A Randomized Controlled Trial of The Impact of Parental Note Taking on the Effectiveness of Anticipatory Guidance: the Suzuki Music Model Applied to Urban Pediatrics

The importance of communicating effectively with families and children is not unique to medicine. In the field of child music education, research has shown that effective parental involvement is linked to musical achievement [1]. The Suzuki method of music education in particular emphasizes this involvement and regards an effective teacher-child-parent relationship as fundamental to learning [2]. Parental engagement both during the music lesion and at home is key, and parents are routinely encouraged to take notes during the lesson so they can accurately recall the instruction for practice at home [1]. The Suzuki method is based on the idea that this model of education can be used with any family in any environment [3]. We are interested to learn whether a similar approach can be applied to pediatric anticipatory guidance in an urban population.

Note taking has been shown to improve both memory and comprehension in a number of settings. In a study of memory aids, participants taking notes exhibited higher levels of accurate recall of information than participants using other techniques [4]. Another study demonstrated that participants who took notes and then had the notes to review had improved recall of information when compared to participants who were given written information to study but did not take notes themselves [5]. Even doodling has been shown to lead to improved memory and to aid with concentration [6]. Interestingly, patient or family note taking for retention of medical information has not been extensively studied.

A number of studies have been done to look at interventions to improve both the delivery of health information and the retention of the information provided. Randomized controlled trials have looked at the impact of specific training programs for providers [7] and at practice-wide changes in office systems [8], and have shown improvements in the amount and quality of guidance provided. A study looking at the impact of physician advice on behavior change found that patients who had received counseling by their physician prior to receiving related written materials had better recall of information and were more likely to share the materials with others when compared to patients who only received the written material with no counseling [9]. A study on information recall of instructions given in the emergency department for otitis media care showed that parents retained more information at one and three days after the encounter when they received either standardized verbal or written instructions, as opposed to the usual verbal instructions [10].

The effective delivery of health information plays a central role in pediatric primary care. In 1990, the Federal Maternal and Child Health Bureau, along with the American Academy of Pediatrics, launched Bright Futures, a set of health supervision guidelines for pediatric patients aged birth to 21 [11]. The guidelines, which provide a framework for well-patient care, emphasize a partnership between the healthcare team, the family, and the child and highlight a number of recommended topics to be covered at routine visits [12]. This is a standard curriculum for primary care in many pediatric residencies, including the Boston Combined Residency Program.

For many families, the first interaction with a healthcare provider for their child occurs during the newborn evaluation prior to discharge from the hospital. The newborn anticipatory guidance recommended by Bright Futures is divided into the five categories of family readiness, infant behaviors, feeding, safety, and routine newborn care [12]. Included in these topics are recommendations for counseling on prone sleeping position, or "back to sleep," breast feeding support, and car seat use, all of which have been shown to improve infant health and safety [13,14,15]. Despite the recommendations for newborn anticipatory guidance, a national survey of parents with young children showed that 38% of parents reported never having discussed newborn care with a healthcare provider [16]. The authors of the study comment that it is difficult to know whether a portion of these families received information but were unable to remember it at the time of the survey. In the same study, a perceived lack of information was correlated with decreased satisfaction with care. The parents who reported discussing fewer anticipatory guidance topics gave their providers lower overall ratings.