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Better communication with children and parents
Occasional review
Better communication with children and parents
What do families want and need from consultations? Amongst adult patients, trustworthiness and good listening skills rate highly, often more highly than other skills. Patients also want the right amount of information about their illnesses, and to be involved in decision-making about their care.6 Patients and parents usually come to consultations needing information rather than prescriptions for treatment.7 From as young as 6 years, children accessing healthcare want more involvement in discussions about their illness and an opportunity to have a say about their treatment.8,9 They would like information to be given in a way which they can understand.
Rachel Howells Tony Lopez
Abstract Consultations with families are a fundamental part of paediatric practice. We will each undertake thousands during a professional lifetime, yet many of us will not have had specific training in how to manage triadic (three-way) consultations involving children. The aim of this review is to start to address this deficiency. Drawing from the communication literature, we will look at what children and parents want from their doctors, where we fall short as clinicians and how we can improve our consultation behaviour.
Where do we fall short? Unfortunately, health professionals do not always live up to patients’ and parents’ expectations. They sometimes misunderstand what patients and parents want, which can lead to overprescribing.10 They do not always promote the active involvement of children in the medical exchange of consultations.11–13 The Commission of Health Improvement’s ‘Children’s Voices Project’ reported that health professionals do not always use ideal language, give the right amount of information for each individual or check that young people have understood what has been said.14 In this study, some children and young people objected to the use of higher-pitched singsong-type vocalization (coined ‘motherese’15) which was perceived as being ‘talked down’ to.
Keywords adult; child; communication; physician–patient relations
What do we stand to gain by effective communication with parents and children? Good communication with patients and their families can have a number of positive effects. One of the easiest to measure is satisfaction; parents are most satisfied when they are allowed to express their concerns and expectations early in consultations.1 Effective communication can improve patient understanding too: giving information to children in a way which is tailored to their needs (not those of their parents) has been shown to improve information retention.2 Happier and better informed patients tend to have improved health outcomes: fewer returns to primary care doctors and emergency rooms for the same condition,3 shorter inpatient stays and improved objective measurements of health such as better diabetic control.4 Patients and parents are not the only stakeholders to benefit from improved communication: use of certain interviewing skills can improve diagnostic accuracy and increase disclosure of psychological problems (which can underlie or exacerbate many paediatric problems). Effective communication may also influence litigation rates.5
How to communicate better It is clear that we could do better in consultations with families. We need to think about what we are trying to achieve during consultations and what skills we use to achieve our goals. Educators in the doctor−patient communication field have developed consultation ‘frameworks’ which are widely used for teaching and learning about communication behaviour.16,17 The ‘Kalamazoo consensus statement’ brings together the elements of these frameworks, containing what we will recognize as the essential components of most consultations18: • Building the doctor–patient relationship • Opening the discussion and gathering information • Understanding the patient’s perspective • Sharing information • Reaching agreement on treatment • Closure These elements are not mutually exclusive, e.g. relationship building goes on throughout consultations. They are often encountered in an opportunistic, variable fashion, especially where young children are involved.
Building the doctor–patient/parent relationship
Rachel Howells MB Bchir MRCP MRCPCH (UK) Dip Med Ed is Consultant Paediatrician at The Children’s and Young People’s Health Directorate, Plymouth Hospitals NHS Trust, Plymouth, UK.
To enable children/young people and their parents quickly to feel comfortable and able to trust you will have its dividends. For young children, it can increase the chance of successfully completing an examination without distress, and for older children/adolescents the possibility of willing participation in information sharing.
Tony Lopez BM BMedSci MRCP MRCPCH (UK) is Consultant Paediatrician at The Children’s and Young People’s Health Directorate, Plymouth Hospitals NHS Trust, Plymouth, UK.
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Occasional review
Elements of rapport building include offering choice of separate patient/parent consultations, preparation of the consultation room and strategies to break the ice with parents and patients.
you may need to take steps to inform and reassure your patient during the examination. Rapport building skills include: • Company + privacy – ask whom your patient would like to have near/leave the room during the examination (if on the couch), and protect him/her from exposure/embarrassment. • Distraction, e.g. “So why is your brother so horrible?” • Praise (particularly valuable for younger children and lengthy examinations), e.g. “You’re really good at this!” • Explanation (what you are about to do and why), e.g. “It may seem really strange but I need to do this because it will tell me…..” • Reassurance (especially once patient has disclosed apprehensions), e.g. “I need to have a look at your tummy but I don’t need to look at your privates, so don’t worry…..”
Offer young people the choice to see you alone first Make it clear, well in advance of the consultation if possible, that you are available to see a young person on their own, if this is what they would like.19 Room preparation Keep your desk out of the way of the space between you and the family, and adjust the height of your chair to be at the patient’s level. Bring out suitable toys for young children, but put them out of the way for adolescent consultations.
