Re: Lost in translation
“Health is the first of all liberties, and happiness gives us the energy which is the basis of health”
Journal Intime, 3 Apr 1865 – Henri Amiel, Swiss philosopher and writer
The article by the general practitioner Des Spence on communication between doctors and patients and especially his argument against doublespeak and pompous professional jargon fully meets my own frontline experience. As a researcher in communication, my over 20-year experience working as a paediatrician in the largest European multicultural children’s hospital underlines the need to avoid alarming parents and to give them hope. To avoid the dangers of being lost in translation we have to ponder on what the child’s parents really hear when the doctor speaks, and what they really mean when replying. The following personal vignettes illustrate the tendency towards an inflexible physician-centred rather than a more friendly parent-centred approach.
In 1990, in times before systematic reviews became available and information on barbiturates and diazepam to prevent and treat febrile episodes remained controversial, my four-year-old daughter had recurrent benign febrile seizures and was admitted to the University paediatric hospital in Rome. At her discharge, as a young doctor specializing in paediatrics, I realized that my daughter was actually recovering from a viral infection and that her EEG contained no epileptic signs. These findings notwithstanding, the Neurologist-in-chief prescribed her barbiturates for a year and intermittent diazepam during febrile episodes, even though these medications induce adverse reactions outweighing their benefits in reducing recurrent seizures. On hearing my objection, ignoring the parent’s point of view, the neurologist wryly commented that she probably knew best. This comment notwithstanding, my daughter never received barbiturates, and to allay my increasing fears that her seizures might recur she continued intermittent diazepam until the age of five. To date my daughter seems perfectly healthy.
The second vignette began in 1992 when the first clinical guideline on managing acute diarrhoea in children was published (http://www.cdc.gov/mmwr/preview/mmwrhtml/00018677.htm). This paper recommended as the best treatment for children with diarrhoea oral rehydration solutions (ORS) rather than intravenous. These recommendations received strong evidence-based support. , Hence, in June 2009 at the hospital emergency department during a viral gastroenteritis epidemic, I prescribed 35 children (range 6 months-9 years), all of whom had otherwise normal clinical findings, ORS for a few hours at home. My medical decision provoked unexpected and scathing comments from colleagues, particularly from a young unemployed paediatrician who sustained that if other hospital colleagues replicated my advice, fewer patients with gastroenteritis would be admitted and the hospital management would “give her the sack.” I retorted that the clinician’s priority is to reduce children’s useless suffering and give them the most appropriate treatment. Nowadays in developed countries, although ORS yield tremendous therapeutic benefit, we meaninglessly and unethically admit many children with acute diarrhoea instead of prescribing ORS and sending them home.
The third vignette is related to “overprognosis.” For over 10 years until 1999, my hospital job involved taking care of children with cystic fibrosis, an almost uncurable genetic disease, whose diagnostic work-up usually requires sweat tests. Later, during a night shift in the hospital, I again encountered the mother of a child in whom I had diagnosed cystic fibrosis 13 years ago. She reminded me about our first meeting, when the child underwent sweat tests. At that time, she asked me whether a new pregnancy put her at risk of having another ill child. When I informed her about this relatively frequent event, my smiling face and comforting words gave her hope and persuaded her to try another pregnancy. Now the family is happy to have a healthy child.
As Spencer astutely remarks, “often neither the doctor nor the patient has any idea what is going on.” So before provoking anxiety by immediately asking for diagnostic tests and prescribing medications you need to give children’s parents hope. The best, simple, safe and cost-free way of giving hope is to smile. Given that every successful human-to-human interaction starts with a smile, why do physicians so rarely smile at the parent, and equally important at the child, when giving information about the disease? Coping with parental anxiety, and taking a more humane, sympathetic attitude might also reduce overdiagnosis, overtreatment, , and our common unrecognised tendency to overstress negative clinical outcomes, namely “overprognosis.”
Wondering how to keep anxious parents happy right from the first hospital encounter, given that people from all cultures understand the same six facial human expressions (happiness, surprise, fear, sadness, pain and loathing), I developed the “smiling rule”, namely S.M.I.L.E. S, Smile before you speak; M, Mind your duty as a doctor to use the best clinical practice; I, Interview parents appropriately remembering that the clinical history gives invaluable clues to the disease; L, Listen to parents and give them time to express their hidden concerns; and E, Empathise with parents and thus reduce their child’s pain and discomfort. In practice, when I used the “smiling rule” over the past 8 years a surprising number of parents attending the outpatients’ clinic happily and willingly came back to me several times to seek help for their children. Standard hospital use of diagnostic blood tests and antibiotic therapy markedly diminished, and my professional fulfilment and parents’ satisfaction increased. Allaying parents’ fear and anxiety, without overdoing an austere white-coat role, generally helps also to decrease the complex hidden social problems related to a major chronic disease. Dr Bernard Lown taught us with his mantra that in every clinical situation you can instil hope if you use words that unburden fear and do “as much as possible for the patient and as little as possible to the patient.”
Paola Rosati MD MSc
Ambulatorio di Pediatria
Dipartimento di Medicina Pediatrica
Bambino Gesù Children’s Hospital, IRCCS
Largo S. Onofrio 4, 00165 Rome, Italy
Competing interests: No competing interests