Introduction

“Thou shall behave and act without arrogance and with undistracted mind, humility, and constant reflection. Thou shall pray for the welfare of all creatures.......” . - Charak Samhita

Doctor-patient relationship is the foundation of contemporary medical practice. We, the medical professionals, are blessed to serve the suffering humanity. Even if we are unable to cure the patient of his illness, we can always give some relief, reduce suffering, and give hope and happiness to the suffering humanity [1]. According to vedic scriptures, there is God or Brahma in every living being (Aham Brahman Asmi), and therefore in our endeavors, we are serving the supreme being. It is no surprise that from times immemorial, the medical profession has been considered as noble and doctors have been given the status of demigods in our society. In order to maintain the high image of medical profession in the society, we must view our work as worship and discharge our responsibilities with inner awareness and with due grace, equanimity and humility. We must be polite, courteous, transparent and competent in our dealings with parents and attendants. Our behavior should not be influenced by the social status of the family. It is an unfortunate fact, that there is a gradual decline of human values at all levels in our society and doctors are no exception to it. In the past doctor-patient relationship was based on transparency, honesty and faith. But due to increasing commercialization and launch of Consumer Protection Act in 1986, it has become a relationship between a commercial service provider and a consumer. The age old concept of paternalism or “doctor knows the best” attitude is being replaced by shared decisions by taking parents into confidence because they are educated, well informed and internet savvy. The situation has been further complicated and compromised due to technology boom because physicians are becoming more of technocrats or “robots” and less of human beings. It is unfortunate that there is increasing incidence of aggressive behavior and vandalism by aggrieved family members against the doctors and health care professionals. The communication and interaction with the parents and attendants takes place in continuum during various stages of clinical assessment, while undertaking investigations and diagnostic procedures and during management of the patients [2]. Communication indeed is the key for building a sound doctor-parent relationship, which is associated with a number of benefits (Table 1).

Table 1 Benefits of good doctor-patient/parent communication
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History Taking

Medicine is an art and its magic and miracles depend upon the quality of doctor-patient/parent relationship. The communication begins when parent (s) and child enter your cabin. The first impression is most important and it determines whether parents are likely to develop faith in the capabilities of their pediatrician or not. Give a smile and respond to their greetings. Patients and parents should be viewed as clients and we must behave with due courtesy and warmth. However, the physician should not behave like a salesman by dramatizing the illness of the child. Physician must exhibit humility, concern and politeness while recording history. We should try to maintain a friendly, warm, relaxed, unhurried and informal atmosphere during interaction with the child and his parents or attendants. We must put the parents at ease and encourage them to talk freely. It is important to keep in mind that when we are taking history and assessing the child and parents, we are also being assessed by them [3, 4]. Our facial expression, tone of the voice, body gestures and attitude of impatience, disbelief and reproach – all are likely to have impact on doctor-parent relationship. You as a physician must know your own personality, recognize your weaknesses and develop strengths and capabilities to improve your communication skills. The atmosphere should be calm and without any distractions or irritating sounds (mobiles should be on silent mode). The physician should be alert and exhibit active listening with interest and empathy. We should provide positive nonverbal cues during the interview viz. lean forward, listen with interest, maintain an eye contact and nod appropriately [5]. Even when parents or attendants ask illogical, repetitive and irritating questions, the physician must respond with due grace, equanimity and calmness without showing any evidences of hurry, anger and arrogance. It is important to remember that most cases of malpractice suits against doctors are lodged because of lack of communication or rude behavior of the doctor or his team member, and not due to lack of knowledge and skills (Table 2). There are many barriers to establish good doctor-parent communication and they include parental anxiety, lack of time because of excessive workload, unrealistic expectations of parents, fear of litigation and risk of physical and verbal abuse by attendants.

Table 2 Common causes of malpractice litigations against doctors
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Physical Examination

Effective doctor-patient communication is determined by the doctor’s “bedside manners” which is considered as the major indicator of general competence of the physician. The interaction between the physician and parent should continue during the physical examination. The pediatrician must have inherent fondness and love for children and examine them with warm hands and warm heart. Patients must be handled with utmost care and reverence because they are the real books of physicians. The examination chamber should be warm, comfortable, well lighted and stocked with soft toys to make it child friendly. The children must be treated as children and not patients, and examination should be conducted in an unstructured playful manner. When you handle the child with confidence, tact and competence, you are likely to gain cooperation of the child and confidence and trust of the parents. When you find additional clues on clinical examination or you are able to identify abnormalities in a specific organ or body system, you should seek more information by asking probing questions [6, 7]. During evaluation of our patients, we screen a large number of prescriptions and investigations conducted by our colleagues. We must review them without any arrogance and with due humility without making any adverse remarks or showing it through our body language. We must treat our professional colleagues as members of a large family and we should never utter a disparaging word or remark against them. Sir William Osler has extolled, “Never let your tongue say a slighting word of a colleague”.

