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Illustrations such as the Academy’s posters of Boney Ben and Muscle Molly can help children and their families better understand the big words they hear.
Courtesy of John M. Purvis, MD

AAOS Now

Published 2/1/2009
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John M. Purvis, MD

The challenge of communicating with pediatric patients

Tips for talking with children

Do you see children in your orthopaedic practice? How’s the communication end of things going for you?

When it comes to communicating with patients, physicians need to remember that children are not just small adults. Applying the four Es—engagement, empathy, enlistment, and education—to pediatric patients and their families requires a much different approach than with adults.

Unfortunately, research and training in doctor-patient communication has generally focused on adult interactions—often leaving the pediatric patient out of the picture. Until recently, few studies reported on doctor-parent-child communication. Now, however, patient advocacy organizations as well as the media are focusing on physician communication skills, and these skills are now being measured as a core competency in graduate medical education.

At the 2008 annual meeting of the Pediatric Orthopaedic Society of North America, I was part of a panel symposium on the challenge of communicating with pediatric patients. Joining me were S. Terry Canale, MD; Robert E. Eilert, MD; Howard R. Epps, MD; Vicki Kalen, MD; Donna P. Phillips, MD; and John R. Tongue, MD. This year, recognizing that special considerations apply to communicating with children and their families, AAOS Now will publish a four-part series based on that symposium.

Pediatric communication is special
Verbal, nonverbal, and electronic communication abilities vary greatly among patients and physicians of diverse generations. Pediatric medical communication has unique aspects that differ in structure, format, and content from adult patient medical communication.

Age and cognitive considerations: Pediatric orthopaedic patients may range in age from newborns through adolescents. Because emotional development and cognitive abilities evolve with age, pediatric patients may be oblivious (infants), uninformed (children), or invincible (teenagers). They may be unable to verbalize (mentally impaired), intimidated (parent in the room), or just abbreviated (txt msgs).

In addition, a child’s concepts of bodily functioning, health, and illness change with age. Physicians may have difficulty in judging what children understand. The extent to which physicians talk to children in substantive areas is associated primarily with a child’s age, but may also be influenced by the child’s gender and family background.

Complexity of the family unit: Pediatric orthopaedic patient visits typically involve a triad of interaction among the parent(s), the child, and the physician. Mercer Rang, MD, has written that “The main difference between children and adults is that children have parents.” Parents may be first-timers, accompanied by their own parents, single, divorced, remarried, recent immigrants whose primary language is not English, burdened by the responsibility of making decisions for their child, or unrealistic in their expectations for their child’s potential.

Investigators have observed that “Pediatric visits are particularly challenging in requiring that the physician engage in a dance with not one but at least two partners—parent and child—and that the physician be able to lead at times and follow at others.” Typically a child’s participation in a medical conversation is limited and is influenced by the communicative behavior of both the physician and the parents.

The environment: Children are definitely influenced by the smells, sounds, and surroundings of their medical visit. The physical environment during an initial visit will have an impact on the subsequent success of any pediatric patient-physician communication.

Reason for the visit: A significant number of pediatric orthopaedic patient visits result from parental concerns about what are actually normal developmental findings. They want to “make sure” that their child is okay, and they may be “hoping this is just a visit to meet you, doctor,” and that follow-up diagnostic tests or medical interventions won’t be necessary. Insightful written and verbal communication skills are required to educate and convince the concerned family.

In contrast, children with newly diagnosed serious problems or chronic handicaps have special needs for considerate and caring communication.

The child’s rights: Hearing a child’s views and encouraging his or her input in decision making may not always result in the child’s making the best medical decisions. Any resultant tension requires the need to balance the rights of the child, the rights of the parents, and the physician’s duty to provide the best medical care for the patient. Legal, moral, and cultural principles unique to pediatric patients may affect communication style and content.

The child’s perspective and future: A child’s satisfaction with healthcare communication may shape both a life-long attitude toward doctors and the healthcare system and the patient’s receptiveness to later interventions or recommendations. Being respected, listened to, and understood—as well as understanding the reasons for a medical procedure or recommendation—can set the stage for a child’s future performance. They may even offset the worrisome stories the child has heard from older siblings or teasing fathers about an upcoming doctor’s visit.

Pediatric communication is serious
Communication is a medical procedure and it matters. It is not limited to obtaining a history. When most effective, communication continues through physical examinations, treatments, and follow-up care. It is the clinician’s responsibility, it cannot be delegated, and it has lasting effects over time.

Teaching communication skills to orthopaedists hasn’t been easy. Learning to listen, being empathetic, involving the patient in shared decision making, and delivering patient-centered care are techniques that must be learned. The lack of communication competencies is one of the most common reasons that a candidate fails to be admitted for the recertification cognitive examinations administered by the American Board of Orthopaedic Surgery.

Future installments in this series will review the child, parent, and physician barriers to effective pediatric patient communication, with suggestions about how to overcome them that you can apply in your practice.

John M. Purvis, MD, is a POSNA member in private practice at Pediatric Orthopaedic Specialists of Mississippi. He can be reached at jpurvis@mbhs.org

Pediatric communication tips
Whisper
—Children usually become so intent on trying to hear what you’re saying that they forget their fear and focus their attention on you.

Never frown at an X-ray—Children are very attuned to facial features and frequently associate frowning with a problem. They may become more worried, scared, and tense.

Don’t hesitate to get help—If you’re having problems communicating with a child, try enlisting the aid of a nurse, a puppet, a parent, or a sibling as a communication intermediary.

Decoy—Identifying the correct patient and the correct extremity are winners in the operating room, but purposefully asking about the wrong patient or wrong extremity often works well in the clinic to engage pediatric patients.

Consider using softer words—Be aware of what you say; some words may have negative connotations.

Instead of

Say

Deformity

Appearance

Worry

Wonder

Shoot an X-ray

Take a picture

Problem

Finding

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Illustrations such as the Academy’s posters of Boney Ben and Muscle Molly can help children and their families better understand the big words they hear.
Courtesy of John M. Purvis, MD
The “No Shot Zone” sign at the entrance to the clinic gets lots of “thumbs-up” approval from the kids and puts them at ease.
Courtesy of John M. Purvis, MD

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