Denise Napoli

WASHINGTON — An empathetic disclosure that a medical error has occurred, accompanied by a genuine apology, may help avoid a malpractice lawsuit, according to Dr. Neil S. Prose, director of pediatric dermatology at Duke University Medical Center, Durham, N.C.

On an almost daily basis, doctors are called on to deal with patient disappointment. Some cases involve medical mistakes and others do not. In any case, “How we communicate with patients and their families is really half of the work we do as doctors, and the other half is diagnosis and treatment,” Dr. Prose said at an annual meeting of the American Academy of Dermatology. “Unfortunately, we spend a lot of time on diagnosis and treatment and never talk about what we say to patients and how they respond, and so a whole half of our lives is neglected.”

In a presentation designed by the Institute for HealthcareCommunication (formerly the Bayer Institute), a nonprofit group dedicated to improving communication between physicians and patients, Dr. Prose discussed empathetic ways of speaking with patients when they have experienced disappointing outcomes, either with or without a medical mistake on the health care provider's behalf. He stressed, however, that his recommendations are generic skills and that, when appropriate, the counsel of a lawyer or risk management team should be heeded:

▸ Create the right setting. Close the door and make sure that the room is quiet. If possible, turn off any phones or pagers. Sit down. Offering the apology while seated, rather than standing, can aid in the patient's eventual acceptance of the apology.

▸ Be as sincere and specific as possible. In addition to telling the truth about what happened—whether the mistake is a botched biopsy or something more serious—Dr. Prose said that offering a sincere and simple apology can make a huge difference. Also, specificity is crucial. Saying, “I'm sorry that your family has been through so much pain this last week as a result of this procedure” is preferable to “I'm sorry this happened.”

Dr. Prose added, “Saying 'I wish things were different' is a wonderful way to create an alliance with the patient and his or her family.”

▸ Have a plan. A pledge to correct the mistake also is important. “People want to know how you're going to prevent this from happening again. You want to have a plan before you go in the room,” he said.

▸ Be aware of your own feelings. Often, the fear of confrontation and the desire to rectify the situation as quickly as possible can prevent physicians from taking into account their own feelings about the situation. “Wanting to run away is a natural response. You have to be aware of how you're feeling before you walk in the room [with a patient]. We have to be knowledgeable about ourselves and our own natural tendencies.” Being either defensive or overly despondent, for instance, can alienate the patient and his or her family. “Seek a balance by knowing who you are and what you tend to do,” he advised, including knowing “what kinds of patients drive you crazy.

“For those of us who internalize [mistakes] and lose sleep over them, you have to be able to talk to yourself and say, 'I'm trying to be a good doctor, and now I'm going to try and do my best to make the situation right.' It's hard sometimes. It's a struggle,” Dr. Prose said.

▸ Be a good listener. “Our biggest pitfall [as physicians] is trying to talk people out of the way they're feeling,” he said. “Listen before giving advice, and relisten to the story, as much as you don't want to hear it.”

▸ Get permission to proceed. Finally, after telling the truth and listening patiently, “you reach a point where you actually ask permission before moving on. Say, 'Would this be an okay time for me to tell you what I think we should do next?' That process has a remarkable effect,” Dr. Prose said.

'How we communicate with patients and their families is really half of the work we do as doctors.' DR. PROSE

WASHINGTON — An empathetic disclosure that a medical error has occurred, accompanied by a genuine apology, may help avoid a malpractice lawsuit, according to Dr. Neil S. Prose, director of pediatric dermatology at Duke University Medical Center, Durham, N.C.

On an almost daily basis, doctors are called on to deal with patient disappointment. Some cases involve medical mistakes and others do not. In any case, “How we communicate with patients and their families is really half of the work we do as doctors, and the other half is diagnosis and treatment,” Dr. Prose said at an annual meeting of the American Academy of Dermatology. “Unfortunately, we spend a lot of time on diagnosis and treatment and never talk about what we say to patients and how they respond, and so a whole half of our lives is neglected.”

