|Year : 2015 | Volume
| Issue : 3 | Page : 117-121
The role of patient (parent) education and counseling in pediatric dermatology practice
Samujjala Deb1, Sandipan Dhar2, Deepak Parikh3
1 Department of Dermatology, Burdwan Medical College and Hospital, Burdwan, India
2 Department of Pediatric Dermatology, Institute of Child Health, Kolkata, West Bengal, India
3 Department of Pediatric Dermatology, Wadia Hospital of Children, Mumbai, Maharashtra, India
|Date of Web Publication||10-Jul-2015|
C-4, New Raipur, Gangulybagan, Kolkata - 700 084, West Bengal
Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.
Effective treatment and management of any dermatoses is dependent not just on simple prescription of medicines to a patient. Adequate education and counseling are equally important when it comes to the holistic management of a disease. It improves patient compliance as well as satisfaction with any treatment. It also improves the doctor-patient (parent) relationship. Patient (parent) education and counseling is even more important when it comes to pediatric dermatology because here patients are young children who can neither verbalize their discomfort nor adhere to the treatment prescribed and are often completely dependent on their parents (caregivers). Thus, adequate counseling and education becomes imperative for the successful outcome of any management protocol.
Keywords: Counseling, patient education, pediatric dermatology
|How to cite this article:|
Deb S, Dhar S, Parikh D. The role of patient (parent) education and counseling in pediatric dermatology practice. Indian J Paediatr Dermatol 2015;16:117-21
|How to cite this URL:|
Deb S, Dhar S, Parikh D. The role of patient (parent) education and counseling in pediatric dermatology practice. Indian J Paediatr Dermatol [serial online] 2015 [cited 2020 Feb 22];16:117-21. Available from: http://www.ijpd.in/text.asp?2015/16/3/117/160662
| Introduction|| |
Patient (parent) education and counseling are the cornerstones of effective management and patient (parent) care in different branches of modern medicine. It has been seen that effective patient (parent) education and counseling can improve treatment outcome as well as patient (parent) satisfaction in a number of diseases like hypertension, arthritis, asthma, rheumatoid arthritis, etc. It becomes even more relevant in the context of dermatologic practice because along with the various treatment modalities, the patient (parent) often needs to understand and follow particular do’s and don’ts which help in quick recovery, prolonged remission as well as prevent exacerbations. With respect to pediatric dermatologic practice, it is more of a challenge as the patient is sometimes too young to verbalize his or her symptoms and complaints and may not be able to take care of himself or herself. In such situation, the onus is on the parents and caregivers who must intuitively understand the needs of the child and respond accordingly. The situation is often further complicated in cases where the child has certain special needs or is either abandoned or orphaned and thus may not have an attentive caregiver at all times. It is of great importance when child has genodermatoses where there is no treatment. Thus, counseling and patient (or rather parent) education becomes an important as well as challenging aspect of dermatologic practice and management.
| Difficulties with pediatric patient (parent) education and counseling|| |
The most arduous obstacle in the successful patient (parent) education and counseling is the use of technical medical jargon. Words and concepts which are often simple for dermatologists are incomprehensible to most parents and caregivers. Along with that instructions which are too elaborate or time-consuming are often either forgotten or skipped altogether by some. There also seems to exist wide variations in the perception of the amount of topical medications required by many patients (parent) and caregivers alike. Hence, all attempts should be made to provide information in the simplest possible manner, with least number of steps and in a language that the caregiver understands best. Cartoons make it is easy for understanding especially for young children who like colorful pictures and illustrations.
The second most important aspect is that children are a special subset of the patient population who are unique in certain aspects. They cannot verbalize their complaints or symptoms and in such cases, the dermatologist must have a keen eye and thorough clinical knowledge in pediatric dermatology so as to identify correctly the skin lesions and disease leading to the child’s discomfort and treat accordingly. The only relevant clinical history that is available is from the parents, which can range from being highly accurate to completely erroneous depending on the educational status, economic condition, and family size among a few factors. On top of that the parents are often over concerned and over cautious, and all efforts must be taken to allay their fears and educate them about their child’s illness.
