In the event that you are treating a child, remember that before you read the X-ray, you must read the patient…and know that they—and their family members—are reading you. Dr. John Purvis, associate professor of orthopedics at the University of Mississippi Medical Center, has devoted a significant amount of time to finding the most appropriate and effective ways of communicating with pediatric patients. And he knows it’s a delicate dance.
Dr. Purvis: “Unlike when you have just one other person in the room, and that person is an adult, when you have a pediatric patient, there is always a parent or other family member in the room. This triangular structure means that attention to one’s communication skills is of heightened importance. Unfortunately, there are not many formal venues where orthopedists can learn such skills. While the American Academy of Orthopaedic Surgeons (AAOS) has increasingly emphasized communication skills, their mentoring programs and nationwide courses have not focused on children as patients.”
From Babies to Teens
If your patient shows up in an infant carrier, rest assured you won’t be directing comments about knock knees to him. “When you have an infant, ” says Dr. Purvis, “the environment is especially important. See if they are more comfortable on their mother’s lap or on the exam table. Do they hear babies crying down the hall? Are there games or toys for them to play with? Can they see mom at all times? Try to keep a calm look on your face and watch your tone of voice. And if the parent is anxious, try to diffuse that if possible. Finally, rely on the parent to tell you what the infant’s nonverbal cues mean.”
Moving up the sophistication scale, we have the little explorer…the toddler.
Use the stethoscope or other instrument on the parent first; then allow the child to hold the instrument while you talk about it a little. You can also do the same with a doll or puppet. You want to explain things as the process moves along, doing your best to ensure that they understand the basics of what you’re saying.
With preschoolers, says Dr. Purvis, be direct and concrete. “Use very simple language and along the way, ask if they are ready for the next step before you proceed. Have little rewards on hand—such as crayons or stickers—that you can give them to promote a more positive impression of ‘a trip to the doctor’s office.’”
If a ten-year-old is poking around the office, notice what he or she is interested in. “Home in on what captures their attention (equipment, etc.), explain it, and see what they think about it. Ask what they think about coming to the doctor, and try to make them comfortable expressing their feelings and/or concerns.”
Courtesy of AAOSAnd if you have a teenager with his head down and thumbs going 40 miles an hour, embrace that as well. Dr. Purvis states, “Recognize that teens may resent being in a pediatric office, and see if you can determine what they are interested in. On occasion, I have started texting my teen patients right from the office. They love that, and I immediately have their attention. Although you should be communicating more with the teen than the parent, it is hard to draw them out. You may have a tough football player with a minor injury who doesn’t want to play football. But the dad, who is in the room, wants him to play. The teen may not feel comfortable talking in front of his dad, so you can ask the parent to give you a few minutes alone with their child.”
When engaging teenagers, advises Dr. Purvis, “Try to give them credit for who they are and engage them with your acceptance. Black fingernail polish or sagging pants may turn you off a bit, but respect their expression of individuality and let them know that it’s not a roadblock to communicating. But don’t make the mistake of asking open ended questions. So often if you ask a teenager, ‘What questions do you have?’ they will not reply. However, if you rephrase that to something like, ‘What are you wondering about?’ or ‘whatcha thinking?’ then that always gets some sort of response.”
The Four ‘E’s of Pediatric Communication
“My colleagues at AAOS have taught a successful method of communicating with patients that can be modified for youngsters, namely, the four ‘E’s: First, engage the patient with an age appropriate technique. If it’s a young child, you may play peek-a-boo or hand them a stuffed bear. And you may want to sit in the corner until they seem comfortable. If you’ve got an eight year old who is on the football team, you can ask about that or inquire about a recent movie or TV show. They tend to hate it if you ask about school, though.
“The second ‘E’ is empathy. Notice, for example, if the child is reluctant to speak in front of the parent. You may want to have a female nurse as an intermediary. Or, you may say to the parent, ‘I want to hear your observations, but let’s start by my talking to your son alone for a few minutes.’”
Dr. Purvis continues,
Then we come to ‘education.’ Let a young patient see her or his X-ray and give them a printed copy for their refrigerator door. Try to have the child name the specific diagnosis and repeat it. When finished with your explanation, ask them what they understand about their condition and the plan. We frequently think we’ve explained things very clearly, but the real test is for them to ‘give it back’ to you. For the school age child, you might ask them what they are going to tell their friends about why they have a cast on.
“Additionally, you should do your best to make it clear that their condition is not their fault—something especially important when you’re dealing with something like scoliosis. With ‘enlistment, ’ the fourth ‘E, ’ you can get their input on a plan of action. Get their ideas and then say, for example, ‘Here are your personal exercises. The more you do them, the sooner you can get back to soccer.”
So much of communication depends on what kids understand about their bodies. Dr. Purvis: “If a child can understand, for example, the basic difference between the cervical spine and lumbar spine, then they feel more in control and less anxious. AAOS and the Pediatric Orthopaedic Society of North America have developed some fantastic visual aids known as Boney Ben and Muscle Molly, cartoon drawings that include some basic anatomy. Items such as this help kids open up and talk about their bodies.”
Communicating with Patients and their Families
One situation where it may be particularly difficult for anyone in the room to open up is one where you have divided families. “The parents may be sitting far apart in the room, and the tension may be palpable. They could each have a different agenda about the child’s treatment. Perhaps the father has brought the child in after ‘his’ weekend, and the mother is upset that he waited until Monday morning to get medical attention for the child. Sometimes it is the case that dad should have gotten Johnny treatment earlier, but at times mom is just trying to be difficult because it has been a bad divorce.”
Get down to it, however, and parents are just looking for reassurance. “Lots of parents use the words ‘make sure.’ They want to ‘make sure’ their child is not going to always be bowlegged or ‘make sure’ they don’t have anything bad. It’s pretty tough to ‘make sure’ about the future, or to rule out every possible disease. You can tell the parent, ‘We can make sure together that we’re going to fully investigate any symptoms, discuss what we expect to happen over what time period, and you can come back to see me if those expectations are not what happens.’ We can ‘make sure’ that we care about their child.”
Final thoughts? “Just don’t forget to include them, ” advises Dr. Purvis. “Don’t ignore them. Don’t just focus on the parent. Let them know that their vote counts.”
