TOW #10: Difficult encounters

One of the more challenging situations in medicine are difficult encounters with families. Many of us in pediatrics feel fairly averse to conflict, and thankfully these scenarios are less common in peds, but when they do happen can be particularly hard. There is data we can prepare and learn to handle them better.


Take-home points:

  1. Difficult encounters are fairly common and stressful (though thankfully probably less in pediatrics than in adult medicine!). Adult providers have reported up to 1 in 6 encounters as difficult. There is less clear data for pediatrics, but we know they are still relatively common. Adverse effects from difficult encounters include higher job stress and dissatisfaction/burn-out.
  2. There are many potential triggers for difficult encounters, many of them are not in our control. These include patient / parent characteristics (e.g., mental health problems, multiple somatic complaints, threatening personality), provider characteristics (e.g., less comfort with diagnostic uncertainty, less experience, differences in cultural background than patients, etc.), and system factors (short time for appointments, busy/overbooked clinics).
  3. While difficult encounters are often beyond our control, we can prepare and control our reactions. Patient/parent rudeness is one mostly non-modifiable factor that has been studied. It’s been found that rudeness impacts our performance yet cognitive training preparing for it can help. In a study about NICU teams published in Pediatrics this year, authors found that “rudeness had adverse consequences not only on diagnostic and intervention parameters (mean therapeutic score 3.81 ± 0.36 vs 4.31 ± 0.35 in controls, P < .01), but also on team processes (mean teamwork score 4.04 ± 0.34 vs 4.43 ± 0.37, P < .05).” A preventative training on cognitive bias modification (CBM), which promoted a more positive/benign rather than threat-based interpretation of information, helped reduce most of the adverse effects of rudeness.
  4. Communication strategies include early acknowledgement and addressing concerns: A brief reflection such as “I see that what I said is upsetting to you. How can I help?” or “Let me try to say it another way” may buffer a statement that triggered a negative reaction. We can also apologize right up front for system factors and running late, or for inadvertently offending someone “I am sorry for appearing insensitive to you.” We should acknowledge feelings, and show we care about the patient/families’ situation and their health. “I really know this is hard for you, and I want to be as helpful as I can be to you and your child.” Knowing the patients’/parents’ agenda and their expectations has been shown to improve outcomes including compliance and follow-through.
  5. Utilize colleagues and modify appointments/ systems when possible: It’s appropriate to refer to a colleague or specialist when more help is needed. It’s often helpful to allow more time for patients/ encounters that we know may be difficult. Yet, it’s still important to set firm, clear limits on what time is available. For example in demands for completing forms/paperwork: “I have time scheduled now for meeting with patients, and then I complete paperwork at a later time after clinic visits.”

TOW #9: Literacy Promotion/ Reach Out and Read (ROR)

Next week we head into September (!), which is back to school time and National Literacy Month. It’s the perfect time to review data about how to promote literacy in our practices. We have a terrific Reach Out and Read (ROR) program in Washington run by Dr. Jill Sells, an alum of our residency program. Email to sign up for training (see below) or the monthly newsletter. Residents can also promote literacy in the hospital, thanks to our inpatient ROR program launched last year. Keep delivering those books to patients!
Here are this week’s materials:

Take-home points for literacy promotion:

  1. Educate yourself: ROR is an evidence-based, nationally recommended program started by pediatricians that improves literacy outcomes. The #1 thing you can do to effectively use Reach Out and Read (ROR) is to complete the online training and additional ROR training resources.
  2. Support parents with information: Highlight for parents how reading aloud with their young children enriches their relationships and enhances their children’s social-emotional development. This builds brain circuits to prepare children to learn language and early literacy skills.
  3. Describe dialogic reading: Teach parents about developmentally appropriate reading activities, including how to use dialogic reading to help promote early literacy. This is a technique that involves prompting the child to have a conversation about the pictures and story as parent and child are reading together.
  4. Provide books: ROR is founded on providing developmentally, culturally, and linguistically appropriate books at health supervision visits for all high-risk, low-income children. Also we can provide educational materials in clinic including info on local libraries.
  5. Review: the 5 R’s of early education-1. Reading together as a daily fun family activity; 2. Rhyming, playing, talking, singing, and cuddling together; 3. Routines and regular times for meals, play, and sleeping; 4. Rewards for everyday successes, particularly for effort toward worthwhile goals such as helping; and 5. Relationships that are reciprocal, nurturing, purposeful, and enduring are the foundation of healthy early brain development.

TOW #8: School Readiness & Challenges

As pediatricians we have a special role in helping promote and assess school readiness and addressing issues when challenges occur. We hope for everyone that school is a great experience, yet the literature tells us that up to 1 in 6 children experience school challenges or failure. (Personally, I prefer using the term “challenges” as it conveys more of a growth mindset; “school failure” is used in the literature on this topic usually to signify failing a grade). Hopefully we can recognize and address issues early on through regular visits and monitoring in the medical home.

Materials for this week:

Take-home points:

  1. What is meant by “school readiness”? As written in the article above by the AAP Councils on Early Childhood and School Health, “school readiness includes not only the early academic skills of children but also their physical health, language skills, social and emotional development, motivation to learn, creativity, and general knowledge.” We have a lot of domains to consider when evaluating children’s readiness for school! In essence, it’s a very holistic approach to recognizing the broad influences on participation and performance in school, much more than knowing the alphabet and how to count to 10.
  2. How we can promote school readiness? In the medical home, we will naturally assess and address physical health needs. Beyond that, we can promote social-emotional health through nurturing strong, connected relationships (see last week’s topic on Promoting First Relationships). We can help families promote early cognitive growth by discussing early brain development and how families support this through reading (using Reach Out and Read), interacting, and enrolling in early learning programs like Head Start. We can also identify children with developmental delays and learning difficulties at an early stage by using appropriate screening tools.
  3. Epidemiology of school challenges: About 10% to 15% of school-age children repeat or fail a grade in school. Grade failure is more likely among males, minorities, children living in poverty, and those in single-parent homes. Children who have disabilities are nearly 3x as likely to repeat at least one grade as are children without disabilities. Similarly, children who were small for gestational age (SGA) are nearly 2x as likely to experience school failure. Children who fail in school are more likely to engage in subsequent health-impairing behaviors as adolescents. Failing students also are more likely to drop out of school and have adverse adult health outcomes.
  4. Differential diagnosis for school difficulties: Possible causes of school challenges should include evaluating exogenous and endogenous factors. Exogenous factors include stressors in the home, poverty, and negative peer influence or school environment. Endogenous factors include learning disabilities, ADHD, chronic illness, perinatal conditions (e.g., prematurity, fetal exposures) and mental health disorders.
  5. How can we help families facing school difficulties? Clinicians can help families identify the causes of school challenges and advocate for resources to improve a child’s academic trajectory. It can be very important for a child’s doctor to get involved with a child’s school to ask questions, discuss resources, and advocate for services. The law protects students’ rights to have their educational needs addressed through the Individuals with Disabilities Education Act (IDEA). Under IDEA, schools must identify children with disabilities, evaluate their needs, provide services, and guarantee due process, including the provision of Individual Education Plans, or IEPs. We can utilize the resources of school family advocates, omsbudsman, counselors, social workers, and medical-legal partners to advocate for children and their access to services.