Pediatric residents’ response to ambiguous words about child discipline and behavior

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Abstract

Frequently, doctors have been noted to seemingly ignore or brush off patients’ bids to discuss sensitive issues. In some of these cases, however, apparent ignoring could be the result of the doctor mistakenly interpreting the meaning of potentially ambiguous terms used by the patient. This study demonstrates the frequency with which parents use and pediatricians clarify ambiguous terms describing child behavior and physical punishment. Sixty-one (26%) of 234 audiotapes from a systematic cross-sectional sample of non-urgent visits with pediatric residents included at least one episode in which such words were used by a parent. Discussion following each use was classified as: (a) clarifying its meaning, (b) discussing without clarification, (c) ignoring the use of the word, or (d) contradicting the negative attribution. In 61 visits, the parent or child was the first to use the potentially ambiguous term. Physicians clarified 7 (11%) of the terms, ignored 23 (38%), contradicted 7 (11%), and discussed without clarification 24 (39%). Clarifying and contradicting were associated with a shorter doctor–patient relationship than ignoring or discussing without clarification. Doctors who sought clarification were the least dominant. A non-dismissive response to ambiguous words may be a marker for both the stage of the doctor–patient relationship and a doctor’s overall interactive style. Considering clarification may be helpful in understanding doctors’ responses to patients’ cues.

Introduction

Miscommunication between patients and providers is associated with a variety of undesirable outcomes, including poor adherence to or refusal of treatment, lack of trust, and unwillingness to disclose concerns [1], [2], [3], [4], [5]. A recent survey in the United States found that 16% of white individuals, 23% of African-Americans, 27% of Hispanics, and 33% of Asian-Americans reported having trouble communicating with their doctor [6].

A commonly reported cause of miscommunication is doctors’ apparent failure to pursue hints and cues offered by patients [7], [8], [9], [10]. Studies in a variety of medical settings have found that doctors often ignore or comment only briefly on statements that disclose emotional or psychosocial aspects of patients’ medical problems. Some patients take this lack of comment as an indication that the doctor has understood them, while others consider the non-response as a signal that emotional or psychosocial topics are inappropriate concerns [1], [11], [12].

Several factors are thought to contribute to doctors’ non-response to patient cues. First, shorter visits are associated with doctors asking fewer and less detailed questions and doing less to facilitate patient participation [13], [14], [15]. Second, as the number of problems presented by a patient increases, a smaller proportion of the patient’s concerns are discussed, with emotional and social problems being particularly likely to be left out [5], [16], [17], [18]. Finally, doctors may not respond to problems that make them feel uncomfortable, for which they feel they lack relevant skills or knowledge, or that they define as outside the scope of their responsibility [19], [20], [21], [22].

One of the difficulties involved in studying doctors’ non-responses is that analyses of these events from transcripts or recordings start from the assumption that patients and doctors share a mutual understanding of the words the patient used. This shared understanding is assumed to have clearly put a topic “on the table” for the doctor to take up or not. In fact, studies suggest that patients and doctors frequently attribute different meanings to words commonly used in medical visits [3], [23], [24], [25], [26]. This raises the possibility that some of what appears to be doctors’ “ignoring” might, in fact, be a failure to realize that the patient has said something of possible significance. For example, across cultures, patients who report problems with “nerves” may be concerned about many different things, ranging from acknowledgment of minor anxiety to a state of dysfunction akin to major depression [27], [28], [29].

In this paper, we examine doctors’ responses to words parents use to describe certain aspects of child behavior and discipline. Discussions of child behavior are common in general pediatric care [30], [31]. In day-to-day language, descriptions of child behavior are often given in slang and regional colloquial terms that doctors and parents, especially if they come from different ethnic or cultural backgrounds, may not use in a similar fashion. For example, the practice of punishing a child by administering a blow to the buttocks with an open hand could be referred to as a beating, tanning, slap, or paddle, and could indicate anything from a mild re-direction to a process that inflicts significant physical and emotional injury [22], [32]. Medical practitioners have an interest in understanding what parents mean when they talk about discipline and behavior. First, the American Academy of Pediatrics suggests that parents be counseled to avoid the use of physical punishment [33]. In addition, US law (as in many countries), requires that doctors report instances of suspected child maltreatment.

Our goal in this study was to go beyond prior analyses of doctors’ responses to hints and cues about psychosocial topics [7], [8]. For example, in Levinson et al.’s study [7], doctors’ responses to patient cues were separated into two broad categories: positive responses and missed opportunities. Each broad category had several sub-categories, but both were based on the assumption that the patient had, indeed, presented a matter that was important to discuss. We wanted to explore a third option, one in which doctors might identify a patient statement as a possible cue, and then decide to try to clarify its meaning. While it requires actually debriefing doctors to get inside the “black box” of ignoring [19], we believed it possible to expand the characterizations made in a purely observational study to include attempts to clarify meaning.

We chose cues associated with behavior and discipline for this study because of the known association of maltreatment concerns with doctors’ anxiety [19], [20]. In particular, many doctors hesitate to pursue discussions that may uncover maltreatment because of their potential length and awkward nature. We thus further hypothesized that doctors’ response to these words might be related to visit length, to when in the visit the word was used, and to the doctor’s overall style with regard to control of conversation in the visit. Finally, we hypothesized that attempts to clarify ambiguous terms would be more likely to occur early in a doctor–patient relationship, with longer relationships yielding more familiarity, and thus perhaps less of a need to clarify.

Section snippets

Population

This research is based on audiotapes of visits between parents, children, and doctors in a hospital-based pediatric residents’ continuity clinic. The visits had been recorded as part of a study assessing the relationship between doctors’ interview style and parents’ discussion of psychosocial topics [34]. Briefly, to be eligible for the study, children had to be 6 months of age or older, coming for a scheduled health maintenance or follow-up visit with their own doctor, and accompanied by his

Results

To examine when ambiguous words first came up within visits, the total time of each visit was divided into quarters. First uses of words related to physical punishment were spread relatively evenly across the quarters, while the first use of ambiguous words related to behavior alone or behavior and physical punishment simultaneously were most likely to occur in the first quarter, compared to the remainder of the visit (Fig. 1).

In 24 visits (39%), doctors responded with a discussion as if they

Discussion

In just over a quarter (61/234) of the pediatric primary care visits in our overall sample, parents or children introduced a potentially ambiguous word or phrase related to physical punishment and/or child behavior. About half the time, doctors seemed to ignore the word or dismiss it through contradiction. Active clarification occurred in only 7 of the 61 visits (11%). These figures are similar to those reported in other settings. In a study of office-based adult primary care encounters, 79% of

Conclusions

The greatest limitation of our data lies in our inability to know parents’ intentions when they used one of our target words or phrases, and what thoughts subsequently guided doctors’ responses. Our data suggest, however, that considering clarification may be an additional avenue for understanding doctors’ apparent non-response to patient cues. In particular, a non-dismissive response that includes an attempt to clarify patient meaning may be a marker for both the stage of the doctor–patient

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