We will be performing site maintenance on AAOS.org on February 8th from 7:00 PM – 9:00 PM CST which may cause sitewide downtime. We apologize for the inconvenience.

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


Published 2/1/2009
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
—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






Shoot an X-ray

Take a picture




Ammentorp J, Mainz J, Sabroe S. Parent’s Priorties and Satisfaction with Acute Pediatric Care. Archives Ped Adol Med. 2005 Feb; 159:127-131

Badarudeen S, Sabharwal S. Readability of patient education materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America web sites. JBJS. 2008 Jan; 90-A(1):199-204.

Bearman M, Bowes G, Jolly B. Looking for the Child’s Perspective. Medical Education. 2005; 39:757-759

Bernzweig J, Takayama JI, Phibbs C, Lewis C, Pantell, RH. Gender Differences in Physician-Patient Communication. Evidence from pediatric visits. Arch Pediatr Adolesc Med. 1997 Jun; 151(6):586-591

Brinkman WB, Geraghty SR, Lanphear BP, Khoury JC, et al. Effect of Multisource Feedback on Resident Communication Skills and Professionalism: A randomized controlled trial. Arch Ped Adolesc Med. 2007 Jan; 161(1):44-9

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

Brinkman WB, Geraghty SR, Lanphear BP, Khoury JC, Gonzalez del Rey JA. Evaluation of Resident Communication Skills and Professionalism: A Matter of Perspective? Pediatrics. 2006 Oct; 118(4):1371-1379

Clowers M. Urban Female Teenagers’ Perceptions of Medical Communication. Adolescence 2000 Nov-Dec; 35(139):571-185

Cox ED, Smith MA, Brown RL. Evaluating Deliberation in Pediatric Primary Care. Pediatrics. 2007; 120(1):e68-e77

Crossley J, Eiser C, Davies HA. Children and their Parents Assessing the Doctor-Patient Interaction: a rating system for doctors’ communication skills. Medical Education. 2005; 39(8):820-8

Crossley J, Davies H. Doctor’s Consultations with Children and their Parents. Medical Education. 2005; 39(8):807-19

Dube CE, LaMonica A, Boyle W, Fuller B, Burkholder GJ. Self-assessment of Communication Skills Preparedness: Adult Versus Pediatric Skills. Ambul Pediatr. 2003 May-Jun; 3(3):137-141

Frymoyer JW, Frymoyer NP. Physician-Patient Communication: A Lost Art? JAAOS. 2002 May; 10(2):95-105

Garfield CF, Isacco A. Fathers and the Well-child Visit. Pediatrics. 2006 Aug; 117(4):637-45

Goore Z, Mangione-Smith R, Elliott MN, McDonald L, Kravitz RL. How Much Explanation is Enough? A Study of Parent Requests for Information and Physician Responses. Ambul Pediatr. 2001;1(6):326-332

Hardoff D, Schonmann S. Training Physicians in Communication Skills with Adolescents using Teenage Actors as Simulated Patients. Medical Education. 2001 Nov; 35(3):206-10

Harrington NG, Norling GR, Witte FM, Taylor J, Andrews JE. The Effects of Communication Skills Training on Pediatricians’ and Parents’ Communication During “Sick Child” Visits. Health Communication. 2007; 21(2):105-114

Hart CN, Drotar D, Gori A, Lewin L. Enhancing Parent-Provider Communication in Ambulatory Pediatric Practice. Patient Educ Couns. 2006 Feb; 63:38-46

Howells RJ, Davies HA, Silverman JD. Teaching and Learning Consultation Skills for Paediatric Practice. Arch Dis Child. 2006 Aug; 91(4):367-370.

