This project has been funded with support from the European Commission.
This web site reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein.
Training of Lecturers
Training for Paediatricians and Paediatric Students
Multilanguage dictionary of medical terms
-
Contractual Partners
From this section it is possible to access to a description of each contractual partner of the Softis-Ped project.
-
Lecturers
From this section it is possible to access to the information about the paediatric lecturers involved in the Softis-Ped Project in the 5 European countries involved.
-
Residents Working with Children Information
From this section it is possible to access to the information about the paediatricians involved in the Softis-Ped Project in the 5 European countries involved.
-
Paediatric students
From this section it is possible to access to the information about the paediatric students involved in the Softis-Ped Project in the 5 European countries involved.
-
Associated Partners
As a result of the exploitation activity a number of associated partners officially joined the project in order to contribute to the improvement of the project impact on their target groups and to ensure the project sustainability by continuing using the project deliverables in the next years.
Events
The Softis-Ped project has been promoted trough conferences and articles.
-
Conferences
The Softis-Ped project was presented in a number of events in order to report about the activities carried out and the results achieved
-
Training Activity
The training activity 'Soft Skills in Pediatrics' was held at the University of Medicine and Pharmacy of Tirgu Mures (RO)
-
Press Review
The Softis-Ped project partnership made contacts with web sites focusing on the fields of paediatrics and education
This section of the Softis-Ped portal provides administrative information for the project contractual partners and for the European Commission and it is password protected.
Training for Paediatricians and Paediatric Students
Homepage > Training > Training for Paediatricians and Paediatric Students
This training package is addressed to students and medical practitioners in paediatrics on how to autonomously learn, develop and consolidate their soft skills for improving the quality of paediatric services.
Communication with Children
1.3 Asking Questions, Teach Back and Show me, Reflection, Mirroring, and Other Communication Techniques
In gathering information about child patients and exploring their problems, pediatricians will encourage them to tell the story of their problems, from when problems first started to the present, in their own words. If a parent monopolizes the conversation and answers questions directed at a 12-year-old child, an effective response would be: “Let me ask Mihai to tell me how he feels to fill in the information a bit. Is that okay? (addressing both mother and patient). (Palazzi, p.23 )
Pediatricians need to encourage children both verbally and through an open and warm attitude to express their feelings and elicit their beliefs and reactions. Older children or adolescents are allowed to tell their own stories first and they are also given the last word in the conversation. For children who are initially hesitant in responding, pediatricians should ask them to tell in their own words what is wrong after establishing the chief complaint from the parent. Children and adolescents are also allowed to express their opinions and feelings, and this will be facilitated with questions.
Pediatricians shouuld not jump to conclusions about or trivialize a child’s or adolescent’s perspective or concern. What may not seem like a problem to us, may be an important issue for the child. (Palazzi, p.61)
To do this, pediatricians will employ some/all the strategies and techniques presented below:
Use open and closed questioning technique, appropriately moving from open to closed.
By 7 years of age, the child develops the ability to relate a coherent narrative that follows a simple story format.
Ask Questions that yield information and offer support. Asking questions is a way of expressing interest and getting the patient’s perspective on the health concern that is the reason for the clinical encounter. It is also essential to gather the information needed to make an accurate diagnosis and provide appropriate care. Open-ended questions will engage the patient more than a “yes” or “no” answer.
What if the patient continues to talk without addressing the issues? Nguyen et al. (2013) suggest asking, “Would it be okay if I interrupt you to ask some specific questions?”
When closed-ended questions are required, try to alternate them with open-ended ones to keep the patient involved and avoid the appearance of a rushed approach. Introduce a series of closed-ended questions by saying, “Now I’d like to ask you several questions that will give me some important information….” Move gradually from less threatening areas of inquiry to those that may be more alarming or difficult for the patient to understand and respond to. (Cullins, V.)
