April 2004 Bulletin
Put pediatric patients and parents in the picture
Recognize the importance of communicating with pediatric patients and families
By John F. Sarwark, MD
What's that?” The little boy cries anxiously at the sight of the huge and somewhat ominous-looking machine.
“Oh, it's nothing,” his mother laughs nervously. “They're just going to take a picture of your hip to see what's wrong.”
“No, no,” the child screams and heads for the door.
This is not a scenario that has to happen. Any child's orthopaedic problem may cause anxiety for both the child and parents. The use of unfamiliar—and often massive—imaging equipment in making a diagnosis may heighten that anxiety. Parents may worry about the effects of radiation and the child's response. The child may fear the unfamiliar surroundings or have an expectation that something unknown is going to happen to him or her.
The key to reducing unnecessary apprehension and anxiety over unfamiliar procedures is advance communications and parent/patient education. This is particularly useful when imaging studies are required. When patients and parents know what to expect, they are less likely to be fearful.
How you prepare the family depends upon the age of the child, the procedure he/she is to undergo, and to some extent, your assessment of the parent's capability and comprehension of the situation. Not all parents are knowledgeable about medical imaging techniques. When faced with a situation where the parent's anxiety level is high as well, you will have to pay special attention to educating the parent(s).
There are general guidelines that should be followed when communicating with pediatric patients and their parents. These include:
Because your time actually is limited, ask parents to write down their questions before they come in whenever possible. That will speed things up and keep the conversation focused on the patient's and family's needs.
- Answer questions truthfully and openly.
- Don't evade questions that have complex answers. Try to break the answer down into simpler components and, if possible, use analogies to help patients understand. When you're giving a long explanation, stop occasionally to ask if the patient or parent has any questions.
- Be prepared for the dicussion. Understand the common questions—and your answers—beforehand.
- Be prepared to spend some extra time, upfront, with pediatric patients and their parents. In the long run, it has been shown that good communication early will ultimately reduce the amount of time required in this interaction. Children and families develop a sense of trust and comfort with the physician and staff when their key questions are discussed early. Giving them adequate time will help later, as they may be more comfortable telling you something important the next time.
Your conversations will be directed toward the parents when the patient is an infant or a very young child. Older children and adolescents, though, will appreciate being included in the discussions.
What do parents/patients want to know? Regardless of the procedure, there are a few basic questions you should cover, even if families forget to ask some of them.
Will it hurt?
Everyone wants to know about possible pain, but some parents may not bring it up for fear of making the child apprehensive. Nevertheless, it's better if the child knows what to expect. For example, you can tell a child scheduled for an intravenous (IV) contrast medium injection, “We're going to rub a cream on your skin, so inserting the IV will be relatively painless.”
Don't forget the follow-up, if there is one. For example, if sedation is involved, say: “You will feel sleepy.” When things are not going to hurt, you should say that too. Most adults know that X-rays are painless, but don't assume that a child knows this.
What is this procedure and why is it needed?
Explain any procedure in a step-by-step fashion using words that the family will understand. Say “X-ray” rather than “radiograph,” for example, or explain that the terms are interchangeable.
Some procedures are easy to describe with a minimum of unfamiliar terms. Others, like complex imaging modalities, are harder to simplify, but give the family at least a brief explanation of what the procedure is and why it's needed. For example, you might say, “The CT is a type of X-ray in which the beams move in a circle around the patient's body to provide different views of [whatever the body part is that's under scrutiny]. It provides much greater detail than a plain X-ray.”
Because any large equipment may be intimidating to children, it is wise to describe it beforehand. Calling a CT scanner “a large rectangular box with a doughnut-shaped hole in the middle” paints a simple picture.
Be sure to tell what's going to happen during the scanning. “You'll be lying on a table that will go in and out of the doughnut hole.” For MRIs, remind the patient and family that the machine is very noisy and that they can wear earphones to reduce the noise.
What else is involved?
Don't forget details that may be obvious to you but unknown to patients and their families. For example, ask if there is a history of allergies if you plan a procedure that uses a contrast medium; say whether or not general anesthesia or sedatives will be used during a procedure; and explain any dietary restrictions or other special instructions that will be required before a procedure.
The loud noises made by MRI machines may be frightening to children. Reassure them that all the whirring and clicking they'll hear is normal and that the machine is not broken.
A child may fear being left alone in the room during a scanning procedure. It's important that both parents and child know beforehand that a parent generally is allowed to stay with the child, and explain about the lead-lined garment that the parent will wear for safety. Stress that someone will be watching and listening to the child at all times and will come in immediately if there's a problem.
Is this procedure safe?
With an imaging modality that involves radiation, parents may be concerned about safety. Here are some reassurances you can offer in appropriate situations:
- Shields will be used if there is a risk of radiation.
- Dosage is always as low as possible to achieve acceptable results.
- The number of radiographic studies are limited to reduce exposure. If further studies are required, another procedure such as ultrasound can be substituted in some circumstances.
Summing it all up
John F. Sarwark, MD is Martha Washington professor of orthopaedic surgery and division head of pediatric orthopaedic surgery at Children's Memorial Hospital, Chicago.
Children and parents are more comfortable undergoing an unfamiliar procedure if they know what to expect beforehand. With pediatric patients this communication principle is especially important. The way you handle the family's preparation for the procedure makes a large difference between a having a relatively quick, easy and comfortable experience versus a frightening one for the child.
With a little attention to the family's concerns upfront, you may guide them through this new experience with a minimum of anxiety. Not surprisingly, these same principles work just as well with adults!