Scott Webb (Host): The doctor-patient relationship is essential in healthcare today because we all want our concerns to be heard and to trust that our doctors have our best interests at heart. Of course, this is especially true when it comes to our kids' doctor. And joining me today to share her perspectives on effective doctor patient relationships is Dr. Edith Haghnazarian. She's a pediatrician with Stanford Medicine Children's Health.

 This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb.

Doctor, it's so nice to have you here today. We're essentially going to talk about the doctor-patient relationship and what does that mean. So I want to have you start by giving us the fundamental principles that define a healthy doctor-patient relationship, and how do they impact, do you think, treatment outcomes?

Edith Haghnazarian, MD: This is a very obviously important thing in especially the world of pediatrics because it's a relationship between us, the family, and the patient at different ages. So to start off, I think the main principles, core principles of doctor-patient relationship is generally we can, I think, divide it into three categories.

One is communication, that one's obvious, but I think having clear, open, empathetic communication, is really important in the relationship built between a doctor and a patient.

Host: Sure.

Edith Haghnazarian, MD: The other one is trust. I think that goes with every service world that we are part of. And healthcare is also a kind of service that you're doing for yourself.

And I think if you don't have trust in it, it's just going to be a very, very difficult process. And I think the other one will be mutual respect. I think when I say mutual respect is both the doctor respects the patient and the families and their cares and wants and values; but on the other end, the patient and the family also respect a doctor in terms of being respectful, being open, honest.

And I think those three, if all of them exist in a relationship, that would be a very solid, doctor-patient relationship; trust, communication, respect.

Host: For sure. And you mentioned communication there, so it makes me think, of course, my kids are older now, so I don't really communicate with their doctors. They can speak for themselves, but how can parents effectively communicate their concerns for their children, you know, effectively with the providers.

And how then can, you know from the other side, how can a doctor effectively communicate as well? Maybe good listening skills, whatever it might be.

Edith Haghnazarian, MD: Sure. For parents, I mean, depends on the age, as you said, but generally having open and honest communication is great. Sometimes it's hard to get the actual honest observation from parents. But that helps us a lot because it does form the final decision, final treatment plan for whatever it is.

So having very honest communication for parents to mention the specific observations that they have of their kid because they spend the most time with the kid. We see them only on the visit. So for us to like kind of have an understanding of what is happening day in and day out is super helpful and for parents, I think one thing to practice is having a clear and calm way of communicating their concerns, and asking questions. I always encourage parents to think of questions about everything we talk about. They don't have to think of it there, but think of it so that next visit we can address those.

And then when it comes to the kids, obviously, the most important communication part for the doctor is using age appropriate language. I'm not going to talk to a 5-year-old or a 3-year-old as I would talk to a teenager. And, kind of trying to actually involve the kids in the process, asking them things, making sure they feel heard.

Sometimes kids will tell you a part of the history that the parent completely forgot I or didn't know. For example, the kid fell down in school and the parent had no idea it happened, and now they're here for this like weird limping. And then we're like, oh, okay, that makes sense. You know, so like giving the kids kind of the space to express their concerns and their history and then simplifying things. I think sometimes some physicians might make it a little complicated so the kid has no idea what's happening. And then on the physician side, as you said, good listening skills. Unfortunately in the modern world, we're all struggling with that to listen and not to interrupt. I think that's super important. Sometimes the doctor will be a little bit busy and we're like, okay, onto the next thing. Onto the next thing. But if we all can practice a little bit of mindfulness. Listen exactly to what the parent is saying because a lot of our questions might be in their full story that they're giving us.

And then I always try to reflect what they said so that we make sure we didn't leave anything out and I make sure they understand and they repeat it to me what they understood. So that kind of, for me, closes that whole communication loop. And I think if everyone does that, then we'll be in a good place.

Host: Yeah, many is the time we were at the doctor when I would hear things for the first time and I would say to one or both of my kids, you know, this might have been good information for me to have before we left the house, before we got to the doctor, but, you know, one way or the other, as long as it gets out eventually and we're able to diagnose as you say, why they might be limping or anything else. Right.

Edith Haghnazarian, MD: Correct.

Host: Yeah. So let's talk then about how we prepare our children for doctor's visits. I know that, when my kids were young, you know, the thought of being able to get lollipops or stickers or toys or those kinds of things, that was definitely an enticement, you know, to get in the car and to go with dad peacefully. But what do you recommend?

Edith Haghnazarian, MD: Yep. That's our secret weapon. The lollipops and the stickers. But, it is different in different age groups. On my newborn visit, I always tell the parents to have a shared note, between them if it's two parents or just have a note taking that they just write down everything that comes up throughout days or weeks until we see them, because then we can go one by one through that note and answer every question and they will feel a reassurance.

