This cross-sectional study explores the content of and responses to the often emotional surgical consultations between otolaryngologists and parents as proxy decision makers for children with obstructive sleep disorder.
Key Points
Question
What is the nature of emotional communication between parents and surgeons during surgical consultations for pediatric obstructive sleep-disordered breathing, and what factors are associated with surgeon responses to parent expressions of worries?
Findings
In this cross-sectional study of 59 parents and 7 otolaryngologists who agreed to audio-recorded consultations, parents often expressed their worries as subtle cues rather than explicit concerns. Surgeons responded to these emotional expressions by allowing parents to elaborate on their worries, but surgeon response types varied according to parental race and ethnicity.
Meaning
Results of this study suggest the existence of implicit biases in emotional communication between surgeons and parents and call for research to inform efforts to promote family-centered, culturally competent communication in surgery.
Abstract
Importance
Little is known about emotional communication between parents and surgeons. Understanding the patterns and correlates of emotional communication may foster collaboration during surgical consultations.
Objective
To describe the emotional expressions by parents when bringing their child for evaluation of obstructive sleep-disordered breathing (SDB) as well as surgeon responses to these emotional expressions and to evaluate the association between parental demographic characteristics and surgeon response types.
Design, Setting, and Participants
This cross-sectional study analyzed the audio-recorded consultations between otolaryngologists and parents of children who underwent their initial otolaryngological examination for obstructive SDB at 1 of 3 outpatient clinical sites in Maryland from April 1, 2016, to May 31, 2017. Data analysis was performed from November 1 to December 31, 2019.
Main Outcomes and Measures
Emotional expressions by parents and surgeon responses were audio recorded, transcribed, and coded using the Verona Coding Definitions of Emotional Sequences.
Results
A total of 59 consultations, of which 40 (67.8%) contained at least 1 emotional expression, were included. Participants included 59 parents (53 women [89.8%]; mean [SD] age, 33.4 [6.4] years) and 7 surgeons (4 men [57.1%]; mean [SD] age, 42.8 [7.9] years). Parents made 123 distinct emotional expressions (mean [SD], 3.08 [2.29] expressions per visit), which were often expressed as subtle cues (n = 103 of 123 [83.7%]) vs explicit concerns (n = 20 [16.3%]). Most expressions (n = 98 [79.7%]) were related to medical issues experienced by the child (eg, symptoms and surgical risks). Most surgeon responses provided parents space for elaboration of emotional expressions (n = 86 [69.9%]) and were nonexplicit (n = 55 [44.7%]). Surgeons were less likely to explore the emotions of parents from racial and ethnic minority groups compared with White parents (OR, 0.47; 95% CI, 0.18-0.98).
Conclusions and Relevance
This cross-sectional study found that emotional communication occurs between surgeons and parents of pediatric patients with obstructive SDB. However, surgeon responses varied according to parental race and ethnicity, suggesting the existence of implicit biases in surgeon-patient communication and calling for further research to inform efforts to promote family-centered, culturally competent communication in surgery.
Introduction
The benefits of patient-centered communication with regard to patient satisfaction, treatment adherence, and clinical outcomes have been widely studied in fields that have historically prioritized long-term relationships and interpersonal interactions, such as medical oncology and primary care.1,2,3,4,5 Surgical training is often perceived as being fixated on technical rather than interpersonal skills, and surgeons are often characterized as impersonal, less empathic, and less compassionate compared with medicine physicians.6,7,8,9 Accordingly, patient-centered and empathic communication has been less explored in the surgical setting, and the association of communication with improved surgical decision-making and care is not well understood.
