Pediatric residents' responses that discourage discussion of psychosocial problems in primary care

Enhancing the primary care pediatrician's role in managing psychosocial issues: a cross sectional study of pediatricians and parents in Israel

Background

Psychosocial issues are an integral part of children's health and well-being, and it is widely acknowledged that pediatricians should be involved in their management. We examined the current perception of the pediatrician’s role in the management of psychosocial problems in Israel from the perspective of parents and pediatricians, and identified possible barriers.

Methods

We assessed parents' and pediatricians' perspectives through a cross sectional survey. 1000 parents with children under 10 were randomly selected from a large database representing the Israeli population and phone-surveyed by a polling company. Due to a low response-rate (5.4%), there was an overrepresentation of married parents and underrepresentation of parents with primary or secondary education. 173 Pediatricians were recruited both at a medical conference and by a web-based questionnaire.

Results

55% of the parents reported they were concerned with at least one psychosocial problem, yet less than 50% of them discussed these issues with the pediatrician. 59.9% of the parents did not perceive psychosocial problems as relevant to the pediatrician's role. Pediatricians with some previous training related to psychosocial issues were more likely to report on a lack of professional confidence (p = .037) and insufficient available resources (p = .022) as barriers to their involvement, while pediatricians who had no training were more likely to report on the parents' perception of their role as the barrier to involvement (p = .035).

Conclusions

Parents tend to avoid the discussion of psychosocial concerns in pediatric settings due to their perception that it's irrelevant to the pediatrician's role. Trained pediatricians feel unconfident in their ability to manage psychosocial issues and report on a lack of suitable resources. These findings suggest current pediatric mental-health training is insufficient to equip pediatricians with the knowledge and skills required to their involvement in psychosocial problems, and imply necessary changes to environment of community-based pediatrics. In order to change the practice of pediatricians in the community to enable them to address a variety of psychological issues, appropriate training is needed, through all stages of the pediatrician’s professional life, including medical school, pediatric residency and continuous medical education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-022-00537-6.

Prediction of health, education, and psychosocial professionals' attitudes in favor of parental use of corporal punishment

BACKGROUND

To date, there have been few studies pertaining to the knowledge and attitudes regarding the use of corporal punishment (CP) among professionals working with parents and children. Yet, many parents turn to these professionals for advice on child discipline.

OBJECTIVE

This study aimed to describe professionals' legal knowledge about parental use of CP and their attitudes toward this practice.

METHOD

A study was conducted among professionals working directly with children or their parents through an online questionnaire.

PARTICIPANTS

A total of 1,758 respondents from three sectors of training (psychosocial, health, education) completed the questionnaire.

RESULTS

The results showed that professionals have little knowledge of the legal guidelines surrounding the use of CP in Canada. This poor knowledge as well as the perceived impacts of CP on children acted as predictors of favorable attitudes toward this disciplinary practice. According to the regression analyses, other personal and professional factors also explain a person's approval of CP, including violence in childhood, religious practice, and sources of knowledge. The results also highlighted some findings related to the respondents' professional sectors.

CONCLUSIONS

The study results emphasize the need to better train professionals by targeting cognitive, personal, as well as professional factors.

Parent Perceptions of Pediatric Primary Care Providers' Mental Health-Related Communication and Practices

INTRODUCTION

The pediatric primary care office is an ideal setting to address children's socioemotional-behavioral health. However, research is limited regarding parents' experiences and satisfaction in sharing mental-health concerns about their children during well-child visits.

METHOD

One thousand seven hundred sixty-three parents and caregivers with children aged 3-17 years completed an online survey that addressed mental-health-related communication.

RESULTS

Findings supported the key role that primary care providers play in communicating about mental-health issues; 75% of parents who had such a concern about their child raised it during the visit, although the majority desired more time devoted to discussing mental health. Parents' comfort discussing mental-health concerns was inversely related to providers' dismissing those concerns.

DISCUSSION

Despite satisfaction with how providers addressed mental-health issues, results suggested that nonjudgmental, knowledgeable staff and discussion of child and parent strengths could facilitate both parental comfort and communication between parents and pediatricians.

Dealing with parental concerns: A study of GPs' practice

OBJECTIVE

To investigate patterns of GPs' exploration and termination of dialogues about parental concerns in preventive child health assessments.

METHODS

Interactional microanalysis of video recordings of 32 preventive child health assessments using conversation analysis.

RESULTS

The GPs asked parents about concerns, but most concerns disclosed by parents were still left unexplored at the end of the consultation. Termination of dialogues about concerns could be achieved effectively by GPs through letting the biomedical agenda dominate or addressing the child directly. The parents generally cooperated with the various approaches to handling concerns.

CONCLUSION

GPs displayed initial attentiveness towards emotional concerns but did not always follow through with subsequent exploration; many concerns raised were left unexplored. However, the same GP could employ both non-exploratory and exploratory practice within individual consultations.

PRACTICE IMPLICATIONS

Preventive child heath assessments offer an opportunity for parents to raise concerns about their children's development. Improved understanding of the conversational mechanisms through which concerns are examined or sidelined could allow clinicians to maximise the effectiveness of their preventive consultations.

Primary Care Practitioner Training in Child and Adolescent Psychiatry (PTCAP): A Cluster-Randomized Trial

OBJECTIVES

Rural primary care practitioners (PCPs) have a pivotal role to play in frontline pediatric mental health care, given limited options for referral and consultation. Yet they report a lack of adequate training and confidence to provide this care. The aim of this study was to test the effectiveness of the Practitioner Training in Child and Adolescent Psychiatry (PTCAP) program, which was designed to enhance PCPs' pediatric mental health care confidence. The program includes brief therapeutic skills and practice guidelines PCPs can use to address both subthreshold concerns and diagnosable conditions, themselves.

METHODS

The study design was a pilot, cluster-randomized, multicenter trial. Practices were randomly assigned to intervention (n practices = 7; n PCPs = 42) or to wait-list control (n practices = 6; n PCPs = 34). The intervention involved 8 hr of training in practice guidelines and brief therapeutic skills for depression, anxiety, attention deficit hyperactivity disorder, and behavioral disorders with case discussion and video examples, while the control practiced as usual. A linear random-effects model controlling for clustering and baseline was carried out on the individual-level data to examine between-group differences in the primary (i.e., confidence) and secondary (i.e., attitude and knowledge) outcomes at 1-week follow-up.