In a presentation designed by the Institute for HealthcareCommunication (formerly the Bayer Institute), a nonprofit group dedicated to improving communication between physicians and patients, Dr. Prose discussed empathetic ways of speaking with patients when they have experienced disappointing outcomes, either with or without a medical mistake on the health care provider's behalf. He stressed, however, that his recommendations are generic skills and that, when appropriate, the counsel of a lawyer or risk management team should be heeded:

▸ Create the right setting. Close the door and make sure that the room is quiet. If possible, turn off any phones or pagers. Sit down. Offering the apology while seated, rather than standing, can aid in the patient's eventual acceptance of the apology.

▸ Be as sincere and specific as possible. In addition to telling the truth about what happened—whether the mistake is a botched biopsy or something more serious—Dr. Prose said that offering a sincere and simple apology can make a huge difference. Also, specificity is crucial. Saying, “I'm sorry that your family has been through so much pain this last week as a result of this procedure” is preferable to “I'm sorry this happened.”

Dr. Prose added, “Saying 'I wish things were different' is a wonderful way to create an alliance with the patient and his or her family.”

▸ Have a plan. A pledge to correct the mistake also is important. “People want to know how you're going to prevent this from happening again. You want to have a plan before you go in the room,” he said.

▸ Be aware of your own feelings. Often, the fear of confrontation and the desire to rectify the situation as quickly as possible can prevent physicians from taking into account their own feelings about the situation. “Wanting to run away is a natural response. You have to be aware of how you're feeling before you walk in the room [with a patient]. We have to be knowledgeable about ourselves and our own natural tendencies.” Being either defensive or overly despondent, for instance, can alienate the patient and his or her family. “Seek a balance by knowing who you are and what you tend to do,” he advised, including knowing “what kinds of patients drive you crazy.

“For those of us who internalize [mistakes] and lose sleep over them, you have to be able to talk to yourself and say, 'I'm trying to be a good doctor, and now I'm going to try and do my best to make the situation right.' It's hard sometimes. It's a struggle,” Dr. Prose said.

▸ Be a good listener. “Our biggest pitfall [as physicians] is trying to talk people out of the way they're feeling,” he said. “Listen before giving advice, and relisten to the story, as much as you don't want to hear it.”

▸ Get permission to proceed. Finally, after telling the truth and listening patiently, “you reach a point where you actually ask permission before moving on. Say, 'Would this be an okay time for me to tell you what I think we should do next?' That process has a remarkable effect,” Dr. Prose said.

'How we communicate with patients and their families is really half of the work we do as doctors.' DR. PROSE

WASHINGTON — An empathetic disclosure that a medical error has occurred, accompanied by a genuine apology, may help avoid a malpractice lawsuit, according to Dr. Neil S. Prose, director of pediatric dermatology at Duke University Medical Center, Durham, N.C.

On an almost daily basis, doctors are called on to deal with patient disappointment. Some cases involve medical mistakes and others do not. In any case, “How we communicate with patients and their families is really half of the work we do as doctors, and the other half is diagnosis and treatment,” Dr. Prose said at an annual meeting of the American Academy of Dermatology. “Unfortunately, we spend a lot of time on diagnosis and treatment and never talk about what we say to patients and how they respond, and so a whole half of our lives is neglected.”

In a presentation designed by the Institute for HealthcareCommunication (formerly the Bayer Institute), a nonprofit group dedicated to improving communication between physicians and patients, Dr. Prose discussed empathetic ways of speaking with patients when they have experienced disappointing outcomes, either with or without a medical mistake on the health care provider's behalf. He stressed, however, that his recommendations are generic skills and that, when appropriate, the counsel of a lawyer or risk management team should be heeded:

▸ Create the right setting. Close the door and make sure that the room is quiet. If possible, turn off any phones or pagers. Sit down. Offering the apology while seated, rather than standing, can aid in the patient's eventual acceptance of the apology.

