Some
families come to your office more often than is required for
a specific problem or checkup. At such times, they may be dealing,
consciously or unconsciously, with some unresolved emotional
problem. For that patient or parent you may be able to find
better ways of helping them articulate such feelings and yearnings
for help. You may be able to help them discover more successful
solutions.
Shift your focus to the entire family
Consider focusing not just on the child but also on the
entire family. At every visit, particularly when a parent
shares with you a concern about a child's emotional health,
think about asking yourself, "Who is the real patient?"
Is it the child in front of you, or is there something else
going on in the family, someone else who needs help?
Shift your view of the parent in the doctor-parent relationship
It is helpful to view parents both as "story tellers"
and teachers. It is a richer way to see them rather than as
people who are only bringing in problems about their children.
What might you accomplish by this changed view?
As a pediatrician, you may be anxious that you haven't the
skills to understand what is going on, emotionally, with children
and families. By making this change in how you view parents,
you may find them helping you to improve your skill in assessing
the child and the family.
You may also discover that you accomplish something else.
By engaging parents with respectful listening, you may enhance
their role with dignity as well as encourage them to develop
a more confident and "activist" self-image. These
attributes can nurture greater feelings of competence in parents
and help achieve your goal of promoting more normal development
for the child and family.
Facilitate the trajectory of parental development
It is traditional for pediatricians to focus on the trajectory
of infant development. But such interventions are more effective
when you also assist parents in their own trajectory.
As you work with parents, you might ask yourself, "What
am I doing to improve their sense of competence and to help
them become better decision-makers, not only in regard to
their children but also with their own physical and emotional
health?”
Help parents develop healthy boundaries in their relationship
with their children
How might you help parents view their children as separate
people? How can you reduce the tendency for them to invest
their children with attributes derived from unresolved conflicts
within their own lives?
You may be able to do so, in part, by using the office visit
as an opportunity to evaluate how the child and the family
are doing.
You may also wish to discuss the issue of "inheritance."
Parents worry about their children inheriting problems such
as mental illness, depression, or personality disorders. You
can often reassure them that such problems need not be passed
on, particularly if you help parents look at what that experience
meant in their own development.
Become aware of the child as an "agent for change"
In pediatric practice, parents frequently ask for help in
understanding and learning how to modify their child's behavior.
We, in turn, make suggestions as to how the parents might
go about doing that.
But what happens if we consider that it is not just the
child but rather the whole family that is, potentially, our
patient? In that case, as we attempt to understand the child's
behavior, we may feel it of value to assess the status and
functioning of all the members of the family system.
The end result may be that, rather than merely trying to
do something with the child, we may be able to suggest ways
of bringing about constructive change in the functioning of
other members of the family including the parents.
What has happened? The child, by virtue of some behavioral
issue, has functioned as an "agent for change" in
the family system by motivating the parent to seek help from
the pediatrician.
Redefine prevention in the context of managed care
Most of us know the preventive tasks pediatricians usually
take on for themselves. They include everything from immunizations
to advocacy for breast feeding. But, up to now, early detection
of mental health problems such as mental illness and depression
has been, at best, a secondary topic for pediatricians. It
is important to emphasize that we are talking as much, if
not more, about parents as we are about children. The pediatrician
may be the health care system’s first “trip wire”
in picking up emotional issues in the parent and within the
family.
By picking up such problems earlier and helping the family
with a timely referral, you may be able to help both parents
and children, as well as society, in an important way.
Why have we given insufficient attention to this responsibility?
Part of it may include lack of training in family systems
theory. In addition, personal issues may make us hesitate
to address similar ones in our medical practice. And, in managed
care, the child is viewed as our only patient, so that time
and reimbursement are allocated accordingly.
Ironically, the worst curse of managed care, capitation,
may become the driving force for change. There are two possibilities.
One is that medicine will increasingly deteriorate as physicians
end up seeing more and more patients in less and less time
as they struggle to survive, professionally and financially.
They may even be relieved if mental health is carved out,
putting that burden on a group of designated providers. By
so doing, it is as if we have chosen not to integrate that
portion of health care within the existing model.
But there are more optimistic possibilities that may come
about from increasing your competence in preventive mental
health:
You might be able to reduce mental health costs
through earlier and shorter interventions, as well as reducing
the costs that result from delays in diagnosis, costly testing,
and needless procedures.
You might even reduce demands for seemingly fruitless
office visits which could be disguised pleas for help.
You might also help parents become better decision-makers
in regard to their overall health, and help them become
partners in reducing health care costs.
Finally, a frequently criticized attribute of managed care
by physicians is what they regard as a sense of entitlement
that patients bring to the doctor-patient relationship.
Might we look at it differently? Can we see it as an opportunity?
Each of these patients represents a diagnostic challenge.
If your guidance and recommendations do not satisfy parents
during repeated visits, why not ask yourself (and ultimately
them), where does the parents’ "neediness"
come from? If you do, you may be astonished by your discoveries.
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