Counseling-Communication-OSCE

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Communication in Pediatrics

DM - ICS - vaccines? communications

Station Flow Summary

• Opening: Greet, build rapport (warm up to child/parent), and clarify your role.
• Assessment: Elicit current understanding and check prior knowledge.
• Connection: Use empathy, reflective listening, and maintain eye contact at the child’s level.
• Explanation: Provide clear, developmentally appropriate information and negotiate the plan.
• Addressing Concerns: Validate and address specific patient/parent worries directly.
• Conclusion: Summarize the discussion, provide written materials (leaflets), and arrange follow-up.

Importance

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• Create a comfortable environment and build rapport (warm up to both the child and parents).
• Use appropriate body language.
• Communicate at the developmental level of both the child and the parents.
• Use empathic statements to communicate concern.
• Use reflective listening to show you have heard the patient’s concerns by reflecting their core message.
• Use silent listening when appropriate.
• Use open-ended statements to encourage dialogue.
• Maintain the child’s level: do not lean over the child; sit at the same level and maintain appropriate eye contact.

Ten Tips for Effective Patient Communication

• Clarification
• Summarization (including providing leaflets)
• Providing clear information
• Positive feedback
• Reassurance
• Follow-up

Structured Approach to a Pediatric Clinical Communication

1. Introduction and rapport (greet, warm up, make eye contact)
2. Clarify your role
3. Conduct the interview
4. Check prior knowledge
5. Address the patient’s and parent’s concerns
6. Provide appropriate explanation and negotiation of the plan
7. Ensure accuracy of information
8. Summarize the discussion
9. Provide written information
10. Arrange follow-up

Scenario 1 — Abdullah (Asthma)

Case summary

• Abdullah is a 5-year-old diagnosed with mild intermittent asthma.
• He has been using salbutamol via spacer PRN.
• He was admitted 3 days ago for an exacerbation and was treated according to guideline with oral steroids and salbutamol via nebulizer.
• Prior to this exacerbation, Abdullah had increased his use of inhaled salbutamol to up to 4 times daily.
• He is otherwise healthy; weight and height at the 25th percentile.
• The medical team has decided to step up treatment and add prophylactic inhaled corticosteroid (ICS).

Task

• Discuss the new plan with the mother and address all her questions and concerns about ICS.

Suggested clinician script and points to cover

1. Opening and rapport

   • “How was your journey to the hospital?”
   • “I am Dr. Salma. I’m here to discuss the new plan for Abdullah.”

2. Elicit current understanding

   • “What do you know so far about Abdullah’s condition?”

3. Acknowledge feelings and provide empathy

   • “I’m so sorry you are feeling upset/worried.”

4. Explain rationale for ICS

   • Explain that inhaled corticosteroids act in the airways and have less systemic absorption than oral or topical steroids.
   • Explain that Abdullah’s lung secretions and symptoms have worsened to a point that preventive (maintenance) ICS is indicated.
   • “If controlled, exacerbations would be reduced. Currently he is not responding sufficiently to salbutamol alone — what do you think about that?”

5. Address concerns about complications and side effects

   • Validate the mother’s concern: “You are a good mother for asking about complications.”
   • Reassure about the small systemic dose with inhaled delivery: “The amount entering the rest of the body is very small.”
   • State monitoring plans: “We will continue to monitor his blood pressure, blood sugar, and other relevant parameters as much as we can.”
   • Ask for the mother’s thoughts: “What do you think about that?”

6. If the mother thinks inhaler alone is enough

   • “I understand you are worried. However, the frequency of salbutamol use (how many times this week?) suggests his asthma is not controlled and we need to step up medication.”

7. Discuss local side effects and when to return

   • “If you notice toothache, oral thrush, or other concerns, come to the doctor.”

8. Address concerns about growth and systemic effects

   • “I know you are a good mother, but asthma exacerbations themselves can affect growth and health. This ICS is inhaled, not oral.”
   • Ask: “Why do you think it will affect growth? What specifically worries you?”

9. If the parent fears coercion

   • “No one will force you. You will choose what is best for your child. I will give you reliable resources to read, and we will arrange follow-up. I hope you will come back so we can start the medication if you agree.”

10. Documentation and follow-up

• If the parent refuses treatment, document the refusal clearly.
• Arrange follow-up if/when the mother decides to return or has further questions.

Scenario 2 — Yara (Education: Correct Use of Spacer/Aerochamber) https://www.youtube.com/watch?v=sQUUJHzO-XQ

Points to cover

• Demonstrate how to use the spacer/aerochamber.
• Consider whether a mask (facemask) is needed for younger children; decide based on the child’s age and cooperation.
• If this is the first time using the inhaler: test and check expiratory function as appropriate, then place the inhaler in the aerochamber.
• Model the technique with the child and have the mother copy the steps.