RESULTS

Findings were a statistically significant difference in the primary outcomes. Compared to the control group, the intervention group indicated significantly greater confidence in managing diagnosable conditions (d = 1.81) and general concerns (d = 1.73), as well as in making necessary referrals (d = 1.27) and obtaining consults (d = 0.74). While the intervention did not significantly impact secondary outcomes (attitudes and knowledge), regression analysis indicated that the intervention may have increased confidence, in part, by ameliorating the adverse impact of negative mental health care attitudes.

CONCLUSION

PTCAP enhances PCPs' child/youth mental health care confidence in managing both general and diagnosable concerns. However, an 8-hr session focused on applying brief therapeutic skills was insufficient to significantly change attitudes and knowledge. Formal testing of PTCAP may be warranted, perhaps using more intensive training and including outcome assessments capable of determining whether increased PCP confidence translates to more effective management and better patient outcomes.

Opinions et positions de médecins à l’endroit de la punition corporelle comme pratique parentale disciplinaire

Contexte de l’étude

Les médecins sont parmi les professionnels les plus sollicités par les parents pour obtenir des conseils sur l’exercice du rôle parental. Pourtant, ils sont rarement formés pour informer les parents, et particulièrement en ce qui concerne la légitimité des pratiques disciplinaires comme la punition corporelle (PC).

Objectifs

Cette étude vise à documenter les attitudes de médecins québécois en faveur de la PC ainsi que leur pratique de soutien auprès des parents.

Méthodes

Au total 113 médecins œuvrant au moins 20% du temps avec des enfants mineurs ou leurs parents ont complété un sondage en ligne sur leurs caractéristiques personnelles et professionnelles, leurs connaissances et attitudes face à la PC et leurs pratiques de soutien.

Résultats

Les résultats montrent que les répondants connaissent bien les balises légales de l’article 43 du Code criminel canadien qui encadrent le recours aux PC et qu’ils sont en désaccord avec cette méthode disciplinaire. Lorsqu’ils soupçonnent une situation de PC envers un enfant, les médecins répondants offrent diverses modalités de soutien aux parent (ex.: aborder le sujet, proposer d’autres pratiques disciplinaires), ce qui est moins souvent le cas lorsque la situation implique un adolescent. Enfin, les résultats montrent que certains facteurs sont associés aux pratiques de soutien des répondants, dont les attitudes face aux PC et le sentiment d’être suffisamment formé pour aborder les pratiques disciplinaires avec les parents.

Conclusions

Ces résultats soulignent l’importance d’outiller et de soutenir les médecins dans leurs interventions auprès des parents en difficulté.

Parental Self-Assessment of Behavioral Effectiveness in Young Children and Views on Corporal Punishment in an Academic Pediatric Practice

This article assesses parental confidence and current behavioral techniques used by mostly African American caregivers of young children in an urban Southeastern setting, including their use and attitudes toward corporal punishment (CP). Two hundred and fifty parental participants of children aged 18 months to 5 years completed a survey on factors affecting their behavioral management and views on CP. Statistical analysis included χ² test and logistic regression with confidence interval significance determined at P <.05. Significant associations of CP usage were found in parents who were themselves exposed to CP and parental level of frustration with child disobedience. A total of 40.2% of respondents answered that they had not received any discipline strategies from pediatricians and 47.6% were interested in receiving more behavioral strategies. Clear opportunities exist for pediatricians to provide information on evidence-based disciplinary techniques, and these discussions may be facilitated through the creation of a No Hit Zone program in the pediatric practice.

Socioemotional developmental surveillance in young children: monitoring and screening best identify young children that require mental health treatment

BACKGROUND

Widely recommended socioemotional developmental surveillance methods include monitoring and development screening techniques. Currently, very little research has compared the effectiveness of monitoring and screening together, and existing research primarily focuses on the relationship between surveillance techniques and referrals or receipt of early intervention (EI). This study investigates the relationship between monitoring and screening and mental health treatment receipt in 3-5 year olds.

METHODS

The authors conducted logistic regression analyses on data from the National Surveys of Children's Health (NSCH; 2007) and NSCH (2011/2012) on the odds of mental health treatment receipt in children aged 3-5 years of age who either received (a) screening only, (b) monitoring only, (c) both monitoring and screening, or (d) no monitoring or screening. Sociodemographic control variables were also considered.

RESULTS

In both 2007 and 2011/2012 datasets, monitoring and screening together was the best predictor of mental health treatment receipt. Neither screening alone nor monitoring alone was associated with mental health treatment receipt.

CONCLUSIONS

Children who received monitoring and screening together had the greatest odds of treatment receipt compared with children receiving screening only, monitoring only, or no monitoring or screening.

[Pediatrician-parent interaction and early prevention : A review about the limits in addressing psychosocial risks during well-child visits]

BACKGROUND

Pediatricians can be a door opener to early prevention for families at risk. The German well-child program is well-established, but there is a gap between the structural possibilities and the observed placements.

OBJECTIVE

The aim of this review is to show how pediatricians and parents talk about psychosocial risks under the very structured conditions of well-child visits. The challenges and traps of the framed interactions will be described and options for early prevention will be shown.

METHODS

The review is primarily based on the work of conversational and ethnomethodological studies reconstructing the pediatrician's discussion with parents about psychosocial issues in the family.

RESULTS

Well-child visits are a highly routinized practice. Talking about family issues for both partners is a difficult task. Discussions about psychosocial issues are seldom and vague . Predominantly, they work cooperatively on reciprocal normalization of the child's development. Based on this shared orientation, pediatricians make an early, mostly general, prescription of parental tasks, supporting the child in the next developmental step. This kind of routine anticipatory counselling puts some pressure on the parents. Parents under unknown stress could be overburdened with this advice.

CONCLUSION

In the script of well-child visits, there are no slots that indicate to pediatricians and parents when, which, how and for what purpose psychosocial issues can be discussed and negotiated. For implementing such slots in well-child visits, three steps are necessary: a structured and regular assessment of psychosocial issues, a trained pediatrician in motivational interviewing and a social worker guiding the family in the network of early prevention.

Follow-up of Mothers with Suspected Postpartum Depression from Pediatrics Clinics

PURPOSE

Pediatric providers are increasingly screening for postpartum depression (PD), yet, it is unknown how often mothers comply with recommendations to seek treatment. The objectives were to describe the rate at which mothers with suspected PD seek treatment and explore factors that predict help-seeking behavior.

DESIGN AND METHODS

Mothers were recruited from four pediatric clinics after identification using the Child Health Improvement through Computer Automation (CHICA) system. Mothers with a positive screen were invited to participate in a telephone interview between January 2012 and December 2014. Mothers reported if they sought treatment or called a community resource.

