Rethinking the well visit — as a chance to listen

  | August 29, 2016

Several years ago, during a pediatric well visit with 2-year-old Charlotte, I sat across from her mother Mary and launched into one of the many questions on my required to-do list.

“How is Charlotte sleeping?” I asked. It turned out, she still wasn’t sleeping through the night. Mary’s answer took longer to unspool than a 30-minute visit tends to allow. She explained that she hadn’t stopped nursing Charlotte at night for fear of “hurting” her. I asked her to tell me more.

Her voice began to quiver as she spoke about the death of her own 2-year-old sister when she was a young child. Now she found herself unable to say “no” to Charlotte. Her daughter’s new developmental stage had brought painful, long-buried feelings front and center. Tears formed in my eyes as Mary wept freely in the quiet that followed her revelation.

I let Mary talk for as long as I could. Still, there was pressure to keep moving. Sleep is one of a long and ever-growing list of issues that current guidelines call on pediatricians to ask about during routine well child visits. Others cover development, safety, psychosocial challenges, and food insecurity.

In guidelines released in April, the American Academy of Pediatrics — responding to a published report on the effects of poverty on child development — added yet another screening question: “Do you have difficulty making ends meet at the end of the month?”

Pediatricians cannot solve the problem of poverty. But we can help to foster safe, secure family relationships that protect the brain from the harmful effects of poverty. How can we do this? By listening.

And how can we ensure that listening happens? Start with changing the way the well visit is coded and reimbursed.

There is a tension inherent in today’s well visit: the well-intentioned questioning versus the significant challenges to getting a meaningful answer.

Parents often arrive at the doctor’s office already highly stressed. Many of the questions we ask bring up difficult subjects and may feel threatening to them.

Our words, in fact, may literally fall on deaf ears: Research of neuroscientist Steven Porges has demonstrated how when we do not feel safe, under the influence of what he terms the “primitive” vagus nerve, the muscles of the face and middle ear do not work properly.

And when clinicians have a waiting room of patients and feel pressured to get to the next visit, we may not be available for listening.

In contrast, when we have protected time simply to offer ourselves, we create an opportunity for healing moments of connection. Vast accumulated research demonstrates that this presence helps to grow healthy brains, minds, and bodies.

We need to restructure the standard well visit to match contemporary developmental science — and to find formal ways to foster a feeling of safety for both clinician and patient.

We know that listening to parents supports parent-child relationships, prevents against the harmful effects of stress, and helps to build healthy brains. So a clinician’s time spent listening should be adequately reimbursed. We could add a CPT code for “brain building” with a guideline of a minimum of 15 minutes per well visit.

In this scenario, screening questions would supplement listening, rather than replace it. When problems are identified, follow-up visits for counseling — using existing codes — would be expected and adequately reimbursed. Such visits might be renamed “advanced brain building.” This approach will likely increase use of subsequent referrals and recommended resources.

A simple change like this could change the dynamic of the well visit, making our work more gratifying and less frustrating, and helping to promote healthy development of children and families.

That’s the beauty of listening: It benefits both sides. When Mary had her breakthrough over Charlotte’s sleep problems, the unexpected moment felt profound and transformative for both of us. The power of the exchange carried me through the long day of patients ahead. At a follow up visit several weeks later, I learned that Charlotte was no longer waking every few hours to nurse, and Mary had slept for the first time in over two years.

When we take time to listen to parents, offering our full presence and caring, we support their efforts to listen to — and be fully present with — their children.

Claudia M. Gold MD is a pediatrician and author, most recently, of “The Silenced Child: From Labels, Medications, and Quick-Fix Solutions to Listening, Growth, and Lifelong Resilience.” Illustration by Michelle Kondrich.

Rethinking the well visit — as a chance to listen