Step-by-step process (practical demonstration)

1. Stand up tall (if an infant, hold in a sitting position).
2. Remove the mouthpiece cover from the inhaler.
3. Shake the inhaler 4 to 5 times.
4. Insert the inhaler into the spacer.
5. Seal the mask over the child’s mouth and nose, or have the child put the mouthpiece in the mouth and form a good seal.
6. Press down once to release one puff of medicine.
7. Continue to hold the mask sealed on the face while the child breathes 5–6 normal breaths.
8. Remove the mask and wait (30s - 1m) to allow the medicine to reach the lungs.
9. Repeat these steps for each additional puff required for the dose.

Additional notes

• Use an illustrative image for the steps when teaching (insert picture during education).
• Device replacement: change the spacer/aerochamber every 6 months if used daily; if not used daily, change every 12 months.
• When administering multiple puffs: give 5 breaths after each puff, then wait (30 seconds to 1 minute as above) and repeat as needed.
• Provide a leaflet or other educational material for home reference.

Cleaning process

• Provide written instructions and a leaflet for cleaning and maintenance (specific cleaning steps should be provided according to the device manufacturer).

Scenario 3 — Omar (Newly Diagnosed Type 1 Diabetes Mellitus)

Case summary

• Omar is an 8-year-old boy admitted with diabetic ketoacidosis (DKA) and newly diagnosed Type 1 Diabetes Mellitus (T1DM).
• He presented with polyuria, polydipsia, weight loss (5 kg over 4 weeks), and vomiting for 2 days.
• Current status: stabilized after IV fluids and insulin protocol; now transitioning to subcutaneous insulin.
• Family history: no known diabetes in immediate family; parents are first cousins.
• The medical team needs to initiate long-term insulin therapy and discharge planning with intensive parental education.

Task

• Explain the diagnosis to the parents, demonstrate insulin injection technique and blood glucose monitoring, teach hypoglycemia management, and address their concerns about lifelong dependency and lifestyle restrictions.

Suggested clinician script and points to cover

1. Opening and rapport

   • “I know you have been through a frightening few days. How is Omar feeling now compared to when he arrived?”
   • “I am Dr. [Name], the pediatric endocrinologist. I will be guiding you through understanding Omar’s condition and how we will manage it together.”

2. Elicit current understanding

   • “What have the nurses and doctors already explained to you about why Omar became so sick?”
   • “What do you understand about the word ‘diabetes’ as it relates to Omar?”

3. Acknowledge feelings and provide empathy

   • “It is completely normal to feel overwhelmed, guilty, or even angry about this diagnosis. Many parents wonder if they could have prevented this.”
   • “I want to reassure you: T1DM is an autoimmune condition. Nothing you did or didn’t do caused this. It is not from eating too much sugar or lack of exercise.”

4. Explain the diagnosis and rationale for insulin

   • “Omar’s pancreas has stopped making insulin, which is essential for life. Without insulin, the body cannot use sugar for energy.”
   • “This is why he lost weight despite eating more—his body was starving even with food. This is not Type 2 diabetes; his body cannot function without insulin injections.”
   • “The injections are not temporary. He will need insulin every day, multiple times a day, until we find a cure. However, children with T1DM live full, healthy lives with proper management.”

5. Demonstrate blood glucose monitoring

   • Show the glucometer: “We need to check his sugar before meals, at bedtime, and sometimes at 3 AM initially.”
   • Demonstrate finger-prick technique on yourself or a doll, then guide the mother to practice.
   • Explain target ranges: “Generally 80-180 mg/dL, though we will individualize this.”

6. Teach insulin injection technique

   • “Omar will need basal insulin (background) and bolus insulin (for meals).”
   • Demonstrate on an insulin pad or doll:
     • Pinch the skin (abdomen, thighs, arms, buttocks—rotate sites)
     • Insert needle at 90 degrees (or 45 if very thin)
     • Count to 10 before withdrawing
   • Have mother practice drawing up insulin and injecting saline into a pad.
   • Address needle phobia: “The needles are very small. Most children adapt within weeks.”

7. Hypoglycemia recognition and emergency management

   • “Low blood sugar is the most immediate danger at home. Signs include shaking, sweating, confusion, irritability, or seizure.”
   • Teach the 15-15 rule: “If sugar is below 70, give 15 grams fast carbs (juice, glucose tablets, honey), wait 15 minutes, recheck.”
   • Provide glucagon kit: “This is for severe lows if he is unconscious or cannot swallow. Show me how you would use it.” (Have them demonstrate)

8. Address concerns about complications and growth

   • Validate: “You are wise to worry about his future. The key is tight control without frequent lows.”
   • “With modern management, Omar can achieve normal height, participate in sports (even professionally), and have a normal lifespan.”
   • “We will check his HbA1c every 3 months, annual eye exams after 5 years, and monitor for thyroid/autoimmune conditions.”