Unique to pediatric surgical care is that surgeons interact primarily with parents and caregivers as proxies for their children. Patient-centered communication that addresses the emotional state of parents and patients may be paramount for building trust and rapport between parents and surgeons to encourage engagement in the decision-making process.10,11,12 Previous research found that parents of children who were being evaluated for elective tonsillectomy consistently reported comfort with and confidence in their surgeon as major factors in their treatment decision.13 Similarly, parents highly valued a surgeon’s interpersonal style as well as demonstration of empathy and concern for the child’s needs.14
The Verona Coding Definitions of Emotional Sequences (VR-CoDES) is a communication coding system that categorizes the types of emotional expressions from patients and the responses of clinicians to these expressions. In this study, we sought to characterize emotional communication in pediatric surgical consultations for obstructive sleep-disordered breathing (SDB) using the VR-CoDES. Specifically, we aimed to (1) describe the emotional expressions by parents when bringing their child for evaluation of obstructive SDB, (2) describe surgeon responses to these emotional expressions, and (3) evaluate the association between parental demographic characteristics (eg, race and ethnicity [which were self-reported by participants in the baseline demographic questionnaire and were categorized as follows: Asian; Black; Hispanic/Latino; White; and Other, which participants were asked to specify], income level, and educational level) and surgeon response types. In addition, we hypothesized that parental characteristics were a factor in how surgeons responded to emotional expressions by parents. We believe the findings enhance the current understanding of the importance of communication in pediatric surgical care and identify potential areas for improving family-centered, culturally competent communication in surgery.
Methods
This cross-sectional study and procedures were approved by the Johns Hopkins School of Medicine Institutional Review Board. Informed consent was obtained from all participants.
Data Collection
Data used in this study were collected as part of a larger study on shared decision-making in consultations for pediatric tonsillectomy.15 Results pertain to the pediatric patients, parents, and surgeons at 3 Johns Hopkins Medicine–affiliated outpatient clinics in Maryland (Johns Hopkins Outpatient Center, Baltimore; Johns Hopkins Greenspring Station, Lutherville; and Johns Hopkins Bayview Medical Center, Baltimore).
From April 1, 2016, to May 31, 2017, English-speaking parents of children aged 2 to 17 years who were being newly evaluated for tonsillectomy at the 3 outpatient sites were identified via electronic records and contacted by telephone. If parents could not be reached by telephone before the otolaryngological consultation, they were approached in clinic on the day of their appointment and asked by the registration staff if they were interested in learning more about the study from a research assistant. Parents and surgeons completed a baseline demographic questionnaire before the consultation. Consultations were audio recorded and transcribed. Parents received $40 as compensation for completing the baseline questionnaire and allowing their visit to be audio recorded, and surgeons received $250 for allowing fewer than 15 of their patients to be enrolled in the study and audio recorded.
Coding of Transcripts Using VR-CoDES
The VR-CoDES was developed to measure emotional communication between clinicians and patients, with a focus on adverse emotional expressions.16,17,18 Widely used in different clinical settings, the VR-CoDES has strong reliability and validity in the evaluation of pediatric and adult populations.19,20,21,22,23,24,25,26,27,28,29,30,31 To ensure coding consistency, 2 research assistants coded each consultation transcript, and discrepancies were resolved by consensus. These research assistants were trained in the use of the VR-CoDES scheme using the manual and codebook (developed by the Verona Network on Sequence Analysis), which provide extensive definitions, exclusions, and examples.
Parental expressions of unfavorable emotions were classified into 2 main categories using the VR-CoDES: cues and concerns. A concern was defined as an “unambiguous expression of an unpleasant emotion that is explicitly verbalized” (eg, “We’re worried about her breathing”), whereas a cue was defined as “a verbal or nonverbal hint that suggests an underlying unpleasant emotion and that lacks clarity” (eg, “So many issues with this kid”).17(p144) Parental cues were further classified into 7 categories (cues A-G) on the basis of communication method (verbal vs nonverbal) and language style (Table 1 provides definitions and examples). Transcriptions were generated from audio recordings of the consultations, thus limiting the ability to capture and code for nonverbal communication, such as facial expressions. Coding was further expanded to the content of the emotional expressions by parents.
Table 1. Definitions, Transcript Examples, and Content of Emotional Expressions by Parents.
