What changes minds? Persuasive communication in decision-making for elective pediatric surgery

Amanda McArthur – Johns Hopkins University; Ellie Thompson – Johns Hopkins University; Emily Boss – Johns Hopkins University

Abstract: A clinician’s efforts to provide recommendations to parents about elective tonsillectomy to treat their child's snoring ideally promotes uptake of clinically-appropriate care in line with family values and preferences. However, these recommendations may cross ethical boundaries if they influence parents negatively or damage the parent-clinician relationship. We characterized how clinicians build discourse recommending surgery and respond to parent hesitance during initial consultations for tonsillectomy. Using qualitative methods informed by conversation analysis, we are analyzing 20 recorded consultations in which the surgeon judged surgery to be in the patient’s best interests. Clinicians who favor surgery pursue four “persuasive tasks” when they believe that surgery is indicated: 1) Accept that inaction is not a viable option due to the severity and impact of obstructive sleep disordered breathing (OSDB) on their child’s well-being, 2) Reject alternatives to surgery (e.g., watchful waiting, medication) as unfavorable options and/or unlikely to promote the preferred outcomes, 3) Accept surgery as an effective strategy that is likely to promote desired outcomes, and 4) Accept the surgical risks as manageable. Prior to making a recommendation, surgeons use priming to present surgery as favorable and alternatives as unfavorable and probing to test parents’ acceptance or resistance to surgery. Surgeons may bypass parental discomfort with a recommendation using escalating tactics to press for parent acceptance, reduce decision conflict, or elicit questions. We will interpret descriptive findings in light of established frameworks for shared decision-making. Findings are expected to inform intervention strategies to promote patient-centered, clinically appropriate decisions about OSDB treatment.

Keywords: Persuasive communication, Shared decision making, Pediatric surgery