▸ Be as sincere and specific as possible. In addition to telling the truth about what happened—whether the mistake is a botched biopsy or something more serious—Dr. Prose said that offering a sincere and simple apology can make a huge difference. Also, specificity is crucial. Saying, “I'm sorry that your family has been through so much pain this last week as a result of this procedure” is preferable to “I'm sorry this happened.”

Dr. Prose added, “Saying 'I wish things were different' is a wonderful way to create an alliance with the patient and his or her family.”

▸ Have a plan. A pledge to correct the mistake also is important. “People want to know how you're going to prevent this from happening again. You want to have a plan before you go in the room,” he said.

▸ Be aware of your own feelings. Often, the fear of confrontation and the desire to rectify the situation as quickly as possible can prevent physicians from taking into account their own feelings about the situation. “Wanting to run away is a natural response. You have to be aware of how you're feeling before you walk in the room [with a patient]. We have to be knowledgeable about ourselves and our own natural tendencies.” Being either defensive or overly despondent, for instance, can alienate the patient and his or her family. “Seek a balance by knowing who you are and what you tend to do,” he advised, including knowing “what kinds of patients drive you crazy.

“For those of us who internalize [mistakes] and lose sleep over them, you have to be able to talk to yourself and say, 'I'm trying to be a good doctor, and now I'm going to try and do my best to make the situation right.' It's hard sometimes. It's a struggle,” Dr. Prose said.

▸ Be a good listener. “Our biggest pitfall [as physicians] is trying to talk people out of the way they're feeling,” he said. “Listen before giving advice, and relisten to the story, as much as you don't want to hear it.”

▸ Get permission to proceed. Finally, after telling the truth and listening patiently, “you reach a point where you actually ask permission before moving on. Say, 'Would this be an okay time for me to tell you what I think we should do next?' That process has a remarkable effect,” Dr. Prose said.

'How we communicate with patients and their families is really half of the work we do as doctors.' DR. PROSE

WASHINGTON — The Bush administration is seeking to promote health care price and quality transparency through its new Value-Driven Health Care Initiative.

The initiative, which will certify and support regional collaboratives of health care payers, providers, and purchasers, was announced by Department of Health and Human Services Secretary Michael Leavitt at a press briefing sponsored by the journal Health Affairs.

Participants in the program's collaborative groups, called Value Exchanges, will share practices for improving quality with fellow members through a federally funded learning network, for which $4 million has been earmarked in the proposed 2008 federal budget. Providers who can demonstrate improved transparency and quality are also likely to reap rewards from payers.

Mr. Leavitt gave as an example one private insurer affiliated with a pilot Value Exchange in California that paid out $50 million to physicians who had met certain standards of care.

Insurers “rewarded the quality practice. But if you don't have a standard way of measuring [quality], then those [bonuses] are not able to be developed or executed,” he said.

Dr. John Tooker, executive vice president and chief executive officer of the American College of Physicians (ACP), said that it is too soon to determine the success of the pilot programs.

“The [level of physician] engagement in the program will determine how much value is to be derived from the program,” Dr. Tooker said. However, “you've got to start somewhere. The ACP and many other medical societies have been supportive of moving the evidence-based performance measures into meaningful field testing. … These Value Exchanges provide an opportunity to test these measures.”

Quality standards by which care will be measured are being formulated by physician groups. Leadership from groups such as the ACP, the Society for Thoracic Surgery, and the American Academy of Family Physicians, as well as the American Medical Association's Physician Consortium for Performance Improvement, will provide the basis, said Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality. “This is what the profession believes is the best science.”

The program will use national measures of quality, but it will be governed locally.

Local control is important for two reasons, Mr. Leavitt said. The first deals with the initial collection of medical records with which the program would develop comparisons between providers. “Until we have a robust system of electronic health records, the [process of acquiring] this information is essentially going in and looking at medical records—most of the time, paper records—to determine what quality is and when it occurs. That, by its very nature, is local.”