9. Lifestyle and school integration

   • “He can eat everything other children eat, but we count carbohydrates to match insulin doses.”
   • Provide school nurse letter and diabetes medical management plan.
   • “He should never be excluded from activities. He just needs snacks for exercise and glucose monitoring.”

10. Address parental guilt and genetic concerns

    • “Because you are first cousins, there is a slightly higher chance of autoimmune conditions, but you could not have predicted this.”
    • “Genetic counseling is available for future family planning, but siblings have only a 5-10% risk, not 50%.”

11. If parents refuse multiple daily injections

    • “I understand this feels like a life sentence. However, without insulin, Omar will die. There is no alternative medicine, herb, or diet that replaces insulin.”
    • “We can discuss insulin pumps later once we stabilize, but for now, injections are non-negotiable.”
    • “Would you like to speak with another parent whose child has T1DM?”

12. Documentation and follow-up

    • Provide written sick day rules (when to check ketones, when to seek emergency care).
    • Schedule diabetes educator follow-up within 3 days, endocrinology in 1 week.
    • Provide 24/7 emergency contact number.
    • Document parental understanding, demonstrated competencies (injection, monitoring), and emotional support needs.

Additional educational materials to provide

• Carb counting guide and food exchange lists
• Logbook or app for glucose monitoring
• Medical alert bracelet information
• Support group contacts (e.g., Diabetes Foundation, local parent networks)
• Ketone testing instructions

Scenario 4 — Layan (Parent Refusing Childhood Immunization)

Case summary

• Layan is a 12-month-old girl who is due for her MMR (measles, mumps, rubella) vaccine and varicella vaccine.
• Her mother, Mrs. Al-Rashid, has refused all vaccines since birth, citing concerns about “toxins,” autism, and religious objections.
• Layan has received no immunizations to date.
• The family is planning to travel to their home country (South Asia) in 3 weeks to visit relatives.
• There is currently a measles outbreak reported in the region they will be visiting.
• The child is otherwise healthy, with no contraindications to vaccination.

Task

• Address the mother’s concerns about vaccines, discuss the risks of travel without immunization, and attempt to gain consent for vaccination while maintaining therapeutic rapport.

Suggested clinician script and points to cover

1. Opening and rapport

   • “Hello Mrs. Al-Rashid, it’s good to see Layan looking so healthy and active. How has she been doing since her last visit?”
   • “I understand we have discussed vaccines before, and I want to take time today to understand your concerns better and share some important information, especially with your upcoming travel.”

2. Elicit current understanding and specific concerns

   • “Can you help me understand what worries you most about vaccines?”
   • “You mentioned concerns about toxins and autism last time—would you like to talk about that more?”
   • “Are there specific vaccines you are more concerned about, or is it all vaccines in general?”
   • “Tell me about your religious perspective—I’d like to understand it better.”

3. Acknowledge feelings and provide empathy

   • “I can see you love Layan very much and want to protect her from any harm. That is exactly what a good mother does.”
   • “It’s completely understandable to have questions about what goes into your child’s body. I respect that you are trying to make the best decision for your family.”
   • “Many parents share these concerns—you are not alone in having these worries.”

4. Address the autism concern with evidence

   • “I want to address the autism concern directly because I know it’s very frightening for parents.”
   • “The original study suggesting a link between MMR and autism was retracted and found to be fraudulent. The author lost his medical license.”
   • “Since then, over 20 large studies involving millions of children have found absolutely no link between vaccines and autism.”
   • “Autism symptoms often appear around the same age as the MMR vaccine, which made people think there was a connection, but research has proven there is not.”
   • “Would you like to see the summary of these studies?”

5. Address concerns about “toxins” and ingredients

   • “Let me explain what is actually in vaccines. The ingredients are there to make the vaccine safe and effective.”
   • “Thimerosal (mercury) was removed from childhood vaccines years ago, except in some flu vaccines—and we have thimerosal-free options available.”
   • “Formaldehyde is used in tiny amounts to kill viruses during production—your baby’s body actually produces more formaldehyde naturally than what is in vaccines.”
   • “Aluminum is present in small amounts to boost immune response—breastfed babies get more aluminum from breast milk in 6 months than from all vaccines combined.”
   • “The immune system handles thousands of antigens daily; vaccines add a very small number by comparison.”

6. Discuss the immediate risk: travel and measles outbreak

   • “I am especially concerned because you are traveling to [region] where there is currently a measles outbreak.”
   • “Measles is one of the most contagious diseases known—if exposed, 9 out of 10 unvaccinated children will get infected.”
   • “Complications include pneumonia, brain swelling, deafness, and death—1-2 out of 1,000 children with measles will die.”
   • “In outbreaks, even babies too young to be vaccinated have died because older children were not vaccinated.”
   • “Airports and airplanes are high-risk places for transmission.”

