Are docs listening to kids, their parents — or both?

3-way communication presents a delicate balance

A 7-year-old child complains of recurring stomachaches, so his mother takes him to a physician’s office. To find out about pain, eating habits, and possible causes, does the doctor ask the parent — or the child?

While most would say the conversation should involve both, physicians often struggle to find a balance in the triangular communication that is an inherent part of children’s health. In fact, one study indicates that physicians favor the parents at the expense of learning more information from kids.1

"The main thing you see in pediatrics is that the doctors talk to kids and are very pleasant and reassuring to the children, but they don’t ask them for very much information, and they don’t get very much information from them," says Larry Wissow, MD, MPH, a child psychiatrist who studied communication patterns in a pediatric emergency setting with children ages 4 to 9.

"What they mostly do is talk to the parents," says Wissow, an associate professor of health policy at the Johns Hopkins School of Hygiene and Public Health in Baltimore. "If there’s any flow, it’s being directive to the kids, getting some information from the kids, and then turning around and talking to the parents. The parents get pretty much all the education; the parents get most of the questions."

In contrast, some physicians have trouble relating to parents, who can range from overanxious to unconcerned. "I have worked with a lot of pediatricians who went into pediatrics because they love kids, and they forgot they had to deal with parents until they got in," says Vaughn Keller, EdD, associate director of the Bayer Institute for Health Care Communication in West Haven, CT. "That became their major challenge."

Managing the parent-child-physician dynamic has broad implications for outcomes, Wissow says. How well physicians engage both parents and children will influence parent satisfaction with care and a child’s likelihood to follow treatment advice, he says.

Start early to set good habits for kids

Encouraging children to participate in their care also sets up habits that children will carry into adulthood, notes Barbara Korsch, MD, a leading researcher of doctor-patient communication and author of The Intelligent Patient’s Guide to the Doctor-Patient Relationship.

"It encourages good attitudes toward health care," says Korsch, who is a professor of pediatrics at Children’s Hospital of Los Angeles. "If the doctor treats children with respect, they will be more inclined to [seek needed medical care] than if he treats them as passive victims."

In the early years of a child’s life, physicians clearly focus most of their questions and information toward the parent. The parent expects not only a level of information from the visit but varying degrees of interpersonal sensitivity and partnering.

That match between a parent’s expectations and physician’s style will impact the success of the office visit, says Frances Prevatt, PhD, director of the school psychology program at Florida State University in Tallahassee.

In a study at a small pediatric group practice, Prevatt found that parents who were happy with their interactions were less likely to call later with follow-up questions for physicians.2 The practice of five physicians fielded about 50 calls a day from parents, she says.

In fact, the study found that physicians often underestimated the parents’ needs for information, interpersonal sensitivity, and partnering.

"When there was a closer relationship between what the parents wanted and what parents thought the physicians were giving them, they did better [on measures such as patient satisfaction]," Prevatt says.

As soon as a child becomes verbal, the physician can address some comments or questions to him or her, says Wissow. "You can set the stage very early on that you’d like the child’s input," he says.

From then on, the three-way dynamic will shift as the child’s competence and sense of independence increases, and the parent’s own confidence grows. How do physicians cope with the ever-changing communication needs?

"They have to do a lot more permission-asking," says Keller. "They cannot make the assumptions that internists can make. They have to ask the mom or dad permission for things. Later, they have to ask the kid’s permission. Do you want your mother with you? Do you want your father with you? They’re always testing the relationship, and they have to do that out front and verbally."

Train all parties to communicate

At the University of California at San Francisco, pediatrician Robert H. Pantell, MD, found that even a short educational intervention could improve communication if it is directed at all parties — parents, physicians, and children.3

In his study, children ranging in age from 5 to 15 saw a 10-minute videotape in which a child actor demonstrated how to ask doctors questions and become more active participants in their care. Patients also received workbooks to write down possible questions or information they learned from physicians.

Parents and physicians also viewed targeted videotapes about increasing the involvement of parents and children in medical encounters. As a result, physicians directed more of their recommendations to the child or child and parent, and children increased their participation. Children also reported a greater rapport with the physician and a higher preference for an active role in medical visits.

"Bob Pantell’s work has shown that if you have a normally developed child, at 5 or 6 years of age, they should be asked to participate," says Korsch. "By [ages] 7, 8, and 9, they are great sources of information."

References

1. Wissow LS, Roter D, Bauman LJ, et al. Patient-provider communication during the emergency department care of children with asthma. Med Care 1998; 36:1,439-1,450.

2. Worchel FF, Prevatt BC, Miner J, et al. Pediatrician’s communications style: Relationship to parent’s perceptions and behaviors. J Pediatr Psychol 1995; 20:633-644.

3. Lewis CC, Pantell RH, and Sharp L. Increasing patient knowledge, satisfaction, and involvement: Randomized trial of a communication intervention. Pediatrics 1991; 88:351-358.