Coaching Patients Through the Care Plan

Robert Sidbury, MD, MPH, gives tips on how to properly coach patients through their care plan after the initial visit in follow up.

Dr Sidbury is associate professor, department of pediatrics, University of Washington School of Medicine, Seattle; and chief, division of dermatology, Seattle Children’s Hospital.

Dr Sidbury: Depending on the practice, a new visit for atopic dermatitis can range anywhere from 10 to 20 minutes. You can spend 10 to 20 minutes just disabusing false notions about the role of bathing in moisturization, let alone food allergies, then, you start talking about comorbidities and all the things the savvy parent might have found on Google linking atopic dermatitis to a learning disability—for instance, just a paper in JAMA Dermatology in April this year. If you, then, wanted to delve into all of those things, you would never, ever get to, really, what the crux of the issue is, which is treating that child appropriately and getting them better, because you spend so much time wheel spinning on things that, certainly, are frightening and concerning to parents but may or may not be relevant at all to that child, then or in the future.

You really do have to meter the information that you talk about and, of course, respond to questions that the parents have and the history that you've taken that you hear is the most relevant to that child and focus on that. Train their attention on the things that you know will be important to that child's skin.

If there are things left on the table that you can't cover in the time allotted, that's when you, potentially, can point them to resources, such as the National Eczema Association, or other ways to extend the educational portion of that visit beyond the constraints of that limited time.

I'm thinking back to the first visits. Presuming they had fairly significant eczema, then they were certainly itching. They were likely losing sleep. They may well have had impact on school performance or concentration or ability to enjoy their friends and activities.

I try and think back to what specific impacts that patient was having and the impacts, particularly, on their quality of life and then, probe there. General questions to start with. Better? Worse? Same? Simple sort of things just to get a gestalt. Then, from there, dig deeper into whether or not if that was a patient who was having some sleep loss due to their itch. How is that going? If it was a patient who was having skin infections, things of that nature, have there been any issues along those lines since the last visit?

Basically, just trying to get an overall view but then, try to tailor it to, particularly, how eczema was impacting that patient. Something that I always tell parents before they leave that first visit is that they're going to be the experts in their child's skin, not me.

That gets to that dynamic state that I don't see, that they're going to see from day to day. That also gets a little bit at the fact that most parents come with that information overload from Dr. Google or whomever, Aunt Gertie, whoever it was that's giving them their information, that sometimes is spot-on and sometimes is spot-off, if that's even a term. They come in with these mixed messages about is bathing good or bad? Do food allergies cause eczema? Really, foundational, fundamental things that, sometimes, they've just gotten these mixed messages from sources they trust. They're just meeting me for the first time, so I assume they trust me less than their pediatrician or their Aunt Gertie or whomever. What I try to do is say, "Listen, let's just talk about the fundamentals." If relevant to that child, for instance, I'll point out the areas of the skin that tend to do better versus the areas that tend to do worse.

Then, link that to, perhaps, wetting, drying, with jeweling, what-have-you, and try to show them those sorts of things on their own child. Then, give them the facts. In general, moisturizing is an unambiguous good. Bathing, it depends. If you bathe and don't moisturize, I'd probably rather you bathe less. If you moisturize after you bathe, then I think bathing every day is just fine. But I have some parents say, "We do exactly what you're saying and little Johnny seems to do worse when he bathes." Then, maybe, bathing twice a week or when he's dirty, when he needs to be bathed is more appropriate when using a daily bath, a soak-and-smear technique as therapy. I just try to make sure they understand the things we know and the many things we don't know. Then, have them realize that they can adjust as they see fit based around those principles at home.