure that I’ve spoken clearly enough. Please repeat for me [child’s name] diagnosis and treatment instructions.”

Barriers to Effective Communication

Barriers to effective communication can be divided into systems-related barriers and interpersonal barriers (Table 2.3). The primary systems barriers are the setting itself and lack of continuity of care. Because of access problems within the health care system (ie, lack of health insurance coverage), many children receive only episodic care from different physicians in acute care clinics or EDs. Without the benefit of long-term relationships, doctor-patient communication may suffer.

Interpersonal barriers include physician time constraints, frequent interruptions, and cultural insensitivity. Frequent interruptions or apparent impatience on the part of the physician conveys to parents and children that the physician does not care or is too busy for them. Language differences may pose a significant barrier, depending on the region in which the physician practices. Ideally, physicians themselves should be able to speak directly with parents and children. If translators are needed, children must not play this role because doing so places them in an awkward situation. Parents of other patients must not be used either, because doing so would violate the patient’s privacy. Only professional translators are recommended. Physicians should be sensitive to cultural differences (eg, issues about sex and gender, views on illness, folk remedies, beliefs). Suggesting treatments that are not culturally acceptable or are contrary to folk wisdom simply decreases compliance with prescribed treatment plans. For example, many Eastern cultures believe in the concept of “hot” and “cold” foods and illnesses. Suggesting to a mother that she feed primarily “hot” foods to a child she believes to have an illness that is also “hot” may not be acceptable to her. Such information is rarely volunteered and must be elicited through culturally sensitive patient interviewing.

Not only is effective communication essential for accurate diagnosis, but it is also correlated with improved patient recall of instructions and adherence to prescribed courses of treatment. Poor communication can have negative consequences for the patient (eg, compromised care) and physician (eg, medicolegal consequences). Effective communication enhances medical outcomes and patient satisfaction.

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