Invite questions using body language, sitting at the same level as the patient, and looking at the patient not at the chart or the computer when talking and listening. Solicited questions could be:
Attentive listening, allowing patients to finish statements without interrupting them, leaving time for patients to think before they answer. Show that you are listening by both verbal and non-verbal responses. Direct the patient with open imperatives, “Tell me more about that.” or open questions, “How did you feel about that?” Do not go into specific questions too early.
Encouragement, silence, repetition, paraphrasing or interpretation should be present whenever necessary.
Reflection. This technique involves repeating a significant word or phrase that the patient has just said. It is particularly useful when a patient has talked about his or her feelings. It is a safe technique in that you are not offering an interpretation; you are simply indicating that you heard what the patient said and perhaps are inviting him or her to elaborate on it.
Clarification. Clarifying is a higher skill level than reflecting. It means rewording or defining what the patient has said. Clarifying can help patients or parents recognize and understand their feelings:
Physician: “So it sounds to me like you’re saying that he makes you so angry that you feel as if you could hurt him.” (It is important to acknowledge that you are offering an interpretation, with which the patient or parent may or may not agree.)
Mirroring. This shows the patient or parent her feelings as you perceive them.
This can encourage the patient to come to grips with feelings that he or she was not quite ready to express. Mirroring and clarification are closely related and can overlap.
Use teach-back or show-me techniques (Schillinger et al., 2003). Ask patients/parents to demonstrate understanding. Avoid asking, “Do you understand?” Patients will frequently answer “yes” even if they understand nothing. According to the Agency for Healthcare Research and Quality (AHRQ),“Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands.” That is why, teach-back is also called demonstration or re-demonstration.
Teach-back to an adolescent: “I want to be sure I explained how to take this medicine clearly. Can you please explain it back to me so I can be sure I did?”
Show-me to a school-aged child: “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure that I did.” “Please show me how you keep the thermometer.”
Platt and Gordon (2004) point out that validation is a critical part of listening. It means explaining to the patient how you interpret what he or she told you and modifying that interpretation if the patient sees it differently.
Summarizing during the interview. Summarizing during an interview is a powerful technique to verify that you understand the patient correctly (Boyle et al., 2005). It also provides the patient with an opportunity to add to the narrative.
Periodical summaries verify own understanding of what the patient has said. If it is the case, pediatrician invites patient to correct interpretation or provide further information.
Pediatricians need to encourage children both verbally and through an open and warm attitude to express their feelings and elicit their beliefs and reactions. Older children or adolescents are allowed to tell their own stories first and they are also given the last word in the conversation. For children who are initially hesitant in responding, pediatricians should ask them to tell in their own words what is wrong after establishing the chief complaint from the parent. Children and adolescents are also allowed to express their opinions and feelings, and this will be facilitated with questions.
Pediatricians shouuld not jump to conclusions about or trivialize a child’s or adolescent’s perspective or concern. What may not seem like a problem to us, may be an important issue for the child. (Palazzi, p.61)
To do this, pediatricians will employ some/all the strategies and techniques presented below:
Use open and closed questioning technique, appropriately moving from open to closed.
E.g. Open-ended inquiry: “Tell me about yourself and what brings you here today.”
By 7 years of age, the child develops the ability to relate a coherent narrative that follows a simple story format.
Ask Questions that yield information and offer support. Asking questions is a way of expressing interest and getting the patient’s perspective on the health concern that is the reason for the clinical encounter. It is also essential to gather the information needed to make an accurate diagnosis and provide appropriate care. Open-ended questions will engage the patient more than a “yes” or “no” answer.
E.g. How would you describe the pain? How often does this occur? How have you handled this problem in the past?
What if the patient continues to talk without addressing the issues? Nguyen et al. (2013) suggest asking, “Would it be okay if I interrupt you to ask some specific questions?”
When closed-ended questions are required, try to alternate them with open-ended ones to keep the patient involved and avoid the appearance of a rushed approach. Introduce a series of closed-ended questions by saying, “Now I’d like to ask you several questions that will give me some important information….” Move gradually from less threatening areas of inquiry to those that may be more alarming or difficult for the patient to understand and respond to. (Cullins, V.)