Opening the discussion and gathering medical information
Break the ice with parents Introduce yourself and explain your role. Make sure you find out who is present, remembering that accompanying adults may not be the child’s parents and so may not have parental responsibility for the child you are seeing.
“Why have you come to see me today?” Although it may seem obvious, it is crucial that the reason(s) for the consultation are clarified with an opening statement. Families may not know why they have been sent to see you. Parents and children returning for a follow-up appointment may have different needs since they last saw you, and they may bring new items to the consultation. Asking about any new concerns upfront can improve consultation planning and efficiency and avoid last minute ‘while I’m here doctor’ moments, e.g.:
Break the ice with children Toddlers are usually suspicious of new people; attempts to engage them with friendly chatter can be unproductive. Maintaining a distance whilst beginning to talk to their parents can afford toddlers the freedom to approach you when ready. Simultaneous conversation with parents and toy-offering to the child on the side (avoiding sustained eye contact) can work well. Children aged 4 years and older will usually respond well to more direct approaches, such as handshaking or talking about familiar things such as siblings and school. School-aged children may have preconceived apprehensions, e.g. about blood tests or an unpleasant examination, which might dominate consultations until resolved. Early in a consultation, make clear what you plan to do as telling children and parents what is going to happen reduces uncertainty, e.g.:
Doctor: “The last time I saw you we talked about Tyler’s anaemia. How are things now?” Mother: “Fine, she seems much better after the iron medicine…” Doctor: “Great (smiles); before I check that with you in more detail, is there anything else you would like to talk about today?” Mother: “Well there was actually, she’s come up in a rash…. I was wondering if you could have a look at it…” Doctor: “I’m sorry to hear that. Would you mind if we talked about the anaemia first then deal with the rash?”
Doctor: “Sam, I think you’ve come to see me today because you’ve been having some tummy aches, is that right?” Sam smiles at Dad, then nods. Doctor: “What I need to do Sam, is talk to you and your Dad about your tummy aches so I can work out what has been causing them. Then I would like to look at your tummy, and then talk to you about what I can do to help. Does that sound OK?”
How to get children involved in information gathering A child of school age and older may only involve themselves in information sharing when encouraged to do so. Behaviours which will promote inclusion of the patient include: • Adopting an open posture (leaning towards child, arms unfolded) • Establishing eye contact • Using his/her name • Waiting patiently for a reply whilst maintaining the same posture/gaze
When a child/young person does not speak Sometimes a child will say very little during the consultation. Patience and gentle coaxing may draw out their voice. Children frequently take longer to respond to questions than adults do, so it is important to maintain your posture and gaze towards your patient when awaiting a reply to a question. Looking to the parent during a child’s pause may well cause the parent to interrupt, so avoid this.20
Listen The longer patients are given early in consultations to speak, the shorter the overall consultations will be.21 You are more likely to uncover psychosocial problems if you let parents have their say early in the consultation, without interrupting.22 You need to show your patient/parent that you are listening: patients tend to stop talking unless you send them signals that you are taking in what is being said. Nonverbal behaviour which shows
Rapport building skills later during the examination Being examined can provoke anxiety. Effective rapport building early in the consultation will help reduce this anxiety but
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Occasional review
that you are really listening includes leaning forward, maintaining eye contact and use of what Silverman and colleagues call ‘facilitative responses’ (gestures such as nodding and phrases such as ‘uh-huh’).16 Reading from or writing in notes should be kept to a minimum – the patient/parent will tend to stop talking and await your renewed interest before starting to speak again – unless you explain the importance of jotting down a few facts. Repeatedly summarizing what has been said is enormously valuable. Not only does summarizing show the patient that you have been listening, but it also helps you organize your thoughts and check these with him/her. It can also help you signal a change of direction in the consultation, e.g. “You’ve told me how you felt dizzy, and then found yourself on the floor. Now what I need to do is ask your Dad about what he saw….”
then tell you about some of the things you can do at home to prevent headaches from coming on so much. How does that sound?” (awaits response from both Matthew and mother) Like adult patients, parents and children will often have concerns which they may feel unable to disclose early on. These may manifest as nonverbal signs, e.g. of anxiety or embarrassment (e.g. fidgeting, loss of gaze). Anticipate and be prepared to ask about common emotions that illness can engender in children, such as guilt and fear, e.g. “You look like you’re really worried about Daisy’s blank spells. Would you like to talk some more about that?”, or “Some people like you have tummy pain because they’re worried about school. Are you like that?”