7. Discuss community protection (herd immunity)

   • “When most children are vaccinated, it protects babies too young to be vaccinated and children who cannot be vaccinated due to medical conditions like cancer.”
   • “We have a responsibility to protect not just our own children but also vulnerable children in our community.”
   • “When vaccination rates drop, diseases that were nearly eliminated come back and children die.”

8. Address religious concerns respectfully

   • “I respect your faith. Many religious leaders, including [relevant religious authorities], have stated that vaccination is consistent with religious teachings because it protects life.”
   • “Some vaccines use cell lines from historical abortions in the 1960s-70s—the Vatican and other religious bodies have stated that given the distance from the original event and the life-saving nature, vaccination is morally acceptable.”
   • “However, if this remains a concern, some vaccines are available that do not use these cell lines.”
   • “Would you like to speak with a religious advisor about this? I can provide you with statements from religious authorities.”

9. Provide risk comparison

   • “I want to be clear about the actual risks. The risk of serious harm from vaccines is extremely small—about 1 in a million for severe allergic reactions.”
   • “The risk of serious harm from measles itself is 1-2 in 1,000—and 1 in 20 children with measles get pneumonia.”
   • “The risk of death or brain damage from measles is far higher than any vaccine risk.”

10. Offer alternatives and accommodation

    • “If you are willing, we can start with just one vaccine today rather than multiple.”
    • “We can delay live vaccines (MMR, varicella) until after travel if you prefer, though I strongly recommend them before travel.”
    • “We can do blood tests to check if Layan has any natural immunity, though at 12 months this is unlikely.”
    • “Would you prefer to give vaccines one at a time to see how she tolerates each?”

11. If the parent continues to refuse

    • “I respect your right to make decisions for your child, even when I disagree. My role is to give you the best information to make that decision.”
    • “I must document that we discussed the risks of measles, the current outbreak in your destination, and that you declined vaccination despite these risks.”
    • “Please reconsider before travel—the risk is very real and immediate.”
    • “If you change your mind, call us anytime. We can vaccinate with short notice, even the day before travel.”

12. Provide resources and follow-up

    • “Here are reputable sources: the CDC, WHO, and the American Academy of Pediatrics all have parent-friendly information.”
    • “I can connect you with other parents in our practice who had similar concerns but chose to vaccinate.”
    • “Let’s schedule a follow-up to discuss this again before your trip.”
    • “Please sign this refusal form so we have a record of our discussion.”

Additional considerations

• Check if Layan has any medical contraindications to vaccination (immunodeficiency, severe allergy to components).
• Verify if there are any legal requirements for vaccination in their destination country.
• Provide a letter for travel if vaccines are given documenting immunization status.
• Discuss infection control measures during travel if vaccines are refused (avoiding crowded places, hand hygiene, masks).

Other Examples of Communication Scenarios

1. Speak with a mother whose child was just diagnosed with hemophilia:

   • Topics: routes of injections (IM vs subcutaneous), need for regular checks, skin changes, red flags, avoidance of aspirin, dehydration, pallor, behavioral changes.
   • First aid education: how to raise the bleeding limb, apply pressure, and when to go to emergency for replacement therapy.
   • Address parental feelings of guilt and genetic counseling concepts (probability and inheritance considerations).

2. Speak with a mother whose child has just been diagnosed with lower UTI:

   • Instructions: measures to avoid recurrence, correct wiping techniques, address constipation as a predisposing factor, and focus on avoiding predisposing behaviors while treating the infection.

3. Speak with a parent who refuses vaccination:

   • Discuss the importance of immunization and potential consequences of vaccine-preventable diseases (e.g., deafness, disability from polio).

   • Explore specific vaccine concerns (some refuse specific vaccines, others refuse all).

   • Provide balanced information, address fears, and offer follow-up discussion.

Documenting and Follow-up

• Always document the discussion, the information provided, parental concerns, and whether consent or refusal was given.
• Provide written materials and arrange timely follow-up to reassess understanding and adherence.

others

ARTIFICIALLY ACQUIRED ACTIVE IMMUNIZATION

• Artificially acquired active immunity can be induced by a vaccine, a substance that contains antigen.

• A vaccine stimulates a primary response against the antigen without causing symptoms of the disease.

WHY WE NEED VACCINES?

• For a few weeks after birth, babies have some protection (passed from their mother) from germs that cause diseases.

• After a short period, this natural protection goes away.

• Vaccines help protect against many diseases that used to be much more common.

• e.g. tetanus, diphtheria, mumps, measles, pertussis (whooping cough), meningitis, and polio.

• Many of these infections can cause serious or life-threatening illnesses and may lead to lifelong health problems.

What Happens if Vaccinations are Neglected?

Your child is your responsibility, Your neglect may cause him to be affected by disease