Furthermore, there are numerous social, religious and cultural customs and rituals that are deep-rooted in society and a cause for various dermatologic illnesses. For example, application of oil over the body and scalp in infants leads to seborrheic dermatitis, application of kohl to the eyes or face of the child can cause conjunctivitis, trachoma and contact dermatitis, use of threads and talismans around the neck to protect from the evil eye can lead to candida intertrigo, use of cow dung or ash over the stump of the umbilical cord can lead to infection, omphalitis and even death from neonatal tetanus. In all these cases, extreme care must be taken explain and counsel in the most nonjudgmental manner as far as possible since these customs are often rooted in fear and not easy to overcome.
Finally, since the child is often dependent on the parents or caregiver for physical, social, psychological, and economical support, they have little choice in decision-making regarding treatment. In such cases, it becomes doubly important to ensure that the child is well taken care of by the caregivers. In cases where the child is without a parent and is not being properly taken care of or being subjected to physical or mental abuse, it sometimes becomes the duty of the dermatologist to inform the social service authorities if the need so arises. Furthermore, disease like molluscum contagiosum or herpes occurring over the genitalia may point toward sexual abuse, and parents should be thoroughly counseled as children may often be unable to provide accurate history.
Children are not miniature adults, and whenever possible, all attempts should be taken to customize treatment and counseling sessions according to their age. Play acting is a great way to bond with children and educate them at the same time. The presence of a parent may help gain the confidence of a young child too. Children are often sensitive to the usage of certain words and whenever possible gentler and simpler sounding words must be used. A child may not be able to distinguish between itch and pain. Or clarify whether the oozing from lesion is hemorrhagic, serous or serosanguinous. In all such situations, a thorough clinical examination becomes imperative. A soft and gentle tone of voice is quintessential to soothe a scared and apprehensive child. It has been seen that children above the age of 2 years can be taught to follow certain simple instructions and by age seven can be trained to have a better understanding of their skin condition by explaining to them in simple and easy to understand words.
Advantages of Patient (Parent) Education and Counseling
The advantages of successful patient (parent) education and counseling are numerous. On one hand, it makes the parent or caregiver equally responsible for the success of failure of any treatment modality and on the other, it builds their confidence and helps to improves adherence to therapeutic regimes.
Dermatologic diseases often have a tendency for chronicity. Most diseases are marked with periods of remissions interspersed with episodes of exacerbations. With successful patient (parent) counseling and educations these periods can be prolonged and the episodes minimized. In totality, it improves patient (parent) compliance and also decreases dropout and a tendency towards “doctor shopping.”
It is true that in everyday dermatologic practice, there are immense constraints on proper time management and few precious minutes are available to diagnose and prescribe treatment to patients (parent). But in spite of that even a few moments spent in educating and counseling the patient (parent) and their caregivers can have a tremendous positive impact on the final treatment outcome. It also makes future follow ups less time-consuming since any queries regarding the disease or treatment would have been answered in the first visit itself. It thus becomes a win-win situation for both the patient (parent) and the doctor. But at the same time, care should be taken so as to not overload the patient (parent) with excess information. Information should ideally be presented early in the interaction and be divided into specific categories.,
A number of dermatologic diseases can be managed efficiently with proper education and counseling. For example in atopic dermatitis, proper patient (parent) education and counseling is imperative to keep the disease process under control. Like use of adequate “barrier-repair” moisturizers, wet wraps and wet dressings, use of hypoallergenic soaps and creams, avoidance of hot humid weather, woolen clothing, nuts, dairy products, etc., In dermatology, in a study carried out by Grillo et al. for parental education in pediatric eczema, it as seen that After 12 weeks, the individuals who participated in the educational course demonstrated significant improvements in their atopic dermatitis scores based on the scoring atopic dermatitis rating as compared to those who had not. Not just that in a study from Germany, it was seen that parents of children when enrolled in an age-appropriate educational intervention for atopic dermatitis, showed higher improvement in improvements in subjective severity, atopic dermatitis scoring, and quality of life. In infections and infestations, avoidance of sharing of items of personal use like combs, towels, etc., In disease like acne vulgaris avoidance of comedogenic creams, cosmetics, and facial products by teenagers and young adults.
In cases of genodermatoses, education and counseling of parents assume significant importance. Many of these children are referred to dermatologist for evaluation of the skin lesions since many genodermatoses have manifestations involving the skin, hair, nails, and mucosae most of the times. Parents are often also concerned about the probability of future offspring having the same disease. In all these cases, the different options must be discussed with the parents and their queries answered empathetically. They should be referred to other specialists for genetic and pre natal diagnosis whenever the need arises.