Sharing information
Obtain more information “Can you tell me more about the pain?” Open questions usually lead to more efficient, accurate patient histories. However, younger children may respond better to closed questioning, e.g. “Was the pain in one little spot or all over your tummy?” Explain why you need sensitive information. Some information is embarrassing for children to disclose. Explaining your reasons for asking a question may harness the cooperation of an otherwise reluctant older child, e.g. “I really need to ask you more about going to the toilet, because sometimes when you get tummy pain you also get a problem doing a poo”. The same is true for parents: questions about relevant family history or consanguinity can need some explanation if you are to avoid misunderstanding. Uncover the family’s perspective on a child’s illness. There is an huge body of evidence that testifies to the value of establishing what patients feel, think and worry about their illness.16 Asking the following three questions (or something similar) of a parent will make him/her happier with your consultation, and will enable you to frame your explanation later on: • “Have you any idea what’s caused this?” (ideas) • “Is there anything particular that you are concerned about?” (concerns) • “What are you hoping for today?” (expectations) The paediatric patient may have a perspective on their illness, too, so you may need to ask parents and the child about their ideas, concerns and expectations. This will take time but is well worth the investment. An example of managing expectations in a triadic consultation is:
The trick here is not merely to say more, but to make what you say easy to understand and remember later. • Frame your explanation in a way which suits your patient and parents • Check you have been understood • Offer to direct patients/parents to other sources of information ‘Frame’ your explanation • Tell your patient and parent what you are going to discuss (as you would when starting a teaching session). • Find out what your family knows already and start from there. This tactic saves you time (not spent explaining something which is already understood well), and can also help you identify misconceptions, which you can put straight, e.g. “Peter, you mentioned that your uncle had Crohn disease. What do you know about that problem?” • Start the explanation from where the child/young patient is coming from. This emphasizes the importance of keeping the patient as the focus of discussion, and ensures information is tailored to his/her needs. • Build on your patient’s/parent’s ideas, concerns and expectations. This will motivate the patient/parent and promote understanding, e.g. “Peter, you said that you wondered whether you had the same thing as your uncle. I don’t think you have Crohn disease – would it help if I explained why?” • Use appropriate language. Young children have different ideas and names for the contents and workings of their bodies. Use age-appropriate language, incorporating the patient’s/parent’s own turns of phrase. Find out about parental medical training and assume no understanding of medical words otherwise. • Use visual aids (e.g. write down medical terms, draw diagrams) to help families conceptualize and remember medical information.
Doctor: “Now that I have found out what your headaches are like Matthew, it would really help me to know what you’d like me to do today?” (focuses on Matthew) Matthew: “Well, I’d really like to try something to stop all of them from happening” (looks at mother) Doctor (looks at Matthew’s mother): “How about you, Mrs Taylor?” Matthew’s mother: “I don’t like the idea of Matthew taking medicine every day, so perhaps if we could try something that really worked when he got a headache?” Doctor (looking from mother to Matthew repeatedly): “It sounds like you would like slightly different things. Can I talk to you about the best treatment for the actual headaches, and
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Check you have been understood The most effective way to check understanding is to ask your patient and/or parent to repeat back to you what you have said. This has the advantage of improving the amount of information that your patient will retain, e.g. “I’m not sure how well I explained that, would you mind telling me what you’ve understood?” Alternatively, watch carefully for nonverbal cues in your patient/parent which might convey good or poor understanding (Table 1). 383
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Transforming recommendations into behaviour change
Nonverbal cues to watch out for whilst giving information Good understanding
Poor understanding
Good eye contact Asking questions (means still engaged) Forward posture (leaning towards you)
Loss of eye contact No questions
In this review, we have highlighted skills to enhance the flow and outcome of your consultations. However, improvement will only come through self-analysis and an opportunity to try out new skills. All the methods described below are discussed in greater detail elsewhere.25,26 Find out what you actually do when with patients Ask a trusted colleague to sit in on some consultations with you, or video yourself in action. Video cameras are less intrusive than someone sitting in on your consultations, and can allow you to analyse yourself at leisure (initially an unsavoury prospect but most people adapt quickly).
Body turned away, restless
Table 1
Use an assessment tool to analyse your performance The paediatric consultation assessment tool, commissioned by the Royal College of Paediatrics and Child Health, can be used for evaluation of consultations.27 Based on the Calgary − Cambridge framework for the consultation, it scores for behaviours similar to the ones presented here.16 A copy of the PCAT is available from the corresponding author e-mail address: rachel.howells@ phnt.swest.nhs.uk, and should be posted on the RCPCH website in the near future.
Offer to direct patients/parents to other sources of information Consultation letters have the potential to improve information recall and decision-making by families. Parents and competent young people should be offered the opportunity to be copied into correspondence about them.23 You will need to strike a balance between conveying all the information needed by the receiving clinician, and making a letter easy for the family to understand. Your department might have patient information leaflets to give to families: make sure they are suitable for children/young people, too. Patients and parents are likely to look up their conditions online as home use of the internet is now widespread.24 We occasionally use clinic time to help families navigate the internet to find good quality information. Preferred website addresses can be incorporated into clinic letters.
Run some role-play sessions using an actor Actors can reproduce roles and develop ad-hoc ones to suit an individual or small group’s learning needs. The advantage role play has over video analysis is the opportunity to practise different communication skills safely.