| Definition | Example | Frequency, No. (%) |
|---|---|---|
| Concern | ||
| An unambiguous expression of an unpleasant emotion that is explicitly verbalized17(p144) | “I think we get worried when they get so large that they touch, ‘cause we’re worried about her breathing.” | 20 (16.2) |
| Cues | ||
| A. Words or phrases that patients use vaguely to describe their emotions | “I’m a little nervous about doing the sleep study.” | 10 (8.1) |
| B. Verbal hints to hidden concerns (eg, emphasizing, unusual words, profanities, exclamations, metaphors, double negatives, and expression of uncertainties and hope) | “This is just the sound, but I have a visual of this, oh my God.” | 38 (30.9) |
| C. Words or phrases that emphasize physiological or cognitive correlates of unpleasant emotional states | “I can’t get no sleep. I’m tired now.” | 8 (6.5) |
| D. Neutral expressions of issues of potential emotional importance that stand out from the narrative background and refer to stressful life events and conditions | “I guess my main thing with jumping to surgery would be … I just really don’t want to be wrong in my symptom observations. If you looked at him without what I had said…” | 44 (35.8) |
| E. Repetition of an expression said previously by a patient | NA | 0 |
| F. Nonverbal, clear expressions of unpleasant emotions (eg, crying, frowning, and trembling voice) | NA | 0 |
| G. Clear and unambiguous expressions of a concern, referring to a past episode of more than 4 wk ago or without a clear time frame | “I would say so. I remember when I was really worried about the apnea, about six months or so ago. He was coming off, he had a cold.” | 3 (2.4) |
| Content | ||
| Medical topics | ||
| No. | NA | 98 (79.7) |
| Symptoms | NA | |
| Snoring and congested breathing | 40 (32.5) | |
| Tonsil size | 6 (4.8) | |
| Poor sleep | 4 (3.2) | |
| Behavioral concerns | 8 (6.5) | |
| Sleep study | NA | 9 (7.3) |
| Risks of surgery | NA | 13 (10.6) |
| Consequences of untreated OSA | NA | 7 (5.7) |
| Comorbidities or unrelated medical symptoms | NA | 11 (8.9) |
| Nonmedical topics | ||
| No. | NA | 25 (20.3) |
| Insurance | NA | 2 (1.6) |
| Communication with health care practitioners | NA | 8 (6.5) |
| General feelings | NA | 9 (7.3) |
| Life or school issues unrelated to medical care | NA | 6 (4.9) |
Abbreviations: NA, not applicable; OSA, obstructive sleep apnea.
Each surgeon response to an emotional expression by parents was coded. The VR-CoDES scheme was used to classify surgeon responses into 17 types, with each type further divided under 4 different categories (explicit, nonexplicit, space provision, and space reduction) based on 2 domains: explicit and space provision.7 Explicit referred to the ambiguity of the clinician response in reference to a cue or concern. An explicit clinician response “unambiguously refer[red] to the cue or concern.”16(p151) A nonexplicit clinician response, in contrast, was ambiguous and did not specifically refer to the content or emotion of the cue or concern.
Space provision referred to whether the surgeon response provided an opportunity for further elaboration by the parent. For example, nonexplicit surgeon responses that reduced space included ignoring or shutting down the parent and giving information or advice to the parent that did not directly address the parent’s emotional expression. In contrast, explicit responses that provided space acknowledged and explored the circumstances that provoked the emotion and showed empathy for the parent’s emotional expression. Categorization of all of the surgeon responses, detailed definitions, and examples from the transcript are shown in Table 2.
Table 2. Coding, Transcript Examples, and Categorization of Surgeon Response Types to Emotional Expressions by Parents.
| Primary response type | Secondary response type with VR-CoDES | Example | Frequency, No. (%) |
|---|---|---|---|
| Nonexplicit | |||
| Space reduction | Ignoring (code: NRIg) |
|
7 (5.7) |
| Shutting down (code: NRSd) |
|
2 (1.6) | |
| Giving information or advice (code: NRIa) |
|
5 (4.1) | |
| Space provision | Back channeling (code: NPBc) |
|
19 (15.4) |
| Actively inviting (code: NPAi) |
|
17 (13.8) | |
| Showing implicit empathy (code: NPIm) |
|
3 (2.4) | |
| Acknowledging (code: NPAc) |
|
2 (1.6) | |
| Being silent (code: NPSi) | NA | 0 | |
| Explicit | |||
| Space reduction | Giving information or advice (code: ERIa) |
|
21 (17.1) |
| Switching topic (code: ERSw) |
|
2 (1.6) | |
| Postponing (code: ERPp) | NA | 0 | |
| Blocking (code: ERAb) | NA | 0 | |
| Space provision | Exploring content (code: EPCEx) |
|
28 (22.8) |
| Acknowledging content (code: EPCAc) |
|
13 (10.6) | |
| Using affective acknowledgment (code: EPAAc) |
|
3 (2.4) | |
| Showing empathy (code: EPAEm) |
|
1 (0.8) | |
| Using affective exploration (code: EPAEx) | NA | 0 | |
Abbreviations: NA, not applicable; VR-CoDES, Verona Coding Definitions of Emotional Sequences.