RESULTS

73 of 133 eligible mothers participated (55% response rate). Fifty women recalled a recommendation to seek help. Only 43.8% (32/73) made a follow-up appointment with an adult provider and even fewer kept the appointment.

CONCLUSION

A majority of mothers suspected of having PD recalled a referral for further intervention; yet, less than half took action. Further investigation of barriers of help-seeking behavior is warranted.

Social workers' role in tempering inequality in healthcare in hospitals and clinics: a study in Israel

The paper presents an empirical examination of the role social workers play in tempering inequality in medical care. Data were collected in 2011 through face-to-face, semi-structured, in-depth interviews with 60 social workers employed in hospitals and clinics in Israel and selected through purposive sampling. The interviews probed the social workers' perceptions of the scope, causes and manifestations of inequality in health and healthcare and the actions they took to ameliorate it. The interviews were analysed using grounded theory. The findings show that all the social workers were acutely aware of the inequalities in their places of work, regarded reducing the inequalities as a major part of their role and made efforts to do so. They facilitated communication between doctors and patients of low socioeconomic status and advocated for such patients with medical staff and administration, as well as with the country's medical and social welfare bureaucracies. The paper details the means they used and the challenges they faced. The study highlights the important role that social workers play in reducing inequality in healthcare.

Variations in Physician Attitudes Regarding ADHD and Their Association With Prescribing Practices

OBJECTIVE

The objective of this study was to test whether physicians' attitudes regarding the impact of ADHD on health-related quality of life (HRQL) explain differences in practices for prescribing psychostimulants in children.

METHOD

In a cross-sectional survey, U.S.-based pediatricians and psychiatrists ("physicians") used the Paper-Standard Gamble--a widely used preference-based assessment of HRQL--to rate four vignettes describing ADHD health states of varying severity. Associations between standard gamble scores and questions about prescribing practices were analyzed using ordinal logistic regression.

RESULTS

Surveys were mailed to 291 physicians; 127 (44%) returned complete forms. Lower standard gamble scores were associated with more emphasis on children's ADHD symptoms (p = .03) and less emphasis on parents' concerns about stimulant side effects (p = .03) when prescribing psychostimulants.

CONCLUSION

Differences in physician perceptions of the severity of ADHD symptoms and in their emphasis on parental concerns about side effects may help explain variations in ADHD psychostimulant prescription patterns.

Communication between health professionals and patients: review of studies using the RIAS (Roter Interaction Analysis System) method

OBJECTIVE

Systematic review of studies that investigate the communication between patients and health professionals with the application of the RIAS methodology.

METHODS

Keyword Roter Interaction Analysis System was searched in the following bibliographic resources: Academic Search Complete, Current Contents, ISI Proceedings, PubMed, Elsevier, SpringerLink, Web of Science, RCAAP, Solo and the official RIAS site. Selection period: 2006 to 2011. Studies were selected using multicriteria dichotomous analysis and organized according to PRISMA.

RESULTS

Identification of 1,262 articles (455 unrepeated). 34 articles were selected for analysis, distributed by the following health professions: family medicine and general practitioners (14), pediatricians (5), nurses (4), geneticists (3), carers of patients with AIDS (2), oncologists (2), surgeons (2), anesthetists (1) and family planning specialists (1). The RIAS is scarcely used and publicized within the scope of healthcare in Portuguese speaking countries.

DISCUSSION

Main themes studied include the influence of tiredness, anxiety and professional burnout on communication and the impact of specific training actions on professional activities. The review enabled the identification of the main strengths and weaknesses of synchronous and dyadic verbal communication within the provision of healthcare.

CONCLUSION

Scientific investigation of the communication between health professionals and patients using RIAS has produced concrete results. An improvement is expected in health outcomes through the application of the RIAS.

Communicating psychosocial problems in German well-child visits. What facilitates, what impedes pediatric exploration? A qualitative study

OBJECTIVE

To examine whether, and if so, how psychosocial topics are discussed between parents and pediatricians.

METHODS

Thirty well-child visits at eight pediatricians' practices in southwest Germany were video recorded. Conversations were analyzed.

RESULTS

Although psychosocial topics were frequently touched upon, they were rarely thoroughly explored. Pediatricians pursued a rather reserved conversation style. Especially when parents withdraw and psychosocial stressors are less baby-related, pediatricians hardly explore the psychosocial situation.

CONCLUSION

In summary, the pediatrician's conversation style, the nature of the stressors and the parents' openness are paramount in determining the depth of psychosocial exploration.

PRACTICE IMPLICATIONS

In order to ensure a good and fair quality of care to all parents, pediatricians should be provided with tailored communicative skills training allowing them to create a climate in which parents may open up and build trust toward their pediatrician.

Mental health screening and consultation in primary care: The role of child age and parental concerns [corrected]

OBJECTIVE

To determine (1) how child age relates to parent concerns about child behavior and (2) how child age and parent concerns correlate with provider referrals and family attendance at mental health consultant (MHC) appointments.

METHODS

Data were obtained from Rhode Island's Project, Linking Actions for Unmet Needs in Children's Health, in which universal developmental and behavioral screening and MHCs were embedded within primary care sites serving low-income diverse families. Children 9 months to 8 years of age were eligible for the study if they had a scheduled screening well-child visit in 2010 (N = 1451). Families completing screening and/or those referred for a MHC appointment were included in analyses (n = 700). Outcome measures included parent-reported concerns about child behavior, referral status following screening, and family attendance at the MHC appointment.

RESULTS

For every 1-month increase in child age, there was a 1.02 times increase in the likelihood of parent behavioral concern and a 1.04 times increase in the likelihood of mental health referral, even when controlling for child behavior. MHC-referred children older than 5 years were 2.61 times more likely to attend than children less than 5 years. When examining parent behavioral concerns and child age jointly, only concerns remained significant.

CONCLUSIONS

Infants and toddlers, who have the highest rates of unmet mental health needs, may be least likely to benefit from universal screening and on-site MHC support. Efforts to incorporate behaviorally based screening tools and increase parent concerns where appropriate appear warranted, particularly for families with very young children.

Which African American mothers disclose psychosocial issues to their pediatric providers?

OBJECTIVE

To determine if parents' self-efficacy in communicating with their child's pediatrician is associated with African American mothers' disclosure of psychosocial concerns during pediatric primary care visits.