Summary Reach agreement on treatment
Good communication with families can improve satisfaction, understanding and compliance with treatment. This review has highlighted skills to improve your communication and how to go about making the transition from theory into practice. ◆
Making a decision on treatment with a child/young person and parent in a collaborative way will optimize family satisfaction and compliance with treatment. For a fully informed discussion of treatment to occur between you, your patient and parents you will need to ensure that: • Your treatment options are understood by everyone. • Your patient/parent gets an opportunity to suggest different treatments (sometimes they come up with good ones you have not thought of!) • Everyone’s preferred options are aired and acknowledged before a final decision is made. Treatment decisions should be agreed by all the parties. Patients/parents are unlikely to comply with a treatment they are unhappy about.
References 1 Korsch BM, Gozzi EK, Francis V. Gaps in doctor-patient communication. 1. Doctor-patient interaction and patient satisfaction. Pediatrics 1968; 42: 855–871. 2 Lewis CC, Pantell RH, Sharp L. Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention. Pediatrics 1991; 88: 351–358. 3 Lewis CE, Rachelefsky G, Lewis MA, de la Sota A, Kaplan M. A randomized trial of A.C.T. (asthma care training) for kids. Pediatrics 1984; 74: 478–486. 4 Greenfield S, Kaplan SH, Ware Jr. JE, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988; 3: 448–457. 5 Levinson W, Roter DL, Mulloly JP, Dull VT, Frankel RM. Physicianpatient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277: 553–559. 6 Elwyn G, Edwards A, Kinnersley P. Shared decision-making in primary care: the neglected second half of the consultation. Br J Gen Pract 1999; 49: 477–482.
Closure Many actions herald the end of the consultation, e.g. clarification of what has been agreed upon and coaxing of young children to put away toys strewn all over the consultation room. Here, however, we emphasize providing a safety net for families. Your patient/parent will feel more secure knowing what to do if things do not go according to plan, e.g. “You’ll be getting a letter from me in the next week. My phone number will be at the top of the letter. I’ll see you in 8 weeks but if things go wrong before that, please give me a ring….”
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7 Rollnick S, Seele C, Rees M, Butler C, Kinersley P, Anderson L. Inside the routine general practice consultation: an observational study of consultations for sore throats. Fam Pract 2001; 18: 506–510. 8 Boylan P. Children’s voices project: feedback from children and young people about their experience and expectations of health care. Commission for Health Improvement: National Health Service England and Wales, 2004. 9 Lewis C, Knopf D, Chastain-Lorber K, et al. Patient, parent, and physician perspectives on pediatric oncology rounds. J Pediatr 1988; 112: 378–384. 10 Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations – a questionnaire study. BMJ 1997; 315: 520–523. 11 Tates K, Meeuwesen L. Doctor-parent-child communication. A (re)view of the literature. Soc Sci Med 2001; 52: 839–851. 12 Tates K, Meeuwesen L, Elbers E, Bensing J. I’ve come for his throat’: roles and identities in doctor-parent-child communication. Child Care Health Dev 2002; 28: 109–116. 13 Cahill P, Papergeorgiou A. Triadic communication in the primary care paediatric consultation: a review of the literature. Br J Gen Pract 2007; 57: 904–911. 14 Healthcare commission patient survey report 2004 – young patients, Healthcare Commission (CHAI), 2004. 15 Tannen D, Wallat C. Doctor-mother-child communication. In: Fisher S, Todd AD, eds. The social organisation of doctor–patient communication. Washington DC: Centre for Applied Linguistics, 1983, p. 203–219.
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16 Silverman J, Kurtz S, Draper J. Skills for communicating with patients, 2nd edn. Oxford: Radcliffe Medical Press, 2005. 17 Makoul G. The SEGUE framework for teaching and assessing communication skills. Patient Educ Couns 2001; 45: 23–34. 18 Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001; 76: 390–393. 19 General Medical Council. 0–18 Years: guidance for all doctors, London: General Medical Council, 2007. 20 Cahill P, Papageorgiou A. Video analysis of communication in paediatric consultations in primary care. Br J Gen Pract 2007; 57: 866–871. 21 Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002; 325: 682–683. 22 Wissow LS, Roter DL, Wilson ME. Pediatrician interview style and mothers’ disclosure of psychosocial issues. Pediatrics 1994; 93: 289–295. 23 Department of Health. Copying letters to patients: good practice guidelines, London: Department of Health, 2003. 24 http://www.comscore.com/press/release.asp?press=1459. 25 Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine, 2nd edn. Oxford: Radcliffe Publishing, 2005. 26 Howells RJ, Davies HA, Silverman JD. Teaching and learning consultation skills for paediatric practice. Arch Dis Child 2006; 91: 367–70. 27 Workplace Assessment Projects. A report of the Steering group, London: Royal College of Paediatrics and Child Health, 2006. .
