While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.
While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.
The first and possibly most important step in engaging parents who are skeptical of accepted medical practice is to be respectfully curious about what is contributing to their skepticism. A different cultural, religious, or racial background may be playing a role in that many cultures have different traditions around treating specific problems. Some parents may have had experiences with health care providers that went poorly and left them harmed and feeling betrayed. There may be disagreement between spouses or intergenerational conflict between parents and grandparents, particularly over treatments that are new or controversial. Treatments such as stimulants for ADHD, avoiding antibiotics for what is likely to be a viral illness, or the human papillomavirus vaccine often are treated as controversial interventions in the popular press, so it would not be surprising if they were generating disagreement in a family. Finally, there are some people who, because of temperament or experience, tend to become oppositional or even hostile when dealing with authority figures offering “official” recommendations.
In each of these cases, launching into an enthusiastic explanation of the advanced statistics that underpin your recommendation is unlikely to bridge the gap. Instead, you want to start with these parents by being curious. Resist the urge to tell, and listen instead. When a parent expresses skepticism, respectfully learn more, and prioritize their dignity. What is their understanding of the problem you are treating or preventing? What have they heard or read about the treatment or test in question? What do they most fear is going to happen to their child if they do or do not accept your recommendation? Are there specific events (with their child or with the health care system) that have informed this fear?
Respectfully listening to their experiences, thoughts, and feelings goes a long way toward building a trusting alliance. It can help overcome feelings of distrust or defensiveness around authority figures. And it models the thoughtful, respectful give and take that are essential to a healthy collaboration between pediatrician and parents.
Once you have heard something about their understanding, opinions, and worries, resist the urge to then explain how they are mistaken! Instead, find out where their trusted information comes from. When you are making important decisions for your family, whose guidance do you seek? Whose support is important to you when managing a challenge with your family? It can be helpful to ask whether there have been other times when they went their own way in raising their child, perhaps at school. How did that go? Was there a lot of conflict or involvement of authorities, such as the Department of Children and Families? Or was it more collaborative? If they go their own way, what markers do they watch to be sure they are on track? Put another way, how would they know if it was time to give another approach a try?
Once you have information about what they think and some about how they think and make decisions, you then can offer your perspective. “You are the expert on your child, what I bring to this equation is experience with (this problem) and with assessing the scientific evidence that guides treatments in medicine. It is true that treatments often change as we learn more, but here is what the evidence currently supports.”
After learning something about how they think, you might offer more data or more warm acknowledgment of how difficult it can be to make medical decisions for your children with imperfect information. Be humble while also being accurate about your level of confidence in a recommendation. Humility is important because it is easy for parents to feel insecure and condescended to. You understand their greatest fear, now let them know what your greatest worry is for their child should they forgo a recommended treatment. Explaining all of this with humility and warmth makes it more likely that the parents will take in the facts you are trying to share with them and not be derailed by suspicion, defensiveness, or insecurity.
Make building an alliance with the parents your top priority. This does not mean that you do not offer your best recommendation for their child. Rather, it means that, if they still decline recommended treatment, you treat them with respect and invest your time in explaining what they should be watching or monitoring their child for without recommended treatment. Building trust is a long game. If you patiently stick with parents even when it’s not easy, they may be ready to trust you with a subsequent decision when the stakes are even higher.
Of course, there may come a time when a parent’s refusal to accept recommended treatment constitutes medical neglect. The decision to file with your state’s Department of Children and Families (or equivalent) should be guided by the severity of the potential consequences to the child, and it will help if you are confident that the parents understood your recommendations and associated risks and benefits. Where there is imminent risk, the law gives you no choice about the decision to file. If you have invested in a strong alliance with the parents, it will be easier to explain filing and its consequences to them. It may even be that they will want to continue with your practice in the aftermath, as they trust in your honesty, your dedication to their child’s health and safety, and your capacity to treat them with respect even in disagreement.
Of course, all this thoughtful communication takes a lot of time! You may learn to block off more time for certain families. It also can be helpful to have these conversations as a team. If you and your nurse or social worker can meet with parents together, then some of the listening and learning can be done by the nurse or social worker alone, so that everyone’s time might be managed more efficiently. And managing skeptical parents as a team also can help to prevent frustration or burnout. It will not always succeed, but in some cases, your investment will pay off in a trusting alliance, mutual respect, and healthy patients.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at firstname.lastname@example.org.