So that's the newborn era because a lot of things are new, obviously in that time. When we get to a point that the kids understand what's happening, helping their brain prepare for what's to be expected at the visit is actually way more important than people think. I never recommend buying plastic toys for kids, but I think the doctor kits are actually helpful.

It doesn't have to be anything crazy, but for kids to know what to expect helps them adapt so much easier and not have a full on fearful experience. Because if they know these are the sequence of events that are happening, then when they come there and that happens, they're like, okay, that makes sense.

That was fine. But when they have no idea that like, we're gong to put you on this exam bed, we're going to have you take off your clothes and put this on, you know, like kind of the sequence of events. So helping them prepare for the visit as like a game at home is super helpful and then, kind of making sure they understand that the doctor is there to help and listen to you and help you, and always positive reinforcement. We're moving away from that time that like, if you don't listen to the doctor, they're going to give you a shot, kind of, vibe. So I think the more we move away from it and the more we go towards if we are doing great at this doctor's visit, we're going to get two stickers and we're going to get a lollipop for your sister as well.

You know, like things that makes them feel better. And, kids are better at understanding parents' feelings as well. So if the parent is feeling anxious, the kid is going to feel anxious as well, which I understand sometimes, vaccine appointments, all those things are a little bit anxiety provoking, but the more the parent can calm themselves down, I think the kids will do better too.

Host: Yeah, those are the only questions my kids ever had. Is anything being swabbed? Right? Are they going to swab my throat or my nose, or like that? And do I have to get any shots? And it was always much easier to get them in the car and to go when they knew that they just had to basically sit there and maybe answer some questions.

You know? I'm thinking about the shared decision making in all of this between doctor, patient, parent, you know, like thinking about the dynamics there. What are some practical ways, because it is important, what are some practical ways to implement that shared decision making?

Edith Haghnazarian, MD: Right. Shared decision making I think is the biggest deal in pediatric practice. Parents want to advocate for the kid, doctor wants to advocate for the kid, the kid might understand or not. But at the end of the day, we all want it to go well, right. Sometimes we might not have the same idea of how that would be, and I think that's when we just have to give everyone the right to express their concerns.

And just having that shared decision making makes sure that everyone has a voice. So inviting parents and older kids into the conversation, making sure that there are options, there are choices, and they understand these choices. And having this open dialogue, helps everyone feel involved, helps them have more compliance with treatment plans, have better outcomes.

Generally how I do about times that I can offer a choice, because there are times that the only way is just that one way to do, which is the best option, which is something that parents have to understand. If there were choices, hopefully your doctor is sharing those choices with you, but if a doctor says, this is what we need to do. And they're not really giving you other choices; sometimes again, we go back to the trust. You have to trust that this is the best decision they've already made. But if there are choices, I usually end up being like, okay, we can do this or we can do this. This option might give the parents a little bit of work to do on their end because they have to monitor a little bit longer to see if we are going to go ahead and like do this treatment that we discussed, or if the parents are like, no, I, don't have time, or I can't do what you're asking me to do, then this is the other option. So like, kind of having that open dialogue of also parents like limitations, like maybe these parents are someone who works a night shift and like doesn't have full access to monitoring certain things overnight.

You know what I mean? So I think like knowing their limitations when making decisions and like expressing those to the doctor helps the doctor make a better treatment plan for the kid. But yeah, generally involving families and having them be heard, also give the family a responsibility to follow and keep them accountable as much as it does for the doctor.

Host: Definitely. You touched on this earlier, and you've mentioned I think a couple of times here, but a common thread seems to me is a trust in this doctor-patient relationship. Also, you know, parents in there as well. How do we do that? How do we build and maintain that trustful important relationship with our providers, between providers, parents and our kiddos?

Edith Haghnazarian, MD: Right. I mean, Scott trust is basically the cornerstone element of at least pediatric practice, I'm assuming every, healthcare professional like health practice. But that's kind of the glue that holds everything together. Because when there's trust, you know, that when a doctor, as a doctor, I'm making a plan for you.

I know that you trust me and you will follow through. But again, trust is not built in one day. The first day you see your pediatrician is not the day that you fully trust them. You hope they are good. But it's built through clear communication, honest communication, and it goes both ways. I have to trust that the parent will do what I am kind of educating them to do, and then the parent has to trust that what I'm asking them to do is the best thing for their child and we kind of continue keeping this trust going and keeping this honest, open conversation going, and that by itself builds trust. Again, I compare it to other things, but obviously healthcare is a little bit more important, more like human side of things, but you trust your mechanic, for example. After seeing a couple of mechanics or like having an experience, you get to a point that you're like, okay, whatever this guy says I'm going to do. Or if you have any other, like a hairstylist or whatever, right? But you trust someone and you're like, okay, I know they'll do a good job. And that is the same with your pediatrician.