Laboratory Investigations and Procedures

Laboratory investigations and diagnostic and therapeutic procedures should be done only when indicated. There is no justification in undertaking routine investigations in every patient. The common practice of ordering complete blood count in every child with cough and cold, and stool culture in a child with acute diarrhea, is without any relevance or need. The pediatrician must have faith in his clinical acumen and use laboratory as an aid for confirmation of diagnosis and assessment of prognosis or response to therapy. It is unethical to order unnecessary investigations merely for the lure of seeking “cuts” from the laboratory or to provide justifications to the management that you are earning money for the corporate hospital [8]. However, when investigations are indicated, they must be done without any delay. We must explain the need of investigations and their likely dividends for the diagnosis, management and monitoring of the patient. When a diagnostic procedure like endoscopy, tissue biopsy and fine needle aspiration cytology is indicated, the parents must be explained about the need and likely complications of the procedure. In case of a school going child, the nature of the procedure should be explained to the child to reduce his anxiety and improve the cooperation. No procedure should be conducted without taking a formal written consent from the parent or accompanying attendant.

Management

“Those who trust their doctor and surrender themselves to his care are more likely to recover than those who approach medicine with distrust, fear and antagonism”.

Depending upon the tentative or most likely diagnosis, institute rational therapy by prescribing a single or least number of therapeutic agent (s) which should be administered through the most convenient and acceptable route. It is unwise and a sign of professional incompetence or lack of confidence to institute “shotgun” therapy with half a dozen drugs. Most diseases are self- limiting and they recover spontaneously by virtue of host defences. The drugs should be prescribed only when indicated because no drug is entirely safe. We should not be enamored or fascinated by “newer drugs” being promoted by the medical representatives. Instead, we must use those medicines which have withstood the test of time with an assured efficacy and safety track record [9, 10].

Patients should not be viewed as systems, organs, tissues, cells and DNA. Instead they must be viewed in totality (body, mind, heart and soul) and that too not in isolation but in context with the dynamics of ecology, friends and society. We must treat the child and not his disease or laboratory reports. We must provide holistic care and not mere cure to the child. Holistic care demands good interaction and communication with parents who are no longer passive recipients. There is a popular saying that “A good physician treats the disease, the great physician treats the patient who has the disease”. The family should be provided with health promotive and preventive guidance by promotion of exclusive breastfeeding, immunizations, and by ensuring personal hygiene and environmental sanitation. Food indeed is the breakthrough drug of 21st century and complete guidance should be provided to the family to ensure that the child receives a balanced diet containing all the essential nutrients. When immune status of the child is boosted by optimal nutrition, he is more likely to ward off or fight the disease process. The parents should be encouraged to introduce life style changes to create a balance and discipline between studies, relaxation or screen time, outdoor games and sports activities. The child should be encouraged to take part in various hobbies including painting, dance and music for wholesome development of the personality.

The Outcome

Children are the greatest asset of the parents. Most parents and family members are worried and concerned about the nature and severity of the disease and likely outcome of the disease. They commonly ask, “What is wrong with the child”? “Will the child become alright”? “How soon is he likely to recover”? Avoid saying, “there is nothing wrong” even when it is a functional disorder. Identify the major worries and fears of the child and his parents. The queries of the parents should be answered in a simple language with due sensitivity, compassion and concern. Even if their query is illogical, repetitive and irritating, we must respond with due grace, sensitivity, equanimity and calmness, without any hurry, anger or arrogance. The pediatrician must establish a rapport with the child and his parents to provide them with emotional support during their distress and win their faith, trust and confidence. It has been rightly said by Terry Canal, “The patients will never care how much you know, until they know how much you care”.

Most diseases are self-limiting and they recover on supportive management without any medications. The recovery and outcome depends upon the nature and severity of the disease process and immune status of the host or victim which is afflicted with the disease. To augment the process of healing, the patient must have faith in his doctor and doctor must have faith in himself and his medicines. The diseases with an acute or sudden onset are likely to have either a dramatic recovery or a deadly outcome. Infants below 3 mo or children having protein-energy malnutrition and immunodeficiency state are likely to have poor outcome. The parents should be told about the nature of the disease, the likely course or outcome and possible side effects of the medications. For example, viral infections are usually self-limiting and likely to take 3–4 d for recovery, acute onset of vomiting may be followed by diarrhea after 12–24 h, and a child with typhoid fever is likely to take 4–5 d to settle even after start of specific antimicrobial therapy.