To condense categories with too few frequencies for the final analysis, we grouped a priori the qualitatively similar response types into 2 broad conceptual categories: space provision and space reduction.32 These categories were not mutually exclusive. Table 3 details the specific VR-CoDES used for the secondary categorization of surgeon response types.
Table 3. Secondary Categorization of Surgeon Response Types .
| Secondary category with VR-CoDES | Surgeon response type | Frequency, No. (%) |
| Space provision | ||
| Exploring (codes: NPAi, EPCEx, EPAEx) | Explicit or nonexplicit | 45 (36.6) |
| Being neutral or passive (codes: NPSi, NPBc, NPAc) | All nonexplicit | 21 (17.1) |
| Acknowledging (codes: NPAc, EPCAc, EPAAc) | Explicit or nonexplicit | 18 (14.6) |
| Explicitly responding to emotional expression (codes: EPAAc, EPAEx, EPAEm) | Acknowledging, exploring, or showing empathy for emotional expression by parents | 4 (3.3) |
| Showing any empathy (codes: NPIm, EPAEm) | Explicit or nonexplicit | 4 (3.3) |
| Space reduction | ||
| Giving information or advice (codes: NRIa, ERIa) | Explicit or nonexplicit | 26 (21.1) |
| Any blocking (codes: NRIg, NRSd, ERSw, ERAb) | Ignoring, shutting down, switching topic, or actively blocking | 11 (8.9) |
Abbreviation: VR-CoDES, Verona Coding Definitions of Emotional Sequences.
Statistical Analysis
The demographic characteristics of parents and surgeons as well as the emotional expressions by parents and surgeon response types were summarized with descriptive statistics. Hierarchical logistic regression models were run for the presence and absence of emotional expressions. To assess for differences in characteristics of parents who did and those who did not express emotional issues in the consultations, we used unpaired, 2-tailed t tests and χ2 tests where appropriate. To evaluate the association between parental race and ethnicity and emotional expression type as well as surgeon response types, multilevel logistic regression analyses were performed to calculate odds ratios (ORs) and 95% CIs. Multilevel logistic regression analyses were conducted to account for biases that may have resulted from parents expressing multiple emotional concerns in a particular visit (clustering of emotional concerns in each visit) or from surgeons interacting with several of these parents (clustering of parents within surgeons). Emotional expressions by parents were nested within each medical consultation, and consultations were nested within surgeons. We used χ2 test for independence to ascertain the correlation between parental race and ethnicity, income level, and educational level. We reported the analyses and results of parental race and ethnicity to use the full data set of the small sample size. Adjustment of these variables in 1 model was not possible because of collinearity.
Data were analyzed using Stata 16 (StataCorp LLC). Data analysis was performed from November 1 to December 31, 2019.
Results
A total of 149 eligible families were approached for participation in the study, with 59 parents (39.6%) agreeing to participate and to have their consultation audio recorded. Parent participants had a mean (SD) age of 33.9 (6.4) years; were predominantly women (n = 53 [89.8%]), with 6 men (10.2%); and had at least some college education (n = 46 [79.3%]). Race and ethnicity were self-reported as follows: 1 parent (1.7%) identified as Asian, 22 parents (37.3%) as Black, 5 parents (8.5%) as Hispanic/Latino, and 30 parents (50.8%) as White individuals; only 1 parent (1.7%) identified under the Other option, specifying Trinidadian. Parental race and ethnicity, income level, and educational level were found to be highly correlated with each other (χ2 = 62.1; 95% CI, 61.1-80.2; P < .001).
Seven otolaryngologists agreed to participate. Of these clinicians, 4 were men (57.1%) and 3 were women (42.9%), with a mean (SD) age of 42.8 (7.9) years. One clinician (14.3%) self-identified as being of Asian race and ethnicity, and 6 clinicians (85.7%) self-identified as White individuals. All participant demographic characteristics are described in Table 4.