Invite questions using body language, sitting at the same level as the patient, and looking at the patient not at the chart or the computer when talking and listening. Solicited questions could be:
E.g. What questions do you still have? Avoid asking: Do you have any questions? This will lead to a quick No – for polite reasons or maybe fear.
Attentive listening, allowing patients to finish statements without interrupting them, leaving time for patients to think before they answer. Show that you are listening by both verbal and non-verbal responses. Direct the patient with open imperatives, “Tell me more about that.” or open questions, “How did you feel about that?” Do not go into specific questions too early.
Encouragement, silence, repetition, paraphrasing or interpretation should be present whenever necessary.
Reflection. This technique involves repeating a significant word or phrase that the patient has just said. It is particularly useful when a patient has talked about his or her feelings. It is a safe technique in that you are not offering an interpretation; you are simply indicating that you heard what the patient said and perhaps are inviting him or her to elaborate on it.
E.g. Patient: “Sometimes I wake up at night wheezing and scared because I can’t breathe.” Physician: “So, wheezing and feeling scared and not able to breathe.”
Clarification. Clarifying is a higher skill level than reflecting. It means rewording or defining what the patient has said. Clarifying can help patients or parents recognize and understand their feelings:
E.g. 1. To a child who says he feels ’light-headed’: ’Could you explain what you mean by ’light-headed’?
E.g. 2. To a parent who says: “When he has a tantrum like that and screams for no reason, it gets to me, really gets to me. I feel like screaming myself. I get so angry, so angry. I just want to make him stop. I’m almost as out of control as he is.”
Physician: “So it sounds to me like you’re saying that he makes you so angry that you feel as if you could hurt him.” (It is important to acknowledge that you are offering an interpretation, with which the patient or parent may or may not agree.)
Mirroring. This shows the patient or parent her feelings as you perceive them.
E.g. “You look very sad when you talk about that, Edgar. You look as if you want to cry.”
This can encourage the patient to come to grips with feelings that he or she was not quite ready to express. Mirroring and clarification are closely related and can overlap.
Use teach-back or show-me techniques (Schillinger et al., 2003). Ask patients/parents to demonstrate understanding. Avoid asking, “Do you understand?” Patients will frequently answer “yes” even if they understand nothing. According to the Agency for Healthcare Research and Quality (AHRQ),“Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands.” That is why, teach-back is also called demonstration or re-demonstration.
E.g.Teach-back with a small child: “What will you tell your baby doll about your tummy ache?”
Teach-back to an adolescent: “I want to be sure I explained how to take this medicine clearly. Can you please explain it back to me so I can be sure I did?”
Show-me to a school-aged child: “I want to be sure I explained everything clearly. Can you please explain it back to me so I can be sure that I did.” “Please show me how you keep the thermometer.”
Platt and Gordon (2004) point out that validation is a critical part of listening. It means explaining to the patient how you interpret what he or she told you and modifying that interpretation if the patient sees it differently.
E.g.To a teenager: “Let me make sure that I have it right. You were angry because you felt the medicine was actually making the pain worse, but no one would listen.”
Summarizing during the interview. Summarizing during an interview is a powerful technique to verify that you understand the patient correctly (Boyle et al., 2005). It also provides the patient with an opportunity to add to the narrative.
E.g. Explain why you are summarizing: “Could we summarize to be sure that I understand what you told me?”
Periodical summaries verify own understanding of what the patient has said. If it is the case, pediatrician invites patient to correct interpretation or provide further information.
Practical Applications
Scenario 5 - Asking questions, teach back and show me, reflection, mirroring, and other communication techniques
The scenario describes an encounter between a pediatrician and Ilinca, an 8-year-old girl who was admitted with her mother due to persistent abdominal pain, constipation, and intermittent rectal bleeding. The mother had administered several treatments without any improvement for approximately 1 year. Thus, being very concerned about her daughter’s condition, she came to the emergency department with her daughter and admitted her. The pediatrician enters the room, and with a calm and warm voice she introduces herself.