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Better communication with children and parents
What do families want and need from consultations? Amongst adult patients, trustworthiness and good listening skills rate highly, often more highly than other skills. Patients also want the right amount of information about their illnesses, and to be involved in decision-making about their care.6 Patients and parents usually come to consultations needing information rather than prescriptions for treatment.7 From as young as 6 years, children accessing healthcare want more involvement in discussions about their illness and an opportunity to have a say about their treatment.8,9 They would like information to be given in a way which they can understand.
Rachel Howells Tony Lopez
Abstract Consultations with families are a fundamental part of paediatric practice. We will each undertake thousands during a professional lifetime, yet many of us will not have had specific training in how to manage triadic (three-way) consultations involving children. The aim of this review is to start to address this deficiency. Drawing from the communication literature, we will look at what children and parents want from their doctors, where we fall short as clinicians and how we can improve our consultation behaviour.
Where do we fall short? Unfortunately, health professionals do not always live up to patients’ and parents’ expectations. They sometimes misunderstand what patients and parents want, which can lead to overprescribing.10 They do not always promote the active involvement of children in the medical exchange of consultations.11–13 The Commission of Health Improvement’s ‘Children’s Voices Project’ reported that health professionals do not always use ideal language, give the right amount of information for each individual or check that young people have understood what has been said.14 In this study, some children and young people objected to the use of higher-pitched singsong-type vocalization (coined ‘motherese’15) which was perceived as being ‘talked down’ to.
Keywords adult; child; communication; physician–patient relations
What do we stand to gain by effective communication with parents and children? Good communication with patients and their families can have a number of positive effects. One of the easiest to measure is satisfaction; parents are most satisfied when they are allowed to express their concerns and expectations early in consultations.1 Effective communication can improve patient understanding too: giving information to children in a way which is tailored to their needs (not those of their parents) has been shown to improve information retention.2 Happier and better informed patients tend to have improved health outcomes: fewer returns to primary care doctors and emergency rooms for the same condition,3 shorter inpatient stays and improved objective measurements of health such as better diabetic control.4 Patients and parents are not the only stakeholders to benefit from improved communication: use of certain interviewing skills can improve diagnostic accuracy and increase disclosure of psychological problems (which can underlie or exacerbate many paediatric problems). Effective communication may also influence litigation rates.5
How to communicate better It is clear that we could do better in consultations with families. We need to think about what we are trying to achieve during consultations and what skills we use to achieve our goals. Educators in the doctor−patient communication field have developed consultation ‘frameworks’ which are widely used for teaching and learning about communication behaviour.16,17 The ‘Kalamazoo consensus statement’ brings together the elements of these frameworks, containing what we will recognize as the essential components of most consultations18: • Building the doctor–patient relationship • Opening the discussion and gathering information • Understanding the patient’s perspective • Sharing information • Reaching agreement on treatment • Closure These elements are not mutually exclusive, e.g. relationship building goes on throughout consultations. They are often encountered in an opportunistic, variable fashion, especially where young children are involved.
Building the doctor–patient/parent relationship
Rachel Howells MB Bchir MRCP MRCPCH (UK) Dip Med Ed is Consultant Paediatrician at The Children’s and Young People’s Health Directorate, Plymouth Hospitals NHS Trust, Plymouth, UK.
To enable children/young people and their parents quickly to feel comfortable and able to trust you will have its dividends. For young children, it can increase the chance of successfully completing an examination without distress, and for older children/adolescents the possibility of willing participation in information sharing.
Tony Lopez BM BMedSci MRCP MRCPCH (UK) is Consultant Paediatrician at The Children’s and Young People’s Health Directorate, Plymouth Hospitals NHS Trust, Plymouth, UK.
PAEDIATRICS AND CHILD HEALTH 18:8
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Crown Copyright © 2008 Published by Elsevier Ltd. All rights reserved.
Occasional review
Elements of rapport building include offering choice of separate patient/parent consultations, preparation of the consultation room and strategies to break the ice with parents and patients.
you may need to take steps to inform and reassure your patient during the examination. Rapport building skills include: • Company + privacy – ask whom your patient would like to have near/leave the room during the examination (if on the couch), and protect him/her from exposure/embarrassment. • Distraction, e.g. “So why is your brother so horrible?” • Praise (particularly valuable for younger children and lengthy examinations), e.g. “You’re really good at this!” • Explanation (what you are about to do and why), e.g. “It may seem really strange but I need to do this because it will tell me…..” • Reassurance (especially once patient has disclosed apprehensions), e.g. “I need to have a look at your tummy but I don’t need to look at your privates, so don’t worry…..”
Offer young people the choice to see you alone first Make it clear, well in advance of the consultation if possible, that you are available to see a young person on their own, if this is what they would like.19 Room preparation Keep your desk out of the way of the space between you and the family, and adjust the height of your chair to be at the patient’s level. Bring out suitable toys for young children, but put them out of the way for adolescent consultations.