Kleiner KD, Akers R, Burke B, Werner EJ. Parent and Physician Attitudes Regarding Electronic Communication in Pediatric Practices. Pediatrics. 2002 May; 109(5):740-744

Korsch BM, Gozzi EK, Francis V. Gaps in Doctor-Patient Communication. Pediatrics. 1968 Nov; 42(5):855-871

Lewis CC, Pantell RH, Sharp L. Increasing Patient Knowledge, Satisfaction, and Involvement: Randomized Trial of a Communication Intervention. Pediatrics. 1991 May; 88(2):351-358

Mendelsohn JS, Quinn MT, McNabb WL. Interview Strategies Commonly Used by Pediatricians. Arch Pediatr Adolesc Med. 1999 Sep; 153(2):154-157

Nobile C, Drotar D. Research on the Quality of Parent-Provider Communication in Pediatric Care: Implications and Recommendations . J Dev Behav Pediatr. 2003 Jan; 24(4):279-90

Nova C, Vegni E, Moja EA. The Physician-Patient-Parent Communication: A Qualitative Perspective on the Child’s Contribution. Patient Educ Couns. 2005; 58:327-333

O’Keefe M. Should Parents Assess the Interpersonal Skills of Doctors Who Treat Their Children? A Literature Review. J. Paediatr Child Health. 2001 Dec; 37(6):531-8

Pantell RH, Stewart TJ, Dias JK, Wells P, Ross AW. Physician Communication with Children and Parents. Pediatrics. 1982 Sep; 70(3):396-402

Participants in the Bayer-Fetzer Conference on Physician-Patient Communication in Medical Education. Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement Academic Medicine. 2001 Apr; 76: 390-3

Paul M. Rights. Arch Dis Child. 2007; 92:720-725

Rang M. The Easter Seal Guide to Children’s Orthopaedics: Prevention, Screening and Problem Solving. Ontario

Rider EA, Keefer C. Communication Skills Competencies: Definitions and a Teaching Toolbox. Medical Education. 2006 Nov; 40:624-629

Rosen P, Kwoh CK. Patient-Physician E-mail: An opportunity to transform pediatric health care delivery. Pediatrics. 2007; 120:701-706

Sarwark JF. Put Pediatric Patients and Parents in the Picture. Bulletin of AAOS. 2004 Apr

Shiminski-Maher T. Physician-Patient-Parent Communication Problems. Pediatr Neurosurg 1993 Sep; 19:104-108

Stebbing C, Wong ICK, Kaushal R, Jaffe A. The Role of Communication in Pediatric Drug Safety. Arch Dis Child. 2007 Apr; 92(5):440-445

Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, et al Physician Scores on a National Clinical Skills Examination as Predictors of Complaints to Medical Regulatory Authorities. JAMA. 2007 Sep; 298(9):1057-1059

Tates K, Elbers E, Meeuwesen L, Bensing J. Doctor-Parent-Child Relationships: a 'pas de trois'. Patient Educ Couns. 2002; 48:5-14

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 Feb;28(1):109-16

Tates K, Meeuwesen L. ‘Let Mum have her say’: Turntaking in Doctor-Parent-Child Communication. Patient Educ Couns. 2000; 40:151-162

Tates K, Meeuwesen L. Doctor-Parent-Child Communication: A (re)view of the Literature. Social Science and Medicine. 2000 Sep; 52:839-851

Tongue JR, Epps HR, Forese LL. Communication Skills for Patient-centered Care: Research-based, easily learned techniques for medical interviews that benefit orthopaedic surgeons and their patients. JBJS. 2005; 87A: 652-658

van Dulmen AM, Holl RA. Effects of Continuing Pediatric Education in Interpersonal Communication Skills. Eur J Pediatr. 2000 Sep; 159:489-495

van Dulmen AM. Children’s Contributions to Pediatric Outpatient Encounters. Pediatrics. 1998 Jan; 102(3):563-568

van Dulmen S. Pediatrician-Parent-Child Communication: Problem-related or Not? Patient Educ Couns. 2004; 52:61-68

Wassmer E, Minnaar G, Aal NA, Atkinson M, Gupta E, Yuen S, Rylance G. How do Paediatricians Communicate with Children and Parents? Acta Paediatr. 2004; 93:1501-6

Wright JAM. The Child Whisperer. BMJ. 2002 Apr; 325:1141

Wu AC, Leventhal JM, Ortiz J, Gnzalez EE, Forsyth B. The Interpreter as Cultural Educator of Residents. Arch Ped Adolesc Med. 2006 Nov; 160(11):1145-1150