Training for Paediatricians and Paediatric Students

1.2 Using Simple Language and Repetition of Key Terms in Communicating with Children

“Think like a wise man but communicate in the language of the people.”
(Poet William Butler Yeats Quotes, 2001)

When interacting with child patients, pediatricians offer a certain amount of information about what they are going to experience, investigations or tests they will need to perform or about the results obtained, according to their level of cognitive development and understanding. Understanding the explanations will lead to the children’s better adherence to therapy.

What does adaptation to the child’s level of understanding mean? For a two- or three-year-old, it would be appropriate to say that you are now going to look in the other ear or listen to the child’s chest. For the older child or adolescent, you would probably just put your stethoscope to the chest and say, “Take a deep breath.” A friendly smile, a gentle touch and small talk can be helpful for children of all ages, and jokes will make the examination less frightening for the young child: “Well, I didn’t see any potatoes growing in your ear.” or “I thought I heard some barking in there (after listening to the abdomen).

The pediatrician should use concise, easily understood language, and avoid or adequately explain medical jargon (using drawings, charts).

Explain in simple language. Children are generally both curious and concrete in their thinking. They will appreciate an explanation of what the pediatrician is going to do and why, in developmentally appropriate language. Explaining what is going to happen next, whether it is a test, an investigation or surgery, will help the patient cope with the illness. Most children have difficulty dealing with uncertainty, and imagined thoughts about what is going to happen to them can be frightening. The more complex the plan, the more challenging it is to be sure that the patient really understands it.

Use repetition and summarise or reinforce information. Repetition is useful in physician-patient and physician-family conversations. Families under stress have difficulty retaining information. Fear, anxiety and emotional distress can cause patients as well as parents to place more significance on individual words and expressions rather than on the contextual conversation (Haney, 1991). Moreover, patients and parents will not remember everything that the pediatrician said, but they will remember how it was said, especially the amount of empathy with which the message was delivered (Luntz, 2007). Repetition helps clarify salient facts. Parents and children should be told the same diagnosis, with the same explanation and the same language as often as needed until they understand.

Check if the child and parent understand your explanations. Even if you think you have explained everything in simple language, there may be place for improvement and key terms should be repeated. A yes answer to, “Do you understand?” does not mean that they comprehended. Many patients and their parents are embarrassed to admit that they don’t understand or think they understand when they do not. The question, “Is there something that I haven’t made clear or something that you would like me to clarify?” is strong encouragement for the child or parent to ask for clarification.

The pediatrician checks understanding of information given or plans made by asking the patient to restate in own words through the Tell/teach-back technique: a child is asked to repeat to the doctor or to another member of the family/or his/her teddy-bear what he/she has to do. This is an effective repetition strategy through which the doctor makes sure that everything important was well understood. For the verbal child, asking, “Now Iulia, why don’t you tell us what’s going to happen today?” can be good feedback for both the doctor and the parent that Iulia has understood she will have to refrain from sweets and avoid strenuous physical exercise for a period of time. For an adolescent patient, the following invitation has the same role and effect: “So, let’s review what we’ve decided to do. Iulia, why don’t you review the plan for us?” The pediatrician clarifies if and as necessary.

The words you choose are very important. Speak in plain language and at the patient’s level of understanding. Avoid acronyms and medical jargon (i.e. med-speak). “The marrow was completely packed with blasts.” is not helpful to the parents of a child with newly diagnosed leukemia. “The bone marrow test confirmed leukemia.” is more easily understood. Not every lay person will understand, “The prognosis is guarded.” but they will easily understand, “His condition is very serious.” or “The outlook is not good.” When using medical terms, explain them, unless you know specifically that the patient or parent understands those terms. Rather than simply saying, “His hemoglobin has been decreasing.” explain, “His hemoglobin has been decreasing. Hemoglobin is the red material in the blood that carries the oxygen. When there is too little, that’s anemia.” Rather than saying, “The CT scan showed a space-occupying lesion.” explain, “The CT scan showed a mass, which might be a tumor.”

Before explaining, ask the patient and parent what they know about their disease/current situation. The pediatrician usually estimates the health literacy level of the parent and child but it is best to underestimate the literacy level, and it is a safe rule to talk to the family in language that the child, who is likely listening even if he or she does not appear to be, can understand. When communicating with a school aged child, it is important to know how he or she perceives the situation before explaining it. A simple question to a school aged child such as, “Why do you think you are here today?” may reveal their understanding or misunderstanding.

The explanations and instructions should be simple, uncomplicated. If the patient still does not understand, the pediatrician can use visual methods of conveying information: drawings, diagrams, models, written information and instructions

Explain the nature of the problem and the approach to diagnosis and treatment, including the rationale for tests and treatments. Explanations are followed by short pauses to let them absorb the information.

In the end, instead of asking “Any questions?”, while you are standing up and moving towards the door, an open-ended question such as: “What questions do you have?” while remaining seated can encourage the patient to ask for further explanations. If the pediatrician notices that the patient is a little confused, he can ask: “You look to me to be a bit uncertain. What can I clarify or go over again?” This is less intimidating than, “What don’t you understand?”

Principles of Communication by Patient Age

Sitting at the same eye level with the child. A technique often used by pediatricians to enhance communication and interaction with toddlers is for the examiner to get down to eye level with the child. This may require sitting on the floor or even lying on the floor to gain the patient’s attention and generate some degree of comfort. While this approach is unlikely to result in the most optimal physical examination of the child, the physician is still able to observe the child’s limb and body movements, flexibility, motor skills, breathing pattern, reluctance or refusal to assume certain positions, eye movement and response to sound and voice. (p.81)

Verbal communication with young children may prove difficult, depending on the child’s temperament and language development. For children 4 to 6 years of age, a sound approach is for the pediatrician to direct most of the visual contact and conversation to the child. Sitting on the examination table next to the patient and speaking directly to him or her is often effective in gaining the child’s trust. During some conversations, it is not unusual for a child to spontaneously divulge to the physician information considered more appropriate for personal family conversation. While this occasionally results in some embarrassment for the parent, the physician generally is able to maintain a professional verbal response and reaction, while suppressing the urge to laugh.

Older Children and Preadolescents.This age group is one in which conversation and communication between patient and physician are generally comfortable and open. The parent may accompany the child to the visitation, but the content of the verbal interchange is directed more to the child. Verbal input by the parent is highly important, but the pediatrician should make every effort to obtain the child’s opinion and viewpoint as well. During routine health visits, the conversation generally focuses on the child’s activities, school work, extracurricular achievements and peer group. It is appropriate, therefore, that the child be given the opportunity to provide this information. Ultimately, this empowers the child to express him or herself, instills a sense of being respected and helps to solidify the relationship between the pediatrician and the patient.

For All Age Groups. When speaking to pediatric or adolescent patients or to adults, it is imperative to use language and terminology that is clearly understandable to them. Avoid the use of medical jargon and explanations that are neither clear nor familiar to the listener. The physician should know that he or she is not communicating successfully when the patient remains quiet or has no questions. Even if some of the information provided was partially understood, it is helpful for the physician to ask the patient or family member to state what he or she heard with regard to the health problem, the possible diagnosis and the treatment plan.

Practical Applications

Online Resources

• 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