Opening the discussion and gathering medical information
Break the ice with parents Introduce yourself and explain your role. Make sure you find out who is present, remembering that accompanying adults may not be the child’s parents and so may not have parental responsibility for the child you are seeing.
“Why have you come to see me today?” Although it may seem obvious, it is crucial that the reason(s) for the consultation are clarified with an opening statement. Families may not know why they have been sent to see you. Parents and children returning for a follow-up appointment may have different needs since they last saw you, and they may bring new items to the consultation. Asking about any new concerns upfront can improve consultation planning and efficiency and avoid last minute ‘while I’m here doctor’ moments, e.g.:
Break the ice with children Toddlers are usually suspicious of new people; attempts to engage them with friendly chatter can be unproductive. Maintaining a distance whilst beginning to talk to their parents can afford toddlers the freedom to approach you when ready. Simultaneous conversation with parents and toy-offering to the child on the side (avoiding sustained eye contact) can work well. Children aged 4 years and older will usually respond well to more direct approaches, such as handshaking or talking about familiar things such as siblings and school. School-aged children may have preconceived apprehensions, e.g. about blood tests or an unpleasant examination, which might dominate consultations until resolved. Early in a consultation, make clear what you plan to do as telling children and parents what is going to happen reduces uncertainty, e.g.:
Doctor: “The last time I saw you we talked about Tyler’s anaemia. How are things now?” Mother: “Fine, she seems much better after the iron medicine…” Doctor: “Great (smiles); before I check that with you in more detail, is there anything else you would like to talk about today?” Mother: “Well there was actually, she’s come up in a rash…. I was wondering if you could have a look at it…” Doctor: “I’m sorry to hear that. Would you mind if we talked about the anaemia first then deal with the rash?”
Doctor: “Sam, I think you’ve come to see me today because you’ve been having some tummy aches, is that right?” Sam smiles at Dad, then nods. Doctor: “What I need to do Sam, is talk to you and your Dad about your tummy aches so I can work out what has been causing them. Then I would like to look at your tummy, and then talk to you about what I can do to help. Does that sound OK?”
How to get children involved in information gathering A child of school age and older may only involve themselves in information sharing when encouraged to do so. Behaviours which will promote inclusion of the patient include: • Adopting an open posture (leaning towards child, arms unfolded) • Establishing eye contact • Using his/her name • Waiting patiently for a reply whilst maintaining the same posture/gaze
When a child/young person does not speak Sometimes a child will say very little during the consultation. Patience and gentle coaxing may draw out their voice. Children frequently take longer to respond to questions than adults do, so it is important to maintain your posture and gaze towards your patient when awaiting a reply to a question. Looking to the parent during a child’s pause may well cause the parent to interrupt, so avoid this.20
Listen The longer patients are given early in consultations to speak, the shorter the overall consultations will be.21 You are more likely to uncover psychosocial problems if you let parents have their say early in the consultation, without interrupting.22 You need to show your patient/parent that you are listening: patients tend to stop talking unless you send them signals that you are taking in what is being said. Nonverbal behaviour which shows
Rapport building skills later during the examination Being examined can provoke anxiety. Effective rapport building early in the consultation will help reduce this anxiety but
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Crown Copyright © 2008 Published by Elsevier Ltd. All rights reserved.
Occasional review
that you are really listening includes leaning forward, maintaining eye contact and use of what Silverman and colleagues call ‘facilitative responses’ (gestures such as nodding and phrases such as ‘uh-huh’).16 Reading from or writing in notes should be kept to a minimum – the patient/parent will tend to stop talking and await your renewed interest before starting to speak again – unless you explain the importance of jotting down a few facts. Repeatedly summarizing what has been said is enormously valuable. Not only does summarizing show the patient that you have been listening, but it also helps you organize your thoughts and check these with him/her. It can also help you signal a change of direction in the consultation, e.g. “You’ve told me how you felt dizzy, and then found yourself on the floor. Now what I need to do is ask your Dad about what he saw….”
then tell you about some of the things you can do at home to prevent headaches from coming on so much. How does that sound?” (awaits response from both Matthew and mother) Like adult patients, parents and children will often have concerns which they may feel unable to disclose early on. These may manifest as nonverbal signs, e.g. of anxiety or embarrassment (e.g. fidgeting, loss of gaze). Anticipate and be prepared to ask about common emotions that illness can engender in children, such as guilt and fear, e.g. “You look like you’re really worried about Daisy’s blank spells. Would you like to talk some more about that?”, or “Some people like you have tummy pain because they’re worried about school. Are you like that?”
