Let your pediatric patients bring out the kid in you

Some orthopaedists are less than comfortable with children while others more easily relate to them. If you are young at heart—or remember what it was like to play—you may have an easier time, but every orthopaedist can use the four Es—engagement, empathy, enlistment, and education—to facilitate communication with pediatric patients. This article focuses on ways to engage and empathize with pediatric patients and their parents.

The opening gambit
Introductions and a warm welcome are the appropriate first steps during any patient visit, but you may need to temper your approach based on the age of the patient. Take your cues from the patient. When you enter the examination room, quickly appraise the patient’s posture and location for clues about how approachable the patient will be. A child who buries her head under her mother’s elbow requires a much different approach than one who’s comfortably playing with toys.

Toddlers and young children usually prefer to be ignored. In that case, it’s okay to focus on the adult(s) in the room. But if the patient is old enough to talk, don’t ignore him or her or you’ll find yourself being ignored.

Offering a smile and knuckle rap to an 8-year-old, or a compliment and handshake to a teenager, can be a winner even before you greet the parents. Finding out who’s who in the room beats out just assuming what the relationships might be. Sitting down (or even getting down) and maintaining eye contact works well regardless of the patient’s age.

Engagement: A chance to build rapport
The first few minutes of a clinic visit are important for building rapport with both the patient and the parents. Your connection should be both on a person-to-person and on a professional basis. Perhaps the best way to engage parents is to engage their child. That’s particularly true if the child has a chronic physical or mental impairment.

Nonverbal strategies such as sharing toys, playing peek-a-boo, and gently touching are frequently used to build rapport with infants and toddlers. With school-aged children, talking is the most common strategy. Investing a little curiosity about the child’s hobbies, sports, pets, or siblings can pay off with freer communication later.

“Before we begin, tell me a little about yourself …” is a good way to start a conversation. Ask about goals or expectations for the visit, and then summarize the patient’s and the parent’s issues so that you can engage their agenda. Share your plans for the visit in terms they can understand, whether it’s “no shots today, for sure!” or “I want to get a picture of that elbow.”

Empathy: Focus on the patient
The ability to connect with others (infant, child, teen, or parent) is a combination of art and process. Listening to their stories and appreciating their feelings, values, and thoughts can be difficult due to time constraints, input from multiple sources, and varying levels of intelligence and understanding.

At times, the child does not know why he or she came to see the doctor and the parent or concerned grandparent runs the show. Preschool-aged children can often answer questions about their medical history; as they get older, their answers become more reliable. Children frequently need encouragement to tell their stories, in contrast to parents whose interruptions might require a little tactful discouragement.

Age-appropriate questions are better than a formal inquisition. If the child is upset or disruptive, you may need to employ calming strategies similar to those used to build rapport. Using a pleasant and consistent tone of voice and asking open-ended questions can help children open up to you. Even if they are reluctant to fully disclose what they are experiencing, your tone and patience will let them know you understand. Allow time to listen to and acknowledge the patient’s story, then supplement it with the parent’s observations.

What works for me may work for you
Studies have found that practicing pediatricians approach children of specific ages and development in similar ways when conducting a patient interview. Common, age-appropriate techniques have traditionally been taught by example and learned by trial and error.

Although an article in AAOS Now can’t replace personal experience or offer a full curriculum, it might encourage us all to share what works well. Got tips? Please send them to me or to aaoscomm@aaos.org

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

Editor’s note: This is the second in a four-part series on the challenges of communicating with pediatric patients. Articles are based on a panel symposium held at the 2008 annual meeting of the Pediatric Orthopaedic Society of North America (POSNA); the first article appeared in the February 2009 issue of AAOS Now.

Pediatric communication tips

• Pay a compliment: “Hey, you look terrific today!” can warm up a shy, awkward teen. But be truthful; children can see through false compliments.
• Listen well: All ages appreciate attentive listening. Show you are paying attention by nodding, encouraging, reflecting, and summarizing. Kids can say the funniest things!
• Watch your body language: Your body position and attitude speak louder than your words. Keeping your distance from infants, while attentively leaning in to parents, can be a balancing act.
• Be aware of surroundings: Engagement goes smoother when babies are in warm, quiet surroundings; when children have toys in the room and a parent’s lap to sit on; and when teens aren’t in a room with pink teddy bears painted all over the walls.
• Be personal: Make a note about something personal that you can follow up on during a return visit. “How was that cheerleading camp?” not only shows you care, it may also open up new avenues of communication.

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