METHODS

Self-identified African American mothers (n = 231) of children 2 to 5 years were recruited from 8 urban pediatric primary care practices in the Washington, DC, metropolitan area. Visits were audiorecorded, and parents completed phone surveys within 24 hours. Maternal disclosure of psychosocial issues and self-efficacy in communicating with their child's provider were measured using the Roter Interactional Analysis System (RIAS) and the Perceived Efficacy in Patient-Physician Interactions (PEPPI), respectively.

RESULTS

Thirty-two percent of mothers disclosed psychosocial issues. Mothers who disclosed were more likely to report maximum levels of self-efficacy in communicating with their child's provider compared to those who did not disclose (50% vs 35%; P = .02). During visits in which mothers disclosed psychosocial issues, providers were observed to provide more psychosocial information (mean 1.52 vs 1.08 utterances per minute, P = .002) and ask fewer medical questions (mean 1.76 vs 1.99 utterances per minute, P = .05) than during visits in which mothers did not disclose. The association between self-efficacy and disclosure was significant among low-income mothers (odds ratio 5.62, P < .01), but not higher-income mothers.

CONCLUSIONS

Findings suggest that efforts to increase parental self-efficacy in communicating with their child's pediatrician may increase parents' likelihood of disclosing psychosocial concerns. Such efforts may enhance rates of identifying and addressing psychosocial issues, particularly among lower-income African American patients.

GPs' strategies in exploring the preschool child's wellbeing in the paediatric consultation

Background

Although General Practitioners (GPs) are uniquely placed to identify children with emotional, social, and behavioural problems, they succeed in identifying only a small number of them. The aim of this article is to explore the strategies, methods, and tools employed by GPs in the assessment of the preschool child’s emotional, mental, social, and behavioural health. We look at how GPs address parental care of the child in general and in situations where GPs have a particular awareness of the child.

Method

Twenty-eight Danish GPs were purposively selected to take part in a qualitative study which combined focus-group discussions, observation of child consultations, and individual interviews with GPs.

Results

Analysis of the data suggests that GPs have developed a set of methods, and strategies to assess the preschool child and parental care of the child. They look beyond paying narrow attention to the physical health of the child and they have expanded their practice to include the relations and interactions in the consultation room. The physical examination of the child continues to play a central role in doctor-child communication.

Conclusion

The participating GPs’ strategies helped them to assess the wellbeing of the preschool child but they often find it difficult to share their impressions with parents.

How do public child healthcare professionals and primary school teachers identify and handle child abuse cases? A qualitative study

Background

Public child healthcare doctors and nurses, and primary school teachers play a pivotal role in the detection and reporting of child abuse, because they encounter almost all children in the population during their daily work. However, they report relatively few cases of suspected child abuse to child protective agencies. The aim of this qualitative study was to investigate Dutch frontline workers’ child abuse detection and reporting behaviors.

Methods

Focus group interviews were held among 16 primary school teachers and 17 public health nurses and physicians. The interviews were audio recorded, transcribed, and thematically analyzed according to factors of the Integrated Change model, such as knowledge, attitude, self-efficacy, skills, social influences and barriers influencing detection and reporting of child abuse.

Results

Findings showed that although both groups of professionals are aware of child abuse signs and risks, they are also lacking specific knowledge. The most salient differences between the two professional groups are related to attitude and (communication) skills.

Conclusion

The results suggest that frontline workers are in need of supportive tools in the child abuse detection and reporting process. On the basis of our findings, directions for improvement of child abuse detection and reporting are discussed.

Parents' professional sources of advice regarding child discipline and their use of corporal punishment

Parents (n = 500) were surveyed about which professional groups they were most likely to seek and follow advice from regarding child discipline as well as their use of corporal punishment (CP). Nearly half of the parents reported that they were most likely to seek child discipline advice from pediatricians (48%), followed by religious leaders (21%) and mental health professionals (18%). Parents who sought advice from religious leaders (vs pediatricians) had nearly 4 times the odds of reporting use of CP. Parents reported that they were more likely to follow the advice of pediatricians than any other professional; however, black parents were as likely to follow the advice of religious leaders as that of pediatricians. Pediatricians play a central role in advising parents about child discipline. Efforts to engage pediatricians in providing violence prevention counseling should continue. Increased efforts are needed to engage other professionals, especially religious leaders, in providing such advice to parents.

Exploring the day-to-day life of mothers dealing with preschool children who have behavioral disorders

INTRODUCTION

The purpose of this study was to explore the day-to-day life of mothers dealing with preschool children who have behavioral disorders and to explore the mothers' experiences with their children's health care.

METHOD

A qualitative design was used to explore mothers' experiences in their day-to-day lives. A purposive sample of eight mothers was interviewed in their homes. A recorded face-to-face format was used that included open-ended, semi-structured questions.

RESULTS

Two major themes emerged from the day-to-day experiences of these mothers: "abandoning my other child" and "parenting in unsupportive environments".

DISCUSSION

The theme of "parenting in unsupportive environments" reflects the frustrations the mothers felt in their day-to-day lives while trying to find help for their children. The theme of "abandoning my other child" refers to the siblings of the children with behavioral disorders being overlooked by the mothers because so much of the mothers' attention and time was given to the child with the behavioral disorder.

Work experience and style explain variation among pediatricians in the detection of children with psychosocial problems

OBJECTIVE

To assess whether variation in the proportion of children identified as having psychosocial problems by individual preventive pediatricians can be explained by pediatrician characteristics, over and above variations in the mix of children. Furthermore, to assess whether the characteristics of preventive pediatricians were related to the quality of problem identification.

METHODS

We used data from approximately 3070 children ages 5 to 6 years who were assessed during a routine well-child visit by a preventive pediatrician in the Netherlands (response rate 85.2%). We obtained data about parent-reported child problems by using the Child Behavior Checklist (CBCL), sociodemographic background of the family, and characteristics of the preventive pediatrician. After each assessment, preventive pediatricians reported whether they had identified any psychosocial problem in the child. Multilevel logistic regression analyses were used to assess whether variation in the proportion of children identified by preventive pediatricians as having a psychosocial problem could be explained by the characteristics of preventive pediatricians and whether these characteristics were related to the quality of problem identification.

RESULTS

Preventive pediatricians varied widely in the proportion of children identified as having psychosocial problems. Pediatrician characteristics such as work experience and work style (for example, on indication use of behavior questionnaires like the CBCL in routine care) explained about a quarter of this inter-pediatrician variation; child characteristics did not explain this variation even though characteristics like gender and parental education level were associated with likelihood of problem identification. More use of the CBCL and less use of the Teacher Report Form in routine care resulted in a better problem identification by preventive pediatricians. Work experience was not related to better problem identification.

