The Art of Scaffolding Conversations

For many years before my medical career started, I was a teacher. First, in college, I worked with early elementary students on reading development through phonics-based instruction. Then, Teach for America took my teaching career to middle school science. I understood the potential impact those formative years would have on my medical career as I talked about it during both medical school and residency interviews but the connections between teaching and medicine became real during intern year.

Between hospital discharge instructions and primary care anticipatory guidelines, I spent much of intern year talking with parents and patients about what to expect next. In the same day, I might discuss a particular topic five to ten times, ranging from developmental milestones to asthma to sickle cell disease to constipation. Families show a great love for their child’s well-being and look for assistance in understanding what to do next.

Scaffolded teaching

I remember the classroom where I engaged with multiple levels of learners that would require teaching the lesson in three or four different ways. Referred to as scaffolded teaching, this approach involves modifying lessons to meet students where they are to get to a common end goal. When I met with parents in conferences, this was regularly a topic of discussion as they were concerned about their child’s performance and wanted to help them improve.

I remember the physics labs where three different activities ended with same end goal, such as experiments with simple machines, and while this made lesson planning take three times the length of time, student learning and helping students to love science made it worth it. The science of scaffolded learning is known; however practicing it can be challenging because you manage the same conversation for learners at different levels, which requires a deep understanding of the topic and, above all, patience.

This idea of scaffolded teaching is very similar to concepts of equity versus equality that we talk about with health disparities in medicine. We know the barriers, such as systemic racism and social determinants of health, that negatively affect the health of our children (and I would argue their education, but that is another topic). These issues are often out of the hands of families and definitely out of the hands of kids, which makes roles in medicine and pediatrics even more challenging because it is not only the patient’s health on the mind of the family at the time of our conversation. Sometimes that inhaler can’t be purchased right away because they have to pay the bills. Families can’t just pack up and move from their house because of violence in the neighborhood. We have scaffolded discussions with families based on their individual situation and personal needs. While the conversation may take longer, which is difficult in an era of medicine ruled by efficiency, in the end the discussions are more helpful to families because they are applicable to their current needs.

The art of communicating with patients and families 

When I talk with medical students working with me in the hospital, I frequently tell them that as the intern I wasn’t necessarily going to teach them the medicine of pediatrics. I focus their time on the art of communication with an emphasis on all the ways we use written and verbal language in a day. On a hospital medicine service with multiple young patients with asthma, disease classification varies, with some kids having their first exacerbation while others having their second or third in a month. In pre-rounding, students hear signout from a night colleague and check in with the nurse and respiratory therapist about the patient’s needs. On family-centered rounds, while the same general information is shared about the pathophysiology and anticipatory guidance for home, the nuance of the discussion is tailored to the family’s needs with family-friendly language. Depending on patient’s severity, there might be additional conversations with the pulmonologist about adjustments to the medication strategy. Adding to the goals of care is assessing the family’s health literacy to incorporate family-friendly language. The feasibility of the plan is important in the end because the family may not have the ability to follow-up with a pediatrician because of their work schedule or because they didn’t have access to one.

This approach incorporating an assessment of health literacy needs and use of scaffolded teaching is often an adjustment for the students; different from the formal medical presentation style they are accustomed to. While this is common across medicine, often the students do not realize the science and the skill of scaffolding in medicine and the importance of cultivating it for professional development in any specialty.

When I interviewed for medical school and residency, I talked about how teaching gave me the confidence in having scaffolded conversations with parents and children. But I didn’t yet appreciate how the art of conversation and the science of scaffolded teaching would be part of my day-to-day life as a pediatrician.

Five tips for how to scaffold conversations with both patients and families:

1.Recognize that it is an essential component of everyday conversations in medicine, be it with patients and families or other medical professionals; it is a skill that has to be understood and an art to be practiced and cultivated.

2.Understand non-medical family-friendly descriptions and plans as a part of your preparation before starting a conversation with families.

3.With patients and families, gaining a quick assessment of their knowledge and health literacy goes a long way to scaffolding the conversation to meet their needs.

4.Use techniques such as:

a.) Pictures or analogies to make connections

b.) Repetition and summarizing to highlight key points

c.) Teach back to assess for understanding

5.Appreciate classroom teachers in your life and have respect for their profession—scaffolding is a multiple times per class, multiple classes per day, everyday occurrence, and is not an easy skill to master.