This study adds to the science of physician-parent communication by examining positive physician communication behaviors (ie, rapport- and partnership-building) important to the informed consent process,18,19
general pediatric practice,48
and the delivery of difficult news.49
Given that previous pediatric research has indicated limitations in parental understanding and parent-physician communication regarding research studies,4–9
this study fills an important gap by providing support for the effectiveness of a tailored intervention aimed at improving positive physician behaviors and communication strategies during ICCs for pediatric leukemia. Our results reveal that intervening with physicians to improve communication may enhance parental participation in the informed consent process.
Results partially supported the hypothesis that physicians in the intervention group would show improvements in communication behaviors during the ICC. Specifically, the PDI improved physician rapport-building behaviors, but only when physicians attended subsequent booster sessions. These findings highlight the importance of including booster sessions in intervention designs, which seem to have an impact on the retention and adoption of targeted skills and strategies.
Partnership-building behaviors were unchanged. One possible conclusion from this finding is that it may be easier to enhance rapport-building behaviors of pediatric oncologists in this emotionally challenging conversation because of a possible preference of physicians and parents to view the physician as “helper” versus “partner” in care. Alternatively, if rapport is established early in the ICC, it may obviate the need for physicians to engage in partnership-building. Nonetheless, it should be noted that Yap et al26
did report that physicians in the PDI group elicited more open-ended questions, which highlights the uptake of some partnership-building behaviors. It is important to note that these possible explanations for our findings cannot be generalized to all communication skills training research, and additional research in pediatric settings is needed for purposes of replication.
Furthermore, our findings that parents in the PDI group + booster session engaged in more general communication and study-related talk during the ICC reveal the physician behaviors targeted via the PDI may stimulate greater parental participation in the ICC. This is further supported by the finding that mothers in both PDI groups asked more questions per minute. No group differences in father participation were found, but the small number of fathers may have limited power to detect differences. Coupled with the findings of Yap et al,26
our results reveal that physicians and parents in the PDI group engaged in more study-related discussions, which was a primary intervention target.
One strength of the current study is the direct observation of ICCs, which provides communication data that are impossible to gather by other methods. In addition, the positive impact of the intervention may have been enhanced by the fact that it was designed based on feedback from parents and previous research specific to this context.29
Limitations of the study should be considered. Physicians who agreed to participate in the PDI and attend booster sessions may have had greater interest in improving their communication skills in conducting ICCs, compared with physicians who chose not to participate. However, control sites were included in our study design to mitigate this limitation. In addition, whereas the RIAS coding system used to measure physician rapport and partnership-building is well established and widely used, it was not specifically tailored to goals of this intervention. This could explain why significant differences were found for rapport-building, but not for partnership-building.
The findings have research and practice implications. Given the importance of physician-parent communication across pediatric practice, the same techniques stressed in our intervention can help general pediatricians and those in varied settings when communicating with parents and patients. Unfortunately, many physicians have time and schedule restraints that hinder one's ability to attend day-long seminars. However, with the growing enthusiasm for Internet-delivered interventions, an interactive online physician intervention aimed at improving positive physician behaviors may prove effective for physicians interested in improving their own skills while also learning techniques to encourage parent and patient participation. Future directions also include the solicitation of qualitative comments from parents and patients to assess physician communication and engage families as active contributors to quality improvement.