Children's Emotional HealthLink: An Innovative Physician-Parent Communication Training Model
by Howard S. King, MD, MPH
Newton-Wellesley Hospital and Harvard Medical School
In October 2004, a group of 15 pediatricians and nurse practitioners began to meet once a month, for a one-year period, to see if they could increase their competence in providing psychosocial assessments of children and families, in response to parental concerns, within their own pediatric practice.
The leaders of this program included two child psychiatrists, a behavioral pediatrician, a clinical social worker, and an evaluator who would attempt to determine the effectiveness of this intervention.
As a pediatrician in full-time practice, I designed and promoted this project, which was ultimately funded by the Department of Mental Health as well as the Kenneth Schwartz Center, among others.
I had observed for many years that if I took the time to invite parents to return for a single, reimbursable crisis-intervention office visit, I could often accomplish the following:
- If I took the time to understand what accounted for a child's problem, often
arising within the context of a stressful family history, parents could be helped to discover why the problem was happening, the potential solution to the problem and,
together, we were often able to reduce the likelihood of future recurrences.
- When appropriate, I would refer parents to the Social Work Therapy Referral Service, in order for them to receive short-term counseling services on parental or couples issues, often not requiring intervention or psychoactive medication for the child.
While I had had some training in these matters prior to starting practice, I discovered over and over again that providing time for parents would result in their teaching me how these problems had arisen and how I could help them achieve a relatively speedy solution.
What was of major help to parents was my being able to invite them back for one uninterrupted hour-long visit, which the payers had agreed to support many years ago. As a result of a special pediatric program in 1998, BCBS and the Tufts Plan agreed to provide this opportunity for reimbursement for all pediatricians. This was a major turning point in our relationship with the payers. But, unfortunately, most pediatricians didn't take advantage of that opportunity.
With the encouragement of Dr. Michael Jellinek, President of Newton-Wellesley Hospital, and funders, I had the opportunity to co-lead a training model with two child psychiatrists, Steve Schlozman and Susan Swick, and a clinical social worker, Julia Swartz. We met with a group of pediatricians and pediatric nurse clinicians to see if we could recreate interventions which I had employed in practice for many years.
We were aided in this project by the website, www.cehl.org, both in its curriculum content as well as the ability to take surveys of both parents and clinicians. In addition, we made use of a secure website forum to share both cases and our individual responses to these cases.
We had two expectations for the participants. They were required to attend 11 of the 12 monthly sessions and present at least one case for discussion. In return, we provided a stipend for each participant and CME credits.
This program was successful in modifying the participants' approach to the families in their practice.
I. COMMON MYTHS ABOUT THE PSYCHOSOCIAL APPROACH
How can we help pediatricians overcome barriers to addressing the emotional health of children and their families? The following myths were confronted and explored in the program:
- There is insufficient time for this approach.
- Pediatricians lack adequate mental health clinicians to make referrals.
- Pediatricians are not reimbursed when they provide adequate assessment.
- The child should always be the primary patient for the pediatrician.
- Pediatricians' responsibilities shouldn't include parents' emotional well-being.
- All pediatricians are motivated to provide earlier diagnosis and intervention.
- Medication is always required to manage the behavioral issues of families.
- It is difficult to adequately train pediatricians to carry out such assessments.
- It isn't necessary for pediatricians to consider their own developmental history.
- Parents are unwilling to return for a follow-up visit for emotional issues.
- Most parents are uncomfortable being asked about psychosocial issues.
- In the healthcare delivery system, emotional problems are equal in importance to physical ones.
II. A PSYCHOSOCIAL APPROACH SAVES TIME IN CLINICAL PRACTICE
The most common assumption about primary care is that while clinicians are concerned about mental health issues, they feel there is insufficient time to address those issues in routine practice. The following observations taken from course discussions contradict that assumption:
- Time spent on the child benefits all family members.
- This approach can reduce drug costs, the frequency of office visits, procedures and telephone calls.
- This approach can increase parents' sense of trust and, as a result, there is enhanced compliance with medical recommendations and fewer malpractice problems.
- By using this approach earlier, problems are less serious and require less time to manage. If "half of therapy is preparation for therapy," then constructive referrals can be successfully achieved in a more timely way, and can reduce mental health costs. There is also earlier identification of intimate partner abuse and the addictions.
- Treatment is not our only goal. By improving the decision-making skills of parents, they, in turn, can reach out more effectively to other family members.
- We are not only trying to help parents cope with isolated episodes, but also help them reduce future problems.
- Pediatricians also benefit, by learning from parents' "stories." Pediatricians discover not only root causes but also how to help parents solve behavioral problems.
- Self-destructive lifestyles repeat from one generation to the next. Using a holistic approach is more likely to help parents break that pattern.
- A doctor-patient relationship built upon compassion, mutual respect and focusing on the whole person in the context of the family is more satisfying than any other.
III. PREQUISITES FOR PRACTICING GOOD PSYCHOSOCIAL CARE
- There is insufficient time to understand problems during the well-child visit. It is beneficial for the parent to return for a follow-up visit.