The second reason why local facilitation is important has to do with trust, he said. “This is a very significant change and it requires people to work together collaboratively in order to be comfortable. [Doctors] will be much less likely to work with Washington, where they can't affect the process [rather than with local networks].”

To become a Value Exchange, a collaborative must submit an application to the HHS that details its adherence to four “cornerstones” of the program. In addition to the adoption of an electronic medical records system, these include public reporting of performance, public reporting of price, and the support of incentives to reward quality and value.

Mr. Leavitt sketched a rough timeline for widespread adoption of the program.

“Five years from now, the word 'value' will be a regular part of the medical lexicon,” he said. “Ten years from now, this network will have matured into a national network.” He added that for this widespread collection and pooling of data to occur, “electronic medical records, as you can see, have to be the backbone of this system.”

WASHINGTON — The Bush administration is seeking to promote health care price and quality transparency through its new Value-Driven Health Care Initiative.

The initiative, which will certify and support regional collaboratives of health care payers, providers, and purchasers, was announced by Department of Health and Human Services Secretary Michael Leavitt at a press briefing sponsored by the journal Health Affairs.

Participants in the program's collaborative groups, called Value Exchanges, will share practices for improving quality with fellow members through a federally funded learning network, for which $4 million has been earmarked in the proposed 2008 federal budget. Providers who can demonstrate improved transparency and quality are also likely to reap rewards from payers.

Mr. Leavitt gave as an example one private insurer affiliated with a pilot Value Exchange in California that paid out $50 million to physicians who had met certain standards of care.

Insurers “rewarded the quality practice. But if you don't have a standard way of measuring [quality], then those [bonuses] are not able to be developed or executed,” he said.

Dr. John Tooker, executive vice president and chief executive officer of the American College of Physicians (ACP), said that it is too soon to determine the success of the pilot programs.

“The [level of physician] engagement in the program will determine how much value is to be derived from the program,” Dr. Tooker said. However, “you've got to start somewhere. The ACP and many other medical societies have been supportive of moving the evidence-based performance measures into meaningful field testing. … These Value Exchanges provide an opportunity to test these measures.”

Quality standards by which care will be measured are being formulated by physician groups. Leadership from groups such as the ACP, the Society for Thoracic Surgery, and the American Academy of Family Physicians, as well as the American Medical Association's Physician Consortium for Performance Improvement, will provide the basis, said Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality. “This is what the profession believes is the best science.”

The program will use national measures of quality, but it will be governed locally.

Local control is important for two reasons, Mr. Leavitt said. The first deals with the initial collection of medical records with which the program would develop comparisons between providers. “Until we have a robust system of electronic health records, the [process of acquiring] this information is essentially going in and looking at medical records—most of the time, paper records—to determine what quality is and when it occurs. That, by its very nature, is local.”

The second reason why local facilitation is important has to do with trust, he said. “This is a very significant change and it requires people to work together collaboratively in order to be comfortable. [Doctors] will be much less likely to work with Washington, where they can't affect the process [rather than with local networks].”

To become a Value Exchange, a collaborative must submit an application to the HHS that details its adherence to four “cornerstones” of the program. In addition to the adoption of an electronic medical records system, these include public reporting of performance, public reporting of price, and the support of incentives to reward quality and value.

Mr. Leavitt sketched a rough timeline for widespread adoption of the program.

“Five years from now, the word 'value' will be a regular part of the medical lexicon,” he said. “Ten years from now, this network will have matured into a national network.” He added that for this widespread collection and pooling of data to occur, “electronic medical records, as you can see, have to be the backbone of this system.”

WASHINGTON — The Bush administration is seeking to promote health care price and quality transparency through its new Value-Driven Health Care Initiative.

The initiative, which will certify and support regional collaboratives of health care payers, providers, and purchasers, was announced by Department of Health and Human Services Secretary Michael Leavitt at a press briefing sponsored by the journal Health Affairs.