Types and Method of Patient (Parent) Education and Counseling
A wide variety of modalities are available for the successful patient (parent) education and counseling. Each has its own advantage and disadvantage. In general, best results are achieved when there is bi-directional and interactive flow of information. Participation of the patient (parent) s and their caregivers has shown to have greater adherence to instructions and improved treatment outcomes.
The most common type of education and counseling provided to the patient (parent) s and their caregivers is verbal. It is often casually offered within the timeframe of the consultation. It is the simplest form of sharing information and time-saving. But it has the disadvantage of the poor patient (parent) recall. Most patients and their caregivers have difficulty recollecting the verbal advice given to them. And since they dermatologist may not always be available for clarifications, it often leads to poor compliance with treatment and unsatisfactory outcomes.
The next most commonly used medium is printed material. It is often made available to the patient (parent) in different local languages and describes the disease and treatment in a simple and easy to follow format. It has the advantage that it saves time spent in giving verbal advice and also helps to overcome problems of recall, since the advice is available for easy reference. To be truly successful, printed advice must be easy to read, with minimum text and maximum illustrations and preferably be colorful, have a least possible number of steps and must be self-explanatory. The disadvantage of printed material lies in the fact the patient (parent)/caregiver must be literate and have sufficient intelligence to comprehend the advice. Young children may not be able to read, and if the caregiver is unable to understand and follow, then the whole purpose of the initiative fails. Another very effective modality of counseling is the use of educational videos. These can be an important armamentarium in the counseling arsenal. These videos can be played in the patient waiting area, given as complimentary CD’s, or even mailed to patients (parents) and uploaded to Facebook or other similar websites.
Another important modality for counseling is group education. [11, 13, 16, 17] This is one of the most beneficial and productive methods. Here, the patient (parent) and the caregiver “learn by doing.” This has the most successful and satisfying outcomes for both the patient (parent) and the dermatologist because there are no ambiguities or confusions. It boosts the morale and confidence of the patient (parent) and the caregivers. And since it is a group activity, there is an interaction between different people and they can form self-help and support groups. This has an immense positive effect on the psyche of the patient (parent) s and their caregivers. This approach has been very successful with various genodermatosis and other chronic conditions. A number of international and national societies and groups have come up and the barriers of race, religion, language and nationalities have been broken down and support is available throughout the world. The disadvantage of this modality lies in the fact that it might not be feasible to persons living in socially and economically backward areas. Also sufficient commitment and interest is quintessential on the part of the caregivers to take part in group activities.
Finally, the least informative and highly misleading source of information in the internet. Hordes of websites crop up each day that provide partial information and falsify facts. In the so-called “internet generation” parents often come up with half-baked and misinterpreted facts and information acquired from different “medical websites” and attempt to guide the dermatologists regarding diagnoses and treatment options., Such situation should be dealt with humor as any confrontation is futile. An emphatic attitude must be maintained and topmost priority given to dispelling myths and providing authentic and accurate information. At the same time, a number of educational websites with patient (parent) information leaflets and printouts are available. If the dermatologists, the patient (parent) s, and caregiver are responsible enough, they can be directed to these websites for better understanding of their disease condition as well as for general information regarding management.
| Conclusion|| |
Successful treatment of any dermatological disorder requires equal participation from the dermatologist, affected children (barring neonates, infants, and young toddlers) and their parents or caregivers. Improvement or worsening of any dermatosis is often visual, and the caregivers can be educated and trained to identify the various relieving and exacerbating factors. Furthermore, positive behavioral outcomes can be reinforced as they get an understanding of the activities that help keep the disease within control and what action leads to worsening.
Different forms of educational and counseling modalities are available nowadays and should be customized depending on the needs of the individual patient (parent) and their caregivers. Information should be shared and counseling done in a non-judgmental and non-confrontational manner. Whenever possible medical jargon should be avoided, and instructions given in simple and lucid fashion. Local customs and traditions must also be kept in mind. It is often said “people learn best by doing.” Thus, group demonstrations should be encouraged so that caregivers and parents may learn the techniques themselves as well as get to interact with others in similar situations.