Sharing information
Obtain more information “Can you tell me more about the pain?” Open questions usually lead to more efficient, accurate patient histories. However, younger children may respond better to closed questioning, e.g. “Was the pain in one little spot or all over your tummy?” Explain why you need sensitive information. Some information is embarrassing for children to disclose. Explaining your reasons for asking a question may harness the cooperation of an otherwise reluctant older child, e.g. “I really need to ask you more about going to the toilet, because sometimes when you get tummy pain you also get a problem doing a poo”. The same is true for parents: questions about relevant family history or consanguinity can need some explanation if you are to avoid misunderstanding. Uncover the family’s perspective on a child’s illness. There is an huge body of evidence that testifies to the value of establishing what patients feel, think and worry about their illness.16 Asking the following three questions (or something similar) of a parent will make him/her happier with your consultation, and will enable you to frame your explanation later on: • “Have you any idea what’s caused this?” (ideas) • “Is there anything particular that you are concerned about?” (concerns) • “What are you hoping for today?” (expectations) The paediatric patient may have a perspective on their illness, too, so you may need to ask parents and the child about their ideas, concerns and expectations. This will take time but is well worth the investment. An example of managing expectations in a triadic consultation is:
The trick here is not merely to say more, but to make what you say easy to understand and remember later. • Frame your explanation in a way which suits your patient and parents • Check you have been understood • Offer to direct patients/parents to other sources of information ‘Frame’ your explanation • Tell your patient and parent what you are going to discuss (as you would when starting a teaching session). • Find out what your family knows already and start from there. This tactic saves you time (not spent explaining something which is already understood well), and can also help you identify misconceptions, which you can put straight, e.g. “Peter, you mentioned that your uncle had Crohn disease. What do you know about that problem?” • Start the explanation from where the child/young patient is coming from. This emphasizes the importance of keeping the patient as the focus of discussion, and ensures information is tailored to his/her needs. • Build on your patient’s/parent’s ideas, concerns and expectations. This will motivate the patient/parent and promote understanding, e.g. “Peter, you said that you wondered whether you had the same thing as your uncle. I don’t think you have Crohn disease – would it help if I explained why?” • Use appropriate language. Young children have different ideas and names for the contents and workings of their bodies. Use age-appropriate language, incorporating the patient’s/parent’s own turns of phrase. Find out about parental medical training and assume no understanding of medical words otherwise. • Use visual aids (e.g. write down medical terms, draw diagrams) to help families conceptualize and remember medical information.
Doctor: “Now that I have found out what your headaches are like Matthew, it would really help me to know what you’d like me to do today?” (focuses on Matthew) Matthew: “Well, I’d really like to try something to stop all of them from happening” (looks at mother) Doctor (looks at Matthew’s mother): “How about you, Mrs Taylor?” Matthew’s mother: “I don’t like the idea of Matthew taking medicine every day, so perhaps if we could try something that really worked when he got a headache?” Doctor (looking from mother to Matthew repeatedly): “It sounds like you would like slightly different things. Can I talk to you about the best treatment for the actual headaches, and
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Check you have been understood The most effective way to check understanding is to ask your patient and/or parent to repeat back to you what you have said. This has the advantage of improving the amount of information that your patient will retain, e.g. “I’m not sure how well I explained that, would you mind telling me what you’ve understood?” Alternatively, watch carefully for nonverbal cues in your patient/parent which might convey good or poor understanding (Table 1). 383
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Transforming recommendations into behaviour change
Nonverbal cues to watch out for whilst giving information Good understanding
Poor understanding
Good eye contact Asking questions (means still engaged) Forward posture (leaning towards you)
Loss of eye contact No questions
In this review, we have highlighted skills to enhance the flow and outcome of your consultations. However, improvement will only come through self-analysis and an opportunity to try out new skills. All the methods described below are discussed in greater detail elsewhere.25,26 Find out what you actually do when with patients Ask a trusted colleague to sit in on some consultations with you, or video yourself in action. Video cameras are less intrusive than someone sitting in on your consultations, and can allow you to analyse yourself at leisure (initially an unsavoury prospect but most people adapt quickly).
Body turned away, restless
Table 1
Use an assessment tool to analyse your performance The paediatric consultation assessment tool, commissioned by the Royal College of Paediatrics and Child Health, can be used for evaluation of consultations.27 Based on the Calgary − Cambridge framework for the consultation, it scores for behaviours similar to the ones presented here.16 A copy of the PCAT is available from the corresponding author e-mail address: rachel.howells@ phnt.swest.nhs.uk, and should be posted on the RCPCH website in the near future.
Offer to direct patients/parents to other sources of information Consultation letters have the potential to improve information recall and decision-making by families. Parents and competent young people should be offered the opportunity to be copied into correspondence about them.23 You will need to strike a balance between conveying all the information needed by the receiving clinician, and making a letter easy for the family to understand. Your department might have patient information leaflets to give to families: make sure they are suitable for children/young people, too. Patients and parents are likely to look up their conditions online as home use of the internet is now widespread.24 We occasionally use clinic time to help families navigate the internet to find good quality information. Preferred website addresses can be incorporated into clinic letters.
Run some role-play sessions using an actor Actors can reproduce roles and develop ad-hoc ones to suit an individual or small group’s learning needs. The advantage role play has over video analysis is the opportunity to practise different communication skills safely.