It is a sense of, like a feeling that parents have. It is by experience. It is seeing that every time this pediatrician told them to do something, it worked out. So that builds trust. But I think just having that open, honest communication, both from the doctors and the parents, helps build that trust.

Host: Build trust for sure. Are there any misconceptions, I, I like to bust myths when I can doctor in podcasts, can we bust any myths or misconceptions about the doctor-patient relationship that families really need to know?

Edith Haghnazarian, MD: Yes. I mean, there's always misconceptions in everything, but I think, one of the big ones in our world is that it's the doctor knows best, right? We rely on inputs from the patients to make the final decision. So it's not like a one way street, whatever. The doctor knows it. I don't have to say anything. I don't have to do anything. So that's one misconception. Like if you have concerns and the doctor hasn't addressed that, you have to get that validated somehow, right? So that's one thing. And the other thing is people think any doctor or most doctors will be offended or it's a wrong thing to do if you seek a second opinion or even like try a new doctor.

I do want to make sure parents understand that we also want to have a patient with us that trusts us just like they do. So if a physician doesn't click for you and you guys don't feel like this is the right fit, that's okay. You can try and see if another person will be a better fit for you. Again, not everyone is a good fit for everybody.

Again, like you see a therapist, not every therapist is good for you, right? That is, I think, something people have a misconception of. They have to stick with this doctor forever. That's not correct. If you don't feel like this is a relationship that you feel heard or just for whatever reason, there could be values, there could be cultural differences that doctor doesn't understand or has not been experienced with, that's totally fine.

Seek another person that you'll feel comfortable with because the thing about pediatrics is it's a very long journey with your doctor.

Host: Yeah, it's marathon, not a sprint, that's for sure.

Edith Haghnazarian, MD: It's a marathon and you want someone by your side that, like sometimes I have parents who I know their whole life story and they come to me and they just, sometimes it's a therapy session for the parents.

You know what I mean? And you want to feel comfortable. You want to feel like it's a safe space. I think that's a misconception that some parents have. Another one is, I think after the COVID pandemic, we've had a little bit of a distrust in the healthcare system. Which is understandable. But I think one other misconception is that certain treatment plans benefit the doctors in some ways. And I'm not saying that's never true, but I think in pediatrics world especially, that's rarely true because most of the time we just want what's best for your kid and we want your kid actually to not have to come to our office. So we do something for them to not come to the office as much as possible.

So yeah, I think those are a few of the things that comes to mind.

Host: Sure. Yeah, it's been great having you on today. I love speaking with pediatricians. It's one of my favorite things to do. I miss. I miss when my kids were little and we to go to the pediatricians. Now they see adult doctors and it's a whole different thing. But as we wrap up here, for anyone who's feeling uncomfortable or unsatisfied, we were just kind of addressing that with that doctor-patient relationship, you know, what do you recommend? How do we handle that? As you say, we don't have to stay with that mechanic or that hairstylist or that pediatrician, right? But help us to figure out how to handle that?

Edith Haghnazarian, MD: Right. Again, if a family is not feeling great about their pediatrician and we're talking specifically, having an honest, open conversation with the doctor could be a first step. Most of us don't take it personally. At work we try to keep it a very professional doctor-patient relationship.

We don't think you hate us as a human, we just think we're not a good fit for you. And having that conversation being like, Hey, doctor. I just feel like, whenever I say this, you ignore it or like, I've mentioned this before and I didn't like how you answered it. That makes the doctor kind of take a step back and change their biases which we all have.

But even if that doesn't help, and it's still not a good fit, it is totally okay to seek other opinions, find a better fit, and just know that you have options. Sometimes insurance makes it a little bit difficult for people to have options, but there's still options. And you can even ask your doctor, Hey, is there another person I can see about this specific thing?

And that for us is a clue of like, okay, you don't like my management of this, which is fine, and I can try and get you someone who can do that better for you. And I think that's a very okay thing to do. We also sometimes even recommend it for certain parents. I think that's what I would recommend.

Host: That's great. Well, it's been lovely having you here. I, as I said, I love speaking with pediatricians and picking their brains, and today we focused on the doctor-patient or doctor-patient-parent relationship. So good stuff. Thank you so much.

Edith Haghnazarian, MD: Thank you.

Host: And for more information, go to stanfordchildrens.org. And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.