CONCLUSIONS

Preventive pediatricians identify psychosocial problems in children in a standardized way, but important inter-pediatrician variation remains. This variation may be reduced further and quality improved by changing their work style and targeted training.

Now what should I do? Primary care physicians' responses to older adults expressing thoughts of suicide

BACKGROUND

Many older adults who die by suicide have had recent contact with a primary care physician. As the risk-assessment and referral process for suicide is not readily comparable to procedures for other high-risk behaviors, it is important to identify areas in need of quality improvement (QI).

OBJECTIVE

Identify patterns in physician-patient communication regarding suicide to inform QI interventions.

DESIGN

Qualitative thematic analysis of video-taped clinical encounters in which suicide was discussed.

PARTICIPANTS

Adult primary care patients (n = 385) 65 years and older and their primary care physicians.

RESULTS

Mental health was discussed in 22% of encounters (n = 85), with suicide content found in less than 2% (n = 6). Three patterns of conversation were characterized: (1) Arguing that "Life's Not That Bad." In this scenario, the physician strives to convince the patient that suicide is unwarranted, which results in mutual fatigue and discouragement. (2) "Engaging in Chitchat." Here the physician addresses psychosocial matters in a seemingly aimless manner with no clear therapeutic goal. This results in a superficial and misleading connection that buries meaningful risk assessment amidst small talk. (3) "Identify, assess, and…?" This pattern is characterized by acknowledging distress, communicating concern, eliciting information, and making treatment suggestions, but lacks clearly articulated treatment planning or structured follow-up.

CONCLUSIONS

The physicians in this sample recognized and implicitly acknowledged suicide risk in their older patients, but all seemed unable to go beyond mere assessment. The absence of clearly articulated treatment plans may reflect a lack of a coherent framework for managing suicide risk, insufficient clinical skills, and availability of mental health specialty support required to address suicide risk effectively. To respond to suicide's numerous challenges to the primary care delivery system, QI strategies will require changes to physician education and may require enhancing practice support.

The consultation as an interpretive dialogue about the child's health needs

BACKGROUND

Though uniquely placed in the health care system, GPs only become aware of a small number of children with behavioural and emotional problems. Research evaluating the challenges and barriers in general practice for identifying children with problems is therefore important.

OBJECTIVES

To identify and articulate GPs' experiences and perceptions of the GP-parent dialogue about children's health problems, in order to broaden our understanding of the challenges inherent to the dialogue.

METHODS

The GPs' experiences and recollections were explored in a qualitative study comprising four focus group discussions and nine individual interviews. The focus of study was to explore GP consultations with children 0-5 years of age and their parent/s.

RESULTS

Though expressing a family-focused approach to the child consultation, the GPs often did not succeed in making the consultation family focused. The analysis revealed that the GPs often were 'stuck' in the traditional role of expert and this made it difficult for them to explore the child's well-being. The consultation became more family focused when the GPs moved away from the role of expert. The GPs experienced that by sharing their uncertainty with parents, they often got more insight into the child's everyday life and family circumstances.

CONCLUSION

The study indicates that through open reflective dialogue the GP is able to assess the child and strengthen mutual trust in the doctor-parent relationship to the benefit of children with special needs.

Perceived social norms, expectations, and attitudes toward corporal punishment among an urban community sample of parents

Despite the fact that corporal punishment (CP) is a significant risk factor for increased aggression in children, child physical abuse victimization, and other poor outcomes, approval of CP remains high in the United States. Having a positive attitude toward CP use is a strong and malleable predictor of CP use and, therefore, is an important potential target for reducing use of CP. The Theory of Planned Behavior suggests that parents' perceived injunctive and descriptive social norms and expectations regarding CP use might be linked with CP attitudes and behavior. A random-digit-dial telephone survey of parents from an urban community sample (n = 500) was conducted. Perceived social norms were the strongest predictors of having positive attitudes toward CP, as follows: (1) perceived approval of CP by professionals (β = 0.30), (2) perceived descriptive norms of CP use (β = 0.22), and (3) perceived approval of CP by family and friends (β = 0.19); also, both positive (β = 0.13) and negative (β = -0.13) expected outcomes for CP use were strong predictors of these attitudes. Targeted efforts are needed to both assess and shift the attitudes and practices of professionals who influence parents regarding CP use; universal efforts, such as public education campaigns, are needed to educate parents and the general public about the high risk/benefit ratio for using CP and the effectiveness of non-physical forms of child discipline.

Medical residency: factors relating to "difficulty in helping" in the resident physician-patient relationship

CONTEXT AND OBJECTIVE

Previous studies have attempted to understand what leads physicians to label patients as 'difficult'. Understanding this process is particularly important for resident physicians, who are developing attitudes that may have long-term impact on their interactions with patients. The aim of this study was to distinguish between patients' self-rated emotional state (anxiety and depression) and residents' perceptions of that state as a predictor of patients being considered difficult.

DESIGN AND SETTING

Cross-sectional survey conducted in the hospital of Universidade Federal de São Paulo (Unifesp).

METHODS

The residents completed a sociodemographic questionnaire and rated their patients using the Hospital Anxiety and Depression Scale (HADS) and Difficulty in Helping the Patient Questionnaire (DTH). The patients completed HADS independently and were rated using the Karnofsky Performance Status scale.

RESULTS

On average, the residents rated the patients as presenting little difficulty. The residents' ratings of difficulty presented an association with their ratings for patient depression (r = 0.35, P = 0.03) and anxiety (r = 0.46, P = 0.02), but not with patients' self-ratings for depression and anxiety. Residents from distant cities were more likely to rate patients as difficult to help than were residents from the city of the hospital (mean score of 1.93 versus 1.07; P = 0.04).

CONCLUSIONS

Understanding what leads residents to label patients as having depression and anxiety problems may be a productive approach towards reducing perceived difficulty. Residents from distant cities may be more likely to find their patients difficult.

Therapeutic alliance in pediatric primary care: preliminary evidence for a relationship with physician communication style and mothers' satisfaction

OBJECTIVES

Studies in pediatric primary care suggest that interactions between parents and providers may have therapeutic impact on children's mental health problems. Methods to measure interactions specific to mental health outcomes have been developed in psychotherapy but are only beginning to be applied in primary care. We tested an adaptation of the Vanderbilt Therapeutic Alliance Scale (VTAS) for rating parent-provider interactions in pediatric primary care.