Summary Reach agreement on treatment
Good communication with families can improve satisfaction, understanding and compliance with treatment. This review has highlighted skills to improve your communication and how to go about making the transition from theory into practice. ◆
Making a decision on treatment with a child/young person and parent in a collaborative way will optimize family satisfaction and compliance with treatment. For a fully informed discussion of treatment to occur between you, your patient and parents you will need to ensure that: • Your treatment options are understood by everyone. • Your patient/parent gets an opportunity to suggest different treatments (sometimes they come up with good ones you have not thought of!) • Everyone’s preferred options are aired and acknowledged before a final decision is made. Treatment decisions should be agreed by all the parties. Patients/parents are unlikely to comply with a treatment they are unhappy about.
References 1 Korsch BM, Gozzi EK, Francis V. Gaps in doctor-patient communication. 1. Doctor-patient interaction and patient satisfaction. Pediatrics 1968; 42: 855–871. 2 Lewis CC, Pantell RH, Sharp L. Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention. Pediatrics 1991; 88: 351–358. 3 Lewis CE, Rachelefsky G, Lewis MA, de la Sota A, Kaplan M. A randomized trial of A.C.T. (asthma care training) for kids. Pediatrics 1984; 74: 478–486. 4 Greenfield S, Kaplan SH, Ware Jr. JE, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988; 3: 448–457. 5 Levinson W, Roter DL, Mulloly JP, Dull VT, Frankel RM. Physicianpatient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277: 553–559. 6 Elwyn G, Edwards A, Kinnersley P. Shared decision-making in primary care: the neglected second half of the consultation. Br J Gen Pract 1999; 49: 477–482.
Closure Many actions herald the end of the consultation, e.g. clarification of what has been agreed upon and coaxing of young children to put away toys strewn all over the consultation room. Here, however, we emphasize providing a safety net for families. Your patient/parent will feel more secure knowing what to do if things do not go according to plan, e.g. “You’ll be getting a letter from me in the next week. My phone number will be at the top of the letter. I’ll see you in 8 weeks but if things go wrong before that, please give me a ring….”
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7 Rollnick S, Seele C, Rees M, Butler C, Kinersley P, Anderson L. Inside the routine general practice consultation: an observational study of consultations for sore throats. Fam Pract 2001; 18: 506–510. 8 Boylan P. Children’s voices project: feedback from children and young people about their experience and expectations of health care. Commission for Health Improvement: National Health Service England and Wales, 2004. 9 Lewis C, Knopf D, Chastain-Lorber K, et al. Patient, parent, and physician perspectives on pediatric oncology rounds. J Pediatr 1988; 112: 378–384. 10 Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations – a questionnaire study. BMJ 1997; 315: 520–523. 11 Tates K, Meeuwesen L. Doctor-parent-child communication. A (re)view of the literature. Soc Sci Med 2001; 52: 839–851. 12 Tates K, Meeuwesen L, Elbers E, Bensing J. I’ve come for his throat’: roles and identities in doctor-parent-child communication. Child Care Health Dev 2002; 28: 109–116. 13 Cahill P, Papergeorgiou A. Triadic communication in the primary care paediatric consultation: a review of the literature. Br J Gen Pract 2007; 57: 904–911. 14 Healthcare commission patient survey report 2004 – young patients, Healthcare Commission (CHAI), 2004. 15 Tannen D, Wallat C. Doctor-mother-child communication. In: Fisher S, Todd AD, eds. The social organisation of doctor–patient communication. Washington DC: Centre for Applied Linguistics, 1983, p. 203–219.
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16 Silverman J, Kurtz S, Draper J. Skills for communicating with patients, 2nd edn. Oxford: Radcliffe Medical Press, 2005. 17 Makoul G. The SEGUE framework for teaching and assessing communication skills. Patient Educ Couns 2001; 45: 23–34. 18 Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001; 76: 390–393. 19 General Medical Council. 0–18 Years: guidance for all doctors, London: General Medical Council, 2007. 20 Cahill P, Papageorgiou A. Video analysis of communication in paediatric consultations in primary care. Br J Gen Pract 2007; 57: 866–871. 21 Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002; 325: 682–683. 22 Wissow LS, Roter DL, Wilson ME. Pediatrician interview style and mothers’ disclosure of psychosocial issues. Pediatrics 1994; 93: 289–295. 23 Department of Health. Copying letters to patients: good practice guidelines, London: Department of Health, 2003. 24 http://www.comscore.com/press/release.asp?press=1459. 25 Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine, 2nd edn. Oxford: Radcliffe Publishing, 2005. 26 Howells RJ, Davies HA, Silverman JD. Teaching and learning consultation skills for paediatric practice. Arch Dis Child 2006; 91: 367–70. 27 Workplace Assessment Projects. A report of the Steering group, London: Royal College of Paediatrics and Child Health, 2006. .
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