A Child with an Intractable Disease

“A person may have learnt a great deal and still be an exceedingly unskillful physician, who awakens little interest in his powers. The manner of dealing with patients, winning their confidence, the art of soothing and consoling them, or of drawing their attention to serious matters – all this cannot be learnt from books”. –John Apley

Breaking bad news to the parents is a complex and challenging task. When a child is suffering from a chronic or incurable disease, or an affliction with a lifelong disability, the parents are likely to respond with disbelief, anger and shock. The news about an intractable or disabling disease should preferably be given to both the parents simultaneously with due concern, compassion and empathy. Avoid being abrupt and blunt in conveying the dismal diagnosis. The nature of the disease, available therapeutic options, cost of care and likely outcome should be explained in a simple language without any medical jargon. The physician should allow the parents to ventilate their feelings and concerns, and should try to answer their queries in an honest and unambiguous manner. We should be careful and diplomatic in conveying the nature of the disease without hurting parental feelings. Instead of bluntly saying “your child is brain damaged or mentally retarded”, it is better to say that the child is rather “slow” or having “developmental delay”. Parents and attendants have emotional feelings, and we should never say, “Nothing can be done”, because something can always be done. Never give hopeless prognosis in order to avoid neglect and sustain the will to fight. Nevertheless, we should be honest and pragmatic but not pessimistic in our approach. It is important to remain positive and hopeful, which have great healing capabilities. We should remember that nature is supreme and miracles do happen. In Indian society, giving a spiritual dimension to parents of a “special child” is useful to buffer their anxiety and feeling of hopelessness. It is a good idea to boost the morale of the parents by saying “God has chosen you to provide care and comfort to the “special child” because you are so caring, compassionate and sensitive human being”. The family should be encouraged to join the Self Help Association of Parents to share their mutual concerns and difficulties, and for effective utilization of available special services. It is important to ensure that normal children in the family are not neglected; instead they should be involved in the care of the “special child”.

A Child with a Life-threatening Disease

During their career, pediatricians and their team members in the intensive care unit, are likely to face several “end-of-life “situations. Despite all the technological advances, medicine can never achieve immortality. It is as natural to die as to be born. When faced with a critically sick or dying child, pediatricians should allow the parents to express their feelings and concerns, and try to answer their queries in a simple language without any medical jargon. In this situation we should follow the well known dictum, “talk less and listen more “– that is why God has given us one mouth and two ears! During the care of critically sick children in the intensive care unit, it is important to show due concern, care and compassion to the parents and attendants. We should give a guarded prognosis but it should be tempered with hope and godly benevolence, to augment the process of healing [11]. It is important, that we should not only provide state-of-the-art care to the child but also make the parents and attendants perceive that whatever was humanely possible, it was done for their child.

The coping of death of the child in the hospital is a painful and challenging experience for everybody concerned with care of the child. Death deflates our ego and teaches us humility and provides strength to handle the greatest reality of life with equanimity, composure and confidence. The family should be emotionally and spiritually prepared before declaration of death. The desire of the parents that death should occur in the familiar atmosphere of home rather than hospital should be honored. The family’s wish for providing religious support (like amulets, mantras, and holy water) and presence of a priest at bedside should be allowed. The news of death should be conveyed with utmost compassion but in no unmistakable terms that the child has died despite our best intents and efforts. When a child is conscious and dying, the parents should be at his bedside holding his hands and talking with him to allay fears and provide him emotional support for his journey to the unknown.

Conclusions

The declining image of the medical profession due to insensitive and commercialized attitude of some physicians and over demanding or unrealistic behavior of educated, internet-savvy, neo rich parents, needs to be checked against further disintegration. The sound doctor-patient/parent relationship is the foundation of contemporary medical practice. Patients, parents and attendants must be treated with due respect, dignity and transparency so that they develop faith and trust in their physician. Effective doctor-parent communication and “bedside manners” not only improve the confidence of parents towards their pediatrician but also reduce the risk of malpractice litigations, verbal and physical abuse against physicians. Doctors are not born with good communication skills but they must learn and practice them [12–15]. It is desirable that all the medical and nursing colleges in the country should initiate regular education programs in the fields of social and behavioral sciences, art of communication and medical ethics for graduate and postgraduate medical and nursing students. The physicians should make concerted efforts to resurrect the declining medical image, master the sublime art of medicine and acquire the divine gift of healing. The world needs caring and concerned physicians and not merely curing and commercial robots that lack sensitivity and human touch.