METHODS

Recoding, using the VTAS, of 50 previously collected audiotapes of visits to a pediatric residents' continuity clinic. Concurrent validity of VTAS coding was measured by comparing it to independent coding using the Roter Interaction Analysis System. Predictive validity was tested by comparing VTAS scores to parent ratings of the residents' behavior in the domains of interpersonal sensitivity, partnership, and informativeness.

RESULTS

The VTAS demonstrated a factor structure very similar to the structure observed when it has been used to rate mental health visits. VTAS patient and provider subscale scores correlated with corresponding Roter Interaction Analysis System measures of parent and resident participation. Total VTAS scores correlated most strongly with Roter Interaction Analysis System scores indicating emotion and rapport-building statements from the resident. Total VTAS scores predicted parents' ratings of residents' interpersonal sensitivity but not ratings of partnership or informativeness.

CONCLUSION

It appears possible to use therapeutic alliance to rate interactions in primary care. Measuring alliance may bring greater efficiency to primary care mental health studies because of its potential specificity as a marker of mental health-related outcomes.

Sugar-coaters and straight talkers: communicating about developmental delays in primary care

OBJECTIVES

The goals were to investigate parents' and early intervention (EI) specialists' beliefs and experiences regarding discussing child development in primary care and to identify communication barriers and opportunities.

METHODS

Focus groups were held with (1) mothers of young children with typical development, (2) mothers of young children who received EI services, and (3) EI specialists. Seven groups (N = 46 participants) were conducted in the greater Cleveland, Ohio, area. Meetings were audio-recorded, transcribed, coded, and analyzed, to identify themes.

RESULTS

Most mothers reported a preference for a nonalarmist style of communication when developmental delays are suspected. In contrast, some mothers preferred a more direct style, including the use of labels to help them understand their child's development. The importance of preparation to accept information about developmental delays emerged as a theme in all groups. Elements contributing to preparedness included information about expected developmental skills, suggestions for promoting skills, and a specific time frame for follow-up evaluation. Mothers of children with disabilities perceived that early reassurance of normalcy by providers in response to their concerns led to self-doubt and increased difficulty accepting the diagnosis.

CONCLUSIONS

Mothers and EI specialists have clear ideas about factors that promote or impede communication regarding child development. This information can inform primary care providers' approaches to monitoring and screening the development of young children and to communicating with parents regarding suspected developmental delays.

Increasing parent-pediatrician communication about children's psychosocial problems

OBJECTIVE

To examine the differential effects of two scoring procedures for a parent-completed measure, the Pediatric Symptom Checklist (PSC), designed to assess children's behavioral and emotional functioning, on parent-pediatrician communication concerning psychosocial issues.

METHODS

Prior to their medical appointment, 174 parents of children aged 4-16 were assigned to one of three experimental conditions: (1) typical medical care control, (2) Staff-Scored PSC administration, or (3) Parent-Scored PSC administration. Following the appointment, parent perception of parent-pediatrician communication was assessed.

RESULTS

For children with more emotional and behavioral problems, participants in the Parent-Scored group and the Staff-Scored group had better parent-pediatrician communication scores than those in the control group.

CONCLUSIONS

Both the Staff-Scored and Parent-Scored administrations of the PSC improved parent-pediatrician communication on psychosocial issues. The Parent-Scored PSC removed the scoring burden on the medical personnel.

Racial/ethnic disparities in the identification of children with autism spectrum disorders

OBJECTIVES

We sought to examine racial and ethnic disparities in the recognition of autism spectrum disorders (ASDs).

METHODS

Within a multisite network, 2568 children aged 8 years were identified as meeting surveillance criteria for ASD through abstraction of evaluation records from multiple sources. Through logistic regression with random effects for site, we estimated the association between race/ethnicity and documented ASD, adjusting for gender, IQ, birthweight, and maternal education.

RESULTS

Fifty-eight percent of children had a documented autism spectrum disorder. In adjusted analyses, children who were Black (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.64, 0.96), Hispanic (OR = 0.76; CI = 0.56, 0.99), or of other race/ethnicity (OR = 0.65; CI = 0.43, 0.97) were less likely than were White children to have a documented ASD. This disparity persisted for Black children, regardless of IQ, and was concentrated for children of other ethnicities when IQ was lower than 70.

CONCLUSIONS

Significant racial/ethnic disparities exist in the recognition of ASD. For some children in some racial/ethnic groups, the presence of intellectual disability may affect professionals' further assessment of developmental delay. Our findings suggest the need for continued professional education related to the heterogeneity of the presentation of ASD.

Enhancing communication skills for pediatric visits through on-line training using video demonstrations

BACKGROUND

Training in communication skills for health professionals is important, but there are substantial barriers to individual in-person training for practicing clinicians. We evaluated the feasibility and desirability of on-line training and sought suggestions for future courses.

METHODS

Based on successful in-person curricula for communication skills and our previous on-line curricula, we created an on-line course consisting of 28 modules (4.75 hours CME credit) about communication skills during pediatric visits that included a mental health concern; each module included a brief case, a multiple choice question, an explanation, and a 1-2 minute video demonstrating key skills. Specific communication skills included: greeting, setting an agenda, discussing diagnosis and treatment, and managing negative interactions. The course was announced by emails in spring, 2007; the course was available on-line for 60 days; we aimed to enroll 50 clinicians. Outcomes were analyzed for those who evaluated the course within 75 days of its initial availability.

RESULTS

Overall, 61 clinicians registered, of whom most were nurses (N = 24), physicians (N = 22), or psychologists or social workers (N = 12). Of the 36 (59%) clinicians who evaluated the course, over 85% agreed that all course objectives had been met; over 90% reported greater confidence in greetings and agenda-setting; and over 80% reported greater confidence in discussing diagnosis and treatment and managing negative interactions. Nearly all, 97% would recommend the course to other clinicians and trainees. Suggestions for improvement included a library of additional video vignettes and written materials to accompany the on-line training.

CONCLUSION

On-line training in communication skills for pediatric mental health visits is feasible, desirable and associated with increased confidence in key skills. Positive feedback from clinicians suggests that a comparison of on-line versus in-person training is warranted.

Residents who stay late at hospital and how they perform the following day

CONTEXT

The limits imposed on the official working hours of paediatric residents do not necessarily reduce the amount of time they spend at work. Fatigue and stress can result from staying late voluntarily, and this in turn can alter clinical performance, much as long obligatory hours did in the past.