Table 4. Demographic Characteristics of Participants.
| Characteristic | No. (%) | ||
|---|---|---|---|
| Surgeons (n = 7) | All parents (n = 59) | Parents with at least 1 emotional expression (n = 40) | |
| Age, mean (SD), y | 42.8 (7.9) | 33.9 (6.4) | 35.2 (6.4) |
| Age of child, mean (SD), y | NA | 5.8 (2.6) | 6.2 (2.7) |
| Child comorbidities | |||
| ADHD | NA | 1 (1.7) | 0 |
| Asthma | NA | 9 (15.3) | 4 (10.0) |
| Obesity | NA | 11 (18.6) | 8 (20) |
| Race and ethnicitya | |||
| Asian | 1 (14.3) | 1 (1.7) | 0 |
| Black | 0 | 22 (37.3) | 12 (30.0) |
| Hispanic/Latino | 0 | 5 (8.5) | 5 (12.5) |
| White | 6 (85.7) | 30 (50.8) | 22 (55.0) |
| Otherb | 0 | 1 (1.7) | 1 (2.5) |
| Female sex | 3 (42.9) | 53 (89.8) | 36 (90.0) |
| Male sex | 4 (57.1) | 6 (10.2) | 4 (10.0) |
| Annual income | |||
| No. of respondents | NA | 57 (96.6) | 38 (95.0) |
| <$20 000 | NA | 13 (22.8) | 6 (15.0) |
| $20 000-49 999 | NA | 15 (26.3) | 7 (17.5) |
| $50 000-79 999 | NA | 8 (14.0) | 7 (17.5) |
| $80 000-100 000 | NA | 8 (14.0) | 7 (17.5) |
| >$100 000 | NA | 13 (22.8) | 11 (28.9) |
| Educational level | |||
| No. of respondents | NA | 58 (98.3) | NA |
| ≤High school diploma | NA | 12 (20.7) | 9 (22.5) |
| At least some college | NA | 46 (79.3) | 31 (77.5) |
| Surgeon years in practice | |||
| <5 | 3 (42.8) | NA | NA |
| 5-10 | 2 (28.6) | NA | NA |
| 11-20 | 1 (14.3) | NA | NA |
| >20 | 1 (14.3) | NA | NA |
| Clinical training | |||
| Attending surgeon | 5 (71.4) | NA | NA |
| Fellow | 2 (28.6) | NA | NA |
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; NA, not applicable.
Race and ethnicity were self-reported by participants in the baseline demographic questionnaire.
Other category included space for participants to specify their race and ethnicity; only 1 participant specified Trinidadian.
Emotional Expressions by Parents
Of the 59 medical consultations, 40 (67.8%) contained at least 1 emotional expression by the parent (ie, cue or concern). The 40 visits with emotional communication between the surgeon and parent were included in the subsequent analyses. The demographic characteristics were not substantially different between the parents who did and those who did not express emotional issues during the consultations (Table 5). A total of 123 distinct emotional expressions were made by parents (mean [SD], 3.08 [2.29], with a range of 1-11 expressions per visit). Emotional expressions were more frequently initiated by parents (n = 100 [81.3%]) rather than elicited by surgeons (n = 23 [18.7%]).
Table 5. Parental Race and Ethnicity as a Factor in Emotional Expression Type and Surgeon Response Types.
| Expression and response types | Parental race and ethnicity, OR (95% CI)a |
|---|---|
| Characteristics of emotional expression type | |
| Concern vs cue | 1.34 (0.32-5.64) |
| Primary categories of surgeon response types | |
| Explicit vs nonexplicit | 2.27 (0.72-7.15) |
| Space provision vs space reduction | 0.56 (0.10-3.08) |
| Secondary categories of surgeon response types | |
| Being neutral or passive | 0.78 (0.25-2.43) |
| Acknowledging | 2.60 (1.07-9.56) |
| Exploring | 0.47 (0.18-0.98) |
| Giving information or advice | 1.54 (0.37-6.29) |
| Any blocking | 2.15 (0.49-9.47) |
Abbreviation: OR, odds ratio.
Compared White parents (reference) with parents with Asian, Black, Hispanic/Latino, or other race and ethnicity.