- Case presentations are the best way to learn how to manage such problems. In their role as storytellers, parents can be our best teachers.
- Pediatricians will be more successful when they are aware of the impact of their own past histories on the way they listen to and advise parents.
- Health systems need to motivate the pediatrician to take this kind of time, not only with appropriate reimbursement but also by valuing its importance.
- When parents and pediatricians join in evaluating this kind of intervention, it enhances success and reaffirms the role of "trust" in the doctor-parent relationship.
- How do you enhance "empathy" among pediatricians? Besides encouraging self-awareness, you can reward participation in courses in the Protection of Human Research on Human Subjects.
- Helping parents mourn unacknowledged losses impacts their ability to respond appropriately to their children's problems. Parents and children experience a variety of losses. These losses can be compounded by ambivalent feelings for various family members, e.g. an abusive or addictive parent.
Why do problems like depression, abuse, or addiction repeat themselves from one generation to another, even when parents swore they would never subject their children to similar experiences? One reason may be the failure to grieve the loss of those relatives because of their complicated relationships.
It isn't easy to grieve. It is difficult to find empathic "listeners." Some may see it as a sign of weakness. Others may not value expressing such feelings. It is hoped that pediatricians will facilitate this process for the families in their practices.
- Internalizing these skills and maintaining a passion for understanding families in this way increases when interest is sustained on a daily basis. One way is to develop a secure forum on a website, like "Participant Discussions." It provides opportunities for posting cases and encourages others to post their responses. Every case, thereby, presents a new opportunity for learning.
- What is at the heart of behavioral problems in children? Taking a good family history may help to understand root causes. Two questions help:
"Whom does he remind you of? " and "What are your worst fears?" They enable the parent to recall the memory and the affect associated with the person(s) or the event, buried in the parent's past.
By helping parents bring memories and assumptions about heredity to the surface, so that their responses can be better understood, their children will be enabled to become the separate creative individuals they have a right to be.
- The fundamental goal in practicing this kind of pediatric care is discovering the uniqueness and diversity of the children and parents within our own practices, and the capacity to bring about healthy change within themselves and their families.
That will happen when we work within a health system, which respects our own individuality and creativity. We can become models for children and parents, when we are valued for our ability to bring about change and innovation, both within families and within the healthcare system.
Questions for Innovative Thinking About Improving Physician-Parent Communication in Pediatric Practice
Before we can answer parents' questions, we have to answer our own questions about pediatric care:
- Why isn't there sufficient time in our health system to allow for psychosocial assessment?
- Do the health plans value holistic care by primary care physicians?
- Because it is hard to put management of psychosocial issues into an "evidence-based framework," is that sufficient reason to exclude it?
- Is the family system "the real patient" for the psychosocial pediatrician?
- To better help parent and families, do we need to redefine the mission of the routine exam so it includes consideration of mental health issues?
- Do we make sufficient efforts to have a "contract" with families in order to assess the emotional state of the child and the family?
- Can the skill of pediatricians to rule out physical problems make it easier to then inquire about emotional problems?
- Do we want to search for emotional problems in families? If not, why not?
- If a routine office visit confronted us with an unexplained emotional problem, would we be willing to invite the parent to return for a careful family history?
- Pediatricians often feel insufficiently trained to address psychosocial problems. By listening to their stories, can parents become our best teachers?
- Are we willing to spend time with families now, to save time in the future?
- Is adequate reimbursement our only goal? What about the role of curiosity in professional development and satisfaction?
- Finally, if we are able to take an active stance on these issues, can we provide a powerful role model for parents to become more active advocates on behalf of their families?
- This program demonstrated that pediatricians can provide psychosocial assessment of children and families, can find adequate time to do so in a managed care environment and that parents are quite receptive to this type of intervention.
- Yet, despite the enthusiasm of these health care clinicians to acquire such skills, it is probable that they represent only a minority of physicians.
- It is unlikely that increased physician training, more efficient use of time, or referral to therapists would make a difference, by themselves, in outcomes for families where parents identify concerns.
Even if reimbursement was increased, assessing families psychosocially isn't easy or easily understood. As one pediatrician put it, "I didn't become a pediatrician to be a psychiatrist." It takes time, empathy and an introspective attitude. The rewards are great, but so are the demands.
What then is required to motivate physicians further? Un-ambivalent support on the part of the health plans.
All primary care physicians are expected to focus on monitoring the use of expensive medications, high cost radiological procedures and other gate-keeping functions. Those primary care physicians who also focus on mental health issues need to spend more time per visit to improve the quality of care, to be proactive in reducing costs and form alliances with patients and families, and yet still comply with the above expectations, with less reimbursement.
The challenge remains - can we expect the same physician to perform both functions adequately and simultaneously? Would managed care and other health systems be willing to live with two different kinds of primary care physicians, working side by side? It could be achieved if mental health was looked upon with value equal to physical health in our health care system.
How can we make that idea a reality, in our time?