METHODS

A cross-sectional analysis was made of a systematic sample of 243 primary care visits conducted in 1990 by 52 paediatric residents at a teaching hospital. The paediatric residents reported on their work responsibilities the night before each primary care visit and their communication style during the visit was analysed from recordings made on audiotapes using the Roter Interactional Analysis System (RIAS).

RESULTS

Paediatric residents who care for critically ill children were more likely to stay late even if they were not on call. During primary care visits the next day, those paediatric residents who stayed late were more verbally dominant--their verbal input, as a proportion of the total, was: 0.67 (stayed late) versus 0.62 (on call), P = 0.007; 0.67 (stayed late) versus 0.64 (left on time), P = 0.02. Paediatric residents who stayed late displayed less patient-centredness: patient-centred talk as a proportion of total 0.31 (stayed late) versus 0.36 (on call), P = 0.02; 0.31(stayed late) versus 0.34 (left on time), P = 0.03. Compared with paediatric residents who left on time, those who stayed late reported feeling less fulfilled; if their clinic was in the afternoon, they also reported more fatigue.

CONCLUSIONS

The care of critically ill children may make paediatric residents more liable to remain at work after the end of their shift. The clinical interactions of such residents were more dominant and less patient-centred. Helping paediatric residents to learn to manage their work while under clinical stress could promote better adherence to guidelines on working hours and have a positive impact on patient care.

Companion participation in cancer consultations

OBJECTIVE

Companions play an important role in cancer care. This investigation compared the communication of unaccompanied patients, accompanied patients, and companions during lung cancer consultations. Factors affecting the active participation of companions were analyzed.

METHODS

Participants included unaccompanied patients (N=48), accompanied patients (N=84), and companions (N=84) of newly diagnosed lung cancer patients seen at a large southern VA medical center. The consultations were audiotaped, then transcribed. Coded utterances included patients' and companions' active participation (asking questions, expressing concerns, and making assertions) and physicians' use of facilitative communication. Mixed linear regression was used for comparisons of accompanied patients' participation to that of their companions and to determine the independent predictors of companion participation and patient satisfaction.

RESULTS

The combined companion plus patient participation did not differ from the participation of unaccompanied patients. Patterns of companion participation varied greatly as almost half the interactions had a relatively passive companion (contributed to less than 40% of the patient plus companion active participation) but 33% of the consultations had an active companion and passive patient. Companions with less active participation accompanied black patients and received proportionally less facilitative communication from physicians. Patient satisfaction was lower when companion and patient had similar levels of participation.

CONCLUSION

Companions vary greatly in their participation in lung cancer visits. Physicians facilitate companion participation through the use of partnership-building and supportive communication. The companions of black patients were less active than their white counterparts which parallels other research indicating that black patients are often less active than white patients. Such communicative discrepancies could contribute to racial disparities in cancer care.

Parent-provider communication and parental satisfaction with care of children with psychosocial problems

OBJECTIVE

The objective of the present paper was to determine the association between parent-provider communication and parent ratings of satisfaction and quality of care for a group of parents of children identified with a psychosocial problem.

METHODS

A sample of 804 parents of children with psychosocial concerns enrolled in the Child Behavior Study (CBS) was used for the present analyses. As part of the CBS, parents of children with psychosocial problems answered questions that assessed parent-provider communication and parent ratings of satisfaction and quality of care.

RESULTS

Overall, parents reported good communication with their child's provider. Eighty-two percent of parents were very satisfied with the care received and 68% reported a very high quality of care. Parent-provider communication (e.g., collaboration and mutual understanding) was strongly related to parental reports of both satisfaction and quality of care.

CONCLUSIONS

Parent-provider communication is an important correlate of parental report of satisfaction and quality of care. Involvement of parents in the treatment planning process was particularly important in determining satisfaction and quality ratings within this sample.

PRACTICE IMPLICATIONS

When working with families with identified psychosocial concerns, the use of collaboration and an empathic style by providers may enhance the quality of care parents report receiving from their primary care clinicians.

Doctors' responses to patients with medically unexplained symptoms who seek emotional support: criticism or confrontation?

OBJECTIVE

Consultations about medically unexplained symptoms (MUSs) can resemble contests over the legitimacy of patients' demands. To understand doctors' motivations for speech appearing to be critical of patients with MUSs, we tested predictions that its frequency would be related to patients' demands for emotional support and doctors' patient-centered attitudes as well as adult attachment style.

METHODS

Twenty-four general practitioners identified 249 consecutive patients presenting with MUSs and indicated their own patient-centered attitudes as well as adult attachment style (positive models of self and others). Before consultation, patients self-reported their desire for emotional support. Consultations were audio recorded and coded utterance by utterance. The number of utterances coded as criticism was the response variable in the multilevel regression analyses.

RESULTS

Frequency of criticism was positively related to patients' demands for emotional support, to doctors' belief in sharing responsibility with patients and to doctors' positive model of themselves. It was inversely associated with doctors' belief that patients' feelings were legitimate business for consultation and was unrelated to their model of others.

CONCLUSIONS

From the perspective of doctors, speech that appears to be critical probably reflects therapeutic intent and might therefore be better described as "confrontation." Understanding doctors' motivations for what they say to patients with MUSs will allow for more effective interventions to improve the quality of consultations.

Healthy Steps for Young Children program in pediatric residency training: impact on primary care outcomes

OBJECTIVE

Incorporating Healthy Steps for Young Children into pediatric practice has been shown to have positive effects for children and families. Although this model of care has also been integrated into several pediatric and family medicine training programs, published reports to date have focused only on residents' perceptions of their interactions with the model of care. In this study, we report the impact on primary care outcomes after integrating Healthy Steps for Young Children into residency training.

METHODS

Continuity of care, longitudinal care in the practice, quality of primary care services, and rates of behavioral, developmental, and psychosocial diagnoses were measured for 3 cohorts: (1) Healthy Steps-enrolled children, (2) non-Healthy Steps-enrolled children who were followed at the same site of care, and (3) non-Healthy Steps-enrolled children who were receiving primary care at a similar residency training site within the same training program. All data were extracted from patient charts at the 2 practice sites.

RESULTS

Continuity of care was significantly better for Healthy Steps-enrolled children compared with non-Healthy Steps-enrolled children at the Healthy Steps site for both total visits and health maintenance visits. Longitudinal care and quality of primary care services did not differ within or between sites. The rates of documentation of behavioral, developmental, or psychosocial diagnoses did not differ between Healthy Steps-enrolled and non-Healthy Steps-enrolled children at the Healthy Steps for Young Children site but were significantly different between the Healthy Steps and the non-Healthy Steps for Young Children sites; the effect was driven wholly by differences in psychosocial diagnoses.