Parents more often expressed emotional issues as subtle cues (n = 103 [83.7%]) than as explicit concerns (n = 20 [16.3%]). Not all types of cues were represented in the sample (cues E and F, repetition of an expression said previously by a patient and nonverbal clear expressions of unpleasant emotions, respectively). Cues were most often expressed by parents as neutral expressions that stood out from the narrative background of stressful life events and conditions (cue D: n = 44 [35.8%]; eg, “I guess my main thing with jumping to surgery would be … I just really don’t want to be wrong in my symptom observations”) or verbal hints to hidden worries (cue B: n = 38 [30.9%]; eg, “This is just the sound, but I have a visual of this, oh my God”). Examples and frequencies of each type of emotional expression by parents are shown in Table 1.
Of the 123 emotional expressions by parents, 98 (79.7%) were medically related and often referred to obstructive SDB symptoms that were experienced by the child (n = 58 [47.2%]; eg, “He snores a lot or his breathing … it’s scary”). The remaining emotional expressions were nonmedical and often referred to poor communication with health care practitioners (n = 8 [6.5%]; eg, “I wasn’t real pleased with the information passing between me and the doctor”) and general feelings (n = 9 [7.3%]; eg, “I can’t get no sleep. I’m tired now”). The contents of emotional expression and their frequencies are shown in Table 1.
Surgeon Responses
Most otolaryngologist responses provided space for elaboration of emotional expressions (n = 86 [69.9%]) and were nonexplicit (n = 55 [44.7%]). The otolaryngologists responded most commonly by exploring the content of these emotional expressions by parents (n = 28 [22.8%]; eg, “And when you say … what do you mean by that?”), followed by giving information or advice (n = 21 [17.1%]). Surgeons infrequently responded to emotional expression by shutting down parents (n = 2 [1.6%]; eg, “There’s no imminent issue.”) or explicitly showing empathy (n = 1 [0.8%]).
In this study, we found that the otolaryngologists did not use active blocking, postponing, silence, or affective exploration to respond to emotional expressions by parents. Within the secondary categories of surgeon response types, showing any empathy, either explicit or nonexplicit, was the least common response type (n = 4 [3.3%]). Table 2 and Table 3 show the frequencies and transcript examples of each surgeon response type as defined by the VR-CoDES and as classified by the secondary categories of surgeon response types. The sex of the otolaryngologists was not associated with their response to the emotional expressions by parents.
Parental Race and Ethnicity and Emotional Communication
Multilevel logistic regression analyses of parental race and ethnicity as a factor in emotional expression type and surgeon response types are shown in Table 5. In this study, parental race and ethnicity were not associated with the type of emotional expression (concern vs cue) (OR, 1.34; 95% CI, 0.32-5.64) but were associated with surgeon response types. The odds of surgeons exploring the emotional expression by parents of Asian, Black, Hispanic/Latino, or other race and ethnicity were 53% less than for White parents (OR, 0.47; 95% CI, 0.18-0.98). Although the otolaryngologists were less likely to explore emotional expressions by parents from racial and ethnic minority groups, they were more likely to acknowledge the emotional expressions by these parents rather than by White parents (OR, 2.60; 95% CI, 1.07-9.56).
Discussion
Patient-centered communication and emotional reassurance are valuable to the relationship of patients and family members with their surgeons.33,34 However, surgeons often focus primarily on education and discussion of treatment options and give considerably less time to the emotional aspects of care.35,36,37,38,39 Clinicians who respond to emotional statements help patients overcome the fears of procedures and enhance patient capacity for decision-making.40 The VR-CoDES has been used extensively for research in medicine subspecialties, allowing for the observation and objective analysis of emotional and patient-centered communication.17,21,32,41,42 Given the unique aspects of surgical consultations that may benefit from empathic and patient-centered communication, such as the discussion of complex and risky procedures and the immediate need to build trust and rapport, it is essential that emotional communication specific to surgical settings be understood and evaluated independently.43
To our knowledge, this is the first study to use the VR-CoDES to characterize emotional expressions and clinician responses in the surgical context. Moreover, this study was among the few that evaluated emotional communication between surgeons and parents.44,45 Previous studies that used the VR-CoDES in pediatric populations have examined the language of pediatric patients themselves.27,31 Because parents often serve as proxy decision-makers for pediatric patients, parent dialogue is important to analyze in the study of physician-patient communication.
We found that parents raised a substantial number of emotional issues to otolaryngologists during their child’s initial medical consultation for obstructive SDB. Surgeons most often responded to parents by providing space in which parents could elaborate on their emotional expressions. We found that surgeons were less likely to explore the emotional issues raised by parents from racial and ethnic minority groups compared with White parents.