A rough outline of counseling would ideally begin at the first visit itself. The consulting dermatologist may try and answer as many (or few) questions as deemed necessary within a time frame to the patient (parent). This establishes a strong and healthy doctor-patient relationship. Subsequently, the patient may be attended to by a trained counselor, or any of the counseling methods discussed above may be tried. All measures must be taken to empower the patients and their caregivers with knowledge regarding the disease and the treatment, this will help the greatest benefit out of any intervention that is being planned for the patient. Thus, at the end of the day, both the dermatologist and the patient (parent) feel satisfied with their respective roles and duties.
Finally, the greatest benefits of the successful patient (parent) education and counseling is to the pediatric dermatologist themselves., Time is often a constraint in day to day clinical practice, but a few minutes spent in sharing educational information with the parents or caregiver can have a multitude of positive outcomes. By involving the parent in the treatment of the child, it helps to gain their confidence and also makes them aware of equal responsibility in therapeutic response. It also becomes easier to manage the child in subsequent follow-ups as the parent can often provide additional information to the clinical history. Finally, the possibility of attrition is also reduced since the caregivers feel that they too can contribute to making the child get better faster and thus look forward to gaining more information from the dermatologist.
The relevance and essence of the patient (parent) education and counseling in pediatric dermatologic practice can be beautifully summed up in the words of Confucius – ”Tell me, and I will forget. Show me and I may remember. Involve me, and I will understand.”
| References|| |
Schroeder K, Fahey T, Ebrahim S. How can we improve adherence to blood pressure-lowering medication in ambulatory care? Systematic review of randomized controlled trials. Arch Intern Med 2004;164:722-32.
Cabana MD, Le TT. Challenges in asthma patient education. J Allergy Clin Immunol 2005;115:1225-7.
Hill J, Bird H, Johnson S. Effect of patient education on adherence to drug treatment for rheumatoid arthritis: A randomised controlled trial. Ann Rheum Dis 2001;60:869-75.
Dent T. Part I. Patient education. Dis Mon 2000;46:785-97.
Lamb MR. Attention in humans and animals: Is there a capacity limitation at the time of encoding? J Exp Psychol Anim Behav Process 1991;17:45-54.
Becker MH. Patient adherence to prescribed therapies. Med Care 1985;23:539-55.
Schraa JC, Dirks JF. Improving patient recall and comprehension of the treatment regimen. J Asthma 1982;19:159-62.
Grillo M, Gassner L, Marshman G, Dunn S, Hudson P. Pediatric atopic eczema: The impact of an educational intervention. Pediatr Dermatol 2006;23:428-36.
Staab D, Diepgen TL, Fartasch M, Kupfer J, Lob-Corzilius T, Ring J, et al
. Age related, structured educational programmes for the management of atopic dermatitis in children and adolescents: Multicentre, randomised controlled trial. BMJ 2006;332:933-8.
Dent T. Part II. Patient education. Dis Mon 2000;46:785-97.
Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics 2008;122:812-24.
Glascoe FP, Oberklaid F, Dworkin PH, Trimm F. Brief approaches to educating patients and parents in primary care. Pediatrics 1998;101:E10.
Davis RH. Overcoming barriers in irritable bowel syndrome with constipation. J Fam Pract 2009;58:S3-7.
Isaacman DJ, Purvis K, Gyuro J, Anderson Y, Smith D. Standardized instructions: Do they improve communication of discharge information from the emergency department? Pediatrics 1992;89:1204-8.
Arnold J, Goodacre S, Bath P, Price J. Information sheets for patients with acute chest pain: Randomised controlled trial. BMJ 2009;338:b541.
Ewan PW, Clark AT. Long-term prospective observational study of patients with peanut and nut allergy after participation in a management plan. Lancet 2001;357:111-5.
Lorig KR, Sobel DS, Stewart AL, Brown BW Jr, Bandura A, Ritter P, et al
. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Med Care 1999;37:5-14.
Hu W, Siegfried EC, Siegel DM. Product-related emphasis of skin disease information online. Arch Dermatol 2002;138:775-80.
Kist JM, el-Azhary RA, Hentz JG, Yiannias JA. The contact allergen replacement database and treatment of allergic contact dermatitis. Arch Dermatol 2004;140:1448-50.
Zirwas MJ, Holder JL. Patient education strategies in dermatology: Part 2: Methods. J Clin Aesthet Dermatol 2009;2:28-34.
Zirwas MJ, Holder JL. Patient education strategies in dermatology: Part 1: Benefits and challenges. J Clin Aesthet Dermatol 2009;2:24-7.