CONCLUSIONS

Multiple indices that measure health service outcomes suggest benefits of incorporating Healthy Steps for Young Children into pediatric residency training. Most important, continuity of care in residents' practices significantly improved, as did the residents' documentation of psychosocial issues in children.

Pediatric emergency medicine physicians' current practices and beliefs regarding mental health screening

BACKGROUND

Only 20% of children with mental health issues are identified and receiving appropriate treatment nationally. The emergency department (ED) may represent a significant opportunity to provide selective pediatric mental health screening to an at-risk population.

OBJECTIVE

To describe the current standard of care and perceived limitations among pediatric emergency medicine (PEM) physicians regarding mental health screening.

METHODS

A 23-question survey on screening practices for pediatric mental illness (PMI) was sent to PEM physician participants identified through the American Academy of Pediatrics Section on Emergency Medicine mailing list.

RESULTS

Of the 576 physicians meeting our inclusion criteria, 384 (67%) surveys were returned. Eighty-six percent of respondents indicated screening for PMI in 10% or less of their eligible patients. Overall, 43% of respondents indicated screening only if the chief complaint was psychiatric in nature. The remaining 217 physicians most commonly screened for depression (83%), suicidality (76%), and substance abuse (67%). Only 9% of physicians stated that they used evidence-based medicine in determining their screening practices. Women physicians (odds ratio, 1.94; 95% confident interval, 1.08-3.47) and those using evidence-based medicine (odds ratio, 3.88; 95% confidence interval, 1.92-7.85) were more likely to conduct screening. Significant limitations to screening identified by respondents include the following: time limitations (93%), absence of a validated screening tool (62%), limited resources (46%), and lack of training (44%). Eighty-eight percent of physicians believe that a validated and standardized screening tool would improve their ability to identify PMI.

CONCLUSIONS

Routine PMI screening is conducted infrequently by most PEM physicians. Improved physician education/training and the development of a validated ED-specific mental health screening tool would assist PEM physicians in the early detection of PMI.

Empathy and patient-physician conflicts

Physicians associate empathy with benevolent emotions and with developing a shared understanding with patients. While there have been many articles on managing "difficult" patients, little attention has been paid to the challenges physicians face during conflicts with patients, especially when both parties are angry and yet empathy is still needed. This topic is especially important in light of recent studies showing that practicing medicine increasingly requires physicians to manage their own feelings of anger and frustration. This article seeks to describe how physicians can learn to empathize with patients even when they are both subject to emotions that lead to interpersonal distancing. Empathy is defined as engaged curiosity about another's particular emotional perspective. Five specific ways for physicians to foster empathy during conflict are described: recognizing one's own emotions, attending to negative emotions over time, attuning to patients' verbal and nonverbal emotional messages, and becoming receptive to negative feedback. Importantly, physicians who learn to empathize with patients during emotionally charged interactions can reduce anger and frustration and also increase their therapeutic impact.

Disparities in diagnoses received prior to a diagnosis of autism spectrum disorder

This study estimated differences by ethnicity in the diagnoses assigned prior to the diagnosis of autism. In this sample of 406 Medicaid-eligible children, African-Americans were 2.6 times less likely than white children to receive an autism diagnosis on their first specialty care visit. Among children who did not receive an autism diagnosis on their first visit, ADHD was the most common diagnosis. African-American children were 5.1 times more likely than white children to receive a diagnosis of adjustment disorder than of ADHD, and 2.4 times more likely to receive a diagnosis of conduct disorder than of ADHD. Differences in diagnostic patterns by ethnicity suggest possible variations in parents' descriptions of symptoms, clinician interpretations and expectations, or symptom presentation.

Role of pediatric health care professionals in the provision of parenting advice: a qualitative study with mothers from 4 minority ethnocultural groups

OBJECTIVE

This study's aim was to elicit the perspectives of minority parents on their expectations of pediatric health care providers as a source of advice on "raising their child" and whether they would seek advice from these providers. A secondary aim was to demonstrate the value of qualitative methods for assessing parental attitudes in pediatric research.

METHODS

Mothers with children between 3 and 12 years of age who identified themselves as African American, Jamaican, Haitian, or Puerto Rican were recruited from community sites. Audiotaped focus groups were conducted by trained moderators using an interview guide, to obtain the perspectives of the participants regarding the role of pediatric providers in the provision of parenting advice.

RESULTS

Ninety-one mothers participated in a total of 20 focus groups, with 4 to 6 discussions per ethnocultural group. The focus groups revealed that, in general, parents do not look to child health care providers for advice on raising their children. The identified themes emphasized the importance of the relationship between providers and families. A few parents had the type of relationship within which the pediatrician already functioned as a provider of parenting advice. Physicians were considered skilled in the maintenance of physical health. The parents expressed a desire to receive more anticipatory guidance on developmental and behavioral stages and milestones. Pediatricians also served specific administrative functions valued by parents.

CONCLUSIONS

Minority parents of preschool-aged and school-aged children do not view the primary care provider's role as including the provision of parenting advice. Expectations must be modified to enable health care professionals to function effectively in the role of advisor regarding parenting issues.

Core assumptions and research opportunities in clinical communication

OBJECTIVE

Contemporary clinical communication teaching and research reflect the axiomatic importance of building a clinical relationship and of empowering patients as partners. The apparent moral unassailability of these principles has inhibited their scientific scrutiny. By questioning this current hegemony in communication teaching and research, our objective is to identify research opportunities that remain to be fully exploited.

METHOD

We identify assumptions in current communication literature and evaluate them from the perspective of relevant empirical and theoretical literature.

FINDINGS

The view that the clinical relationship is an objective thing which needs to be 'built' can lead researchers to neglect factors within patients that influence their subjective sense of the relationship. The model of partnership is hard to reconcile with patients' vulnerability and associated dependency needs. The widespread use of the term 'communication skills' emphasises processes at a skill level at the expense of those at levels of cognition, emotion, and value.

CONCLUSION

Research is needed into: the extent to which patients' sense of relationship arises from factors outside the relationship; the implications of their vulnerability and dependency for clinical relationships; and the processes at the level of cognition, emotion and value, as well as skill, that are entailed in clinical communication and in communication teaching. RESEARCH AND PRACTICE IMPLICATIONS: Pursuing the research opportunities that we have identified will enhance the theoretical validity and practical relevance of clinical communication research and teaching.