Previous studies that used the VR-CoDES have found that 33% to 57% of visits contained emotional expressions.46 These studies examined patient-physician communication across a variety of medical specialties and patient populations, presenting an expansive description of emotional expression in clinical consultations. Specialties ranged from general practitioners to psychiatrists, and the patients included both children and adults. In this study, 67.8% of the consultations analyzed contained at least 1 emotional expression. Emotional expressions were more often initiated by parents rather than in response to a surgeon’s question. This finding is similar to those in previous studies that reported that emotional concerns were more often offered spontaneously by patients rather than initiated by surgeon questions.32,47 Similar to patient participants in research across multiple specialties, parents in the present study more frequently expressed their emotional issues as ambiguous and subtle cues rather than explicit concerns.19,20,21,28,42 Cue D (ie, neutral expressions of issues of potential emotional importance that stand out from the narrative background and refer to stressful life events and conditions) was the most common form of emotional expression by parents in this study compared with other studies in which patients often expressed their emotions with the cue B form (ie, verbal hints to hidden concerns [eg, emphasizing, unusual words, profanities, exclamations, metaphors, double negatives, and expression of uncertainties and hope]).20,29 This finding may be explained by the burden and stress that obstructive SDB has on the entire family and not only the child.13,48 Surgical consultations for obstructive SDB that address these parent stressors may provide parents with an opportunity to specify concerns to which surgeons may respond with greater levels of information and experience sharing.
In response to emotional expressions by parents, the otolaryngologists most often provided space for further elaboration by back channeling and acknowledging and exploring the content of the expressions. In contrast, the otolaryngologists less often responded with empathy or explored or acknowledged the affect embedded in these expressions. This pattern in surgeon responses has been reported in other studies, with clinicians in other specialties missing empathic opportunities in consultations by 53% to 79% of the time.46,47,49 Clinicians were also more likely to focus on the factual or medical content of patient worries rather than the emotion.50 Exploring physical symptoms, diagnosing, and treating from a biomedical perspective are inherent in a clinician’s role and are often the reasons that patients seek out medical expertise. Clinicians may be so focused on these tasks and the biomedical perspective that they may not recognize patient emotions or may not realize that patient affect is valuable. The finding that giving information or advice was the most common space reduction response technique that was used by surgeons supports this explanation. This pattern has been found across numerous specialties.20,21 Although giving biomedical information and exploring physical symptoms are often adequate responses to patient cues,21 validation of patient emotions has been associated with improved treatment adherence and patient satisfaction.51,52,53
Surgeons were less likely to explore the content of and affect in emotional expressions by parents from racial and ethnic minority groups compared with those of White parents, suggesting racial disparities in surgeon-patient communication. Previous studies have found similar communication behaviors, with clinicians being more verbally dominant, less patient centered, less empathic, and less emotionally engaged with patients from racial and ethnic minority groups than with White patients.32,54,55,56 Emotional and patient-centered communication not only promotes rapport building between patients and clinicians but also has been associated with improved treatment adherence and health outcomes.57,58,59 Content and affect exploration of emotional expressions by parents may help surgeons engage parents in the medical dialogue and gain insights into their specific worries. In addition, we found that surgeons were more likely to acknowledge the content and affect of emotional expressions by parents from racial and ethnic minority groups compared with White parents. It is hard to adequately understand and interpret this finding as it may seem to directly contradict the previous finding. However, an explanation may be that surgeons wanted to show their recognition of parental worries without encouraging further emotional disclosure from the parents. Further analysis of the association between empathic and emotional communication behaviors (ie, showing explicit and implicit empathy, using affective acknowledgment, and using affective exploration) and patient race and ethnicity may help in the interpretation of this finding. The low frequencies of these response types limited our ability to analyze this association.
The present study is among the few works to explore racial disparities in patient-clinician communication in the surgical setting.33,37,60 In the first study of this kind, Levinson and Chaumeton37 found that orthopedic surgeons were much less successful in building rapport and relationships with patients from racial and ethnic minority groups than with White patients. By using the VR-CoDES, we were able to identify which surgical communication behaviors were used less often with parents from racial and ethnic minority groups. Previously, parental race and ethnicity were shown to play a role in the extent to which surgeons involved parents in decision-making.13 However, surgeon perceptions of parental preference to be involved in treatment decisions were often misdirected, with surgeons inaccurately believing that parents wished to be less involved in treatment decisions.61,62
The findings of this study highlight the necessity for increased awareness and understanding of the implications of surgeon racial biases for patient care. Given that surgeons may tailor their communication style according to their preconceived perceptions of cultural needs or preferences, the racial and ethnic biases of surgeons may diminish parent engagement and disrupt opportunities for developing familiarity and trust between surgeons and parents.63 Studies are scarce on the racial disparities in patient-physician communication, specifically in the surgical setting. Although parallels can be drawn from existing research in the medicine subspecialties, surgical discussions and the surgeon-patient relationship have unique features that warrant further research in this area. A study has suggested that racial concordance in the patient-physician relationship can mediate racial disparities in communication, making this an important area of research.64 Future work should also explore the association of patient-reported and clinical outcomes with surgeon responses and overall communication.
Strengths and Limitations
A strength of this study is the novel use of the VR-CoDES in surgical consultations, allowing for a detailed analysis of cues and concerns expressed by parents of children with obstructive SDB. Despite the growing emphasis for research on productive communication between surgeons and parents, emotional communication and empathy in surgical consultations is not well understood. This analysis of emotional communication using the VR-CoDES suggests the presence of racial disparities in surgeon-parent communication.
This study also has limitations. First, although validated in multiple patient populations, the VR-CoDES has not been used to study pediatric populations wherein the parent is the proxy decision maker. Given that no instrument currently exists that has been validated for studying parents as proxy decision makers, we used the VR-CoDES. Second, the coding of the surgeon-parent dialogue was performed using the transcripts of the audio-recorded visits to preserve the integrity of the diction used by surgeons and parents in the dialogue. However, in doing so, the VR-CoDES could not adequately capture the nonverbal expression of emotions and communication in the data. This detail may explain why nonverbal cues (eg, cue F) and silence as a surgeon response type were not represented in this study. Furthermore, audio recordings and transcripts cannot capture any emotional distress or worry displayed through facial expressions and body language, both of which are important to nonverbal expressions of underlying emotion.65
Third, there was limited representation of parents from racial and ethnic minority groups, impeding us from identifying any differences between specific groups. Demographic information was also not collected from parents who declined to participate, limiting our ability to assess selection bias in the sample. Because this study included only English-speaking parents, we were unable to examine the implication of language barriers for the surgeon-parent emotional dialogue. Because of the lack of sex and racial diversity in the small sample of otolaryngologists, we were unable to examine the role of sex or racial concordance in emotional communication. In addition, because blinding was not used in the methods, performance bias in the use of or response to emotional dialogue could have affected the results. Physician-patient communication is multifaceted and informed by factors on the patient, clinician, and consultation levels; however, many of these factors were not collected in this study, preventing their evaluation. Patient-level factors include parental medical knowledge before consultation, parental preferences, and parental communication style. Consultation-level factors include length of consultation, timing of clinic schedules, and clinician documentation behaviors. An important constraint to consider about standardized coding schemes, such as the VR-CoDES, is their inability to consider contextual factors in dialogue.
Fourth, the small sample size limited any conclusions that can be drawn. We did not perform a power analysis because the focus of the study was exploratory and descriptive. Based on the literature on multilevel regression analyses, a sample size of fewer than 50 people resulted in greater biases in SEs, but regression coefficient estimates remained accurate and unbiased.66 However, the findings do show valid indications of preliminary differences, which may suggest avenues for future investigation. Fifth, in the study population, parental race and ethnicity, educational level, and income level were found to be highly correlated. Adjustment of these variables in 1 regression model was not performed to avoid multicollinearity.
Conclusions
This cross-sectional study found that emotional communication between parents of pediatric patients and otolaryngologists frequently occurred in the first surgical consultation for obstructive SDB, with parents often expressing their worries. Surgeons often responded to these emotional expressions by providing space in which parents could elaborate on their worries. However, surgeon responses varied according to parental race and ethnicity. These findings highlight the need for increased awareness of the implicit biases in surgeon-patient communication and call for further research to inform efforts to promote family-centered, culturally competent communication in surgery.
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