The scenario underlines the importance of using open questions to elicit the patient’s story and slowly moving to closed questions. The pediatrician listens carefully, uses simple language, repetitions, asks for clarification and the teach-back technique checks the patient’s understanding. Mirroring shows the patient how the doctor perceives his pain and condition. The pediatrician supports her communication with appropriate non-verbal behaviour, eye contact, open posture and postion, maintains eye contact, uses vocal cues: adequate rate of speech for a child, volume and a warm tone
Softskills in the video: use of open questions, introducing and addressing the child patient, allowing the child to describe the pain, mirroring, repetitions and summarizing, speak at a pace at which both parent and child can take in information, the teach-back technique.
The Transcript in English is available
The scenario underlines the importance of using open questions to elicit the patient’s story and slowly moving to closed questions. The pediatrician listens carefully, uses simple language, repetitions, asks for clarification and the teach-back technique checks the patient’s understanding. Mirroring shows the patient how the doctor perceives his pain and condition. The pediatrician supports her communication with appropriate non-verbal behaviour, eye contact, open posture and postion, maintains eye contact, uses vocal cues: adequate rate of speech for a child, volume and a warm tone
Softskills in the video: use of open questions, introducing and addressing the child patient, allowing the child to describe the pain, mirroring, repetitions and summarizing, speak at a pace at which both parent and child can take in information, the teach-back technique.
The Transcript in English is available
Scenario 6 - Asking questions, teach back and show me, reflection, mirroring, and other communication techniques
The scenario describes an encounter between a pediatrician and Ilinca, a 10-year-old girl who was admitted for wheezing and the inability to breathe. After a few hours of oxygen therapy and different medications, she feels better. The pediatrician enters her room, she smiles gently and discusses with her.
The scenario underlines the importance of using open questions to elicit the patient’s story and slowly moving to closed questions. The pediatrician listens carefully without interruption, uses simple language, repetitions, asks for clarification and the teach-back technique checks the patient’s understanding. Mirroring shows the patient how the doctor perceives her pain and condition. The pediatrician supports her communication with appropriate non-verbal behaviour, eye contact, open posture and postion, maintains eye contact, uses vocal cues: adequate rate of speech for a child, volume and a warm tone.
Softskills in the video: open questions, simple language and repetitions, teach-back technique, mirroring, appropriate non-verbal behaviour, appropriate nonverbal behaviour.
The Transcript in English is available
The scenario underlines the importance of using open questions to elicit the patient’s story and slowly moving to closed questions. The pediatrician listens carefully without interruption, uses simple language, repetitions, asks for clarification and the teach-back technique checks the patient’s understanding. Mirroring shows the patient how the doctor perceives her pain and condition. The pediatrician supports her communication with appropriate non-verbal behaviour, eye contact, open posture and postion, maintains eye contact, uses vocal cues: adequate rate of speech for a child, volume and a warm tone.
Softskills in the video: open questions, simple language and repetitions, teach-back technique, mirroring, appropriate non-verbal behaviour, appropriate nonverbal behaviour.
The Transcript in English is available
Online Resources
- Teach-back: communicating more effectively with patients to improve health outcomesIt offers further details on communication aspects in pediatrics
- Debra L Palazzi, Martin I Lorin, Teri L Turner, Mark A Ward, Antonio G Cabrera (2015) Communicating with Pediatric Patients and their Families: the Texas Children’s Hospital Guide for Physicians, Nurses and other Healthcare Professionals, Houston TX, by Texas Children’s HospitalIt is a comprehensive guide to communication in pediatrics
- Schillinger et al., 2003 Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health LiteracyIt offers information about communication strategies in pediatrics, especially with diabetic patients.
- Cullins, V.E. et al (Eds) Communicating with patients. A quick reference guide to clinicians.It offers information about communication strategies in pediatrics.
- Platt FW, Gordon GH. (2004) Field guide to the difficult patient interview. Philidelphia: Lippincott Williams & Wilkins, Teach back techniqueThe article offers details on the teach-back strategy. Please also check https://www.youtube.com/watch?v=e5jxeZWM3tw.