Participants in the program's collaborative groups, called Value Exchanges, will share practices for improving quality with fellow members through a federally funded learning network, for which $4 million has been earmarked in the proposed 2008 federal budget. Providers who can demonstrate improved transparency and quality are also likely to reap rewards from payers.

Mr. Leavitt gave as an example one private insurer affiliated with a pilot Value Exchange in California that paid out $50 million to physicians who had met certain standards of care.

Insurers “rewarded the quality practice. But if you don't have a standard way of measuring [quality], then those [bonuses] are not able to be developed or executed,” he said.

Dr. John Tooker, executive vice president and chief executive officer of the American College of Physicians (ACP), said that it is too soon to determine the success of the pilot programs.

“The [level of physician] engagement in the program will determine how much value is to be derived from the program,” Dr. Tooker said. However, “you've got to start somewhere. The ACP and many other medical societies have been supportive of moving the evidence-based performance measures into meaningful field testing. … These Value Exchanges provide an opportunity to test these measures.”

Quality standards by which care will be measured are being formulated by physician groups. Leadership from groups such as the ACP, the Society for Thoracic Surgery, and the American Academy of Family Physicians, as well as the American Medical Association's Physician Consortium for Performance Improvement, will provide the basis, said Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality. “This is what the profession believes is the best science.”

The program will use national measures of quality, but it will be governed locally.

Local control is important for two reasons, Mr. Leavitt said. The first deals with the initial collection of medical records with which the program would develop comparisons between providers. “Until we have a robust system of electronic health records, the [process of acquiring] this information is essentially going in and looking at medical records—most of the time, paper records—to determine what quality is and when it occurs. That, by its very nature, is local.”

The second reason why local facilitation is important has to do with trust, he said. “This is a very significant change and it requires people to work together collaboratively in order to be comfortable. [Doctors] will be much less likely to work with Washington, where they can't affect the process [rather than with local networks].”

To become a Value Exchange, a collaborative must submit an application to the HHS that details its adherence to four “cornerstones” of the program. In addition to the adoption of an electronic medical records system, these include public reporting of performance, public reporting of price, and the support of incentives to reward quality and value.

Mr. Leavitt sketched a rough timeline for widespread adoption of the program.

“Five years from now, the word 'value' will be a regular part of the medical lexicon,” he said. “Ten years from now, this network will have matured into a national network.” He added that for this widespread collection and pooling of data to occur, “electronic medical records, as you can see, have to be the backbone of this system.”

WASHINGTON — Simple techniques can smooth the dermatologic surgery experience and outcomes for children, Dr. Brandie J. Metz said at the annual meeting of the American Academy of Dermatology.

For instance, while it may seem obvious to explain a procedure as thoroughly as possible without scaring the child, it's also important not to lie about any aspect of the procedure, to remain especially "bright and friendly" throughout the discussion, and to engage the child in discussion as much as possible.

Sitting at or below the level of the child can also help put him or her at ease, the dermatologic surgeon said.

Dr. Metz, of the University of California, Irvine, also recommended having the child's parent sit at the head of the table during a procedure and obscuring the child's view of the surgical tray and any blood-soaked gauze.

When it comes to injections, slow infiltration is less painful than rapid infiltration, she said.

It can also help to use topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA) or 4% liposomal lidocaine (ELA-Max) to numb the area before injection. Technically, topical anesthetics do not need to be occluded, but "it doesn't seem wise to put a big glob of cream on a kid and then let [him] run around without occluding it," Dr. Metz said.

A nurse—not a parent—should be the one to restrain the child if he or she is squirming or very frightened.

"A lot of [children's] impressions of pain and anxiety are based on past experiences," she said. So for more extensive procedures in young children, "consider doing them under general anesthesia," even if that means referring the child to a pediatric dermatologist or a plastic surgeon.

After the operation is over, Dr. Metz said, "No matter how disastrous it was, always praise the child."

Also, reward the child with stickers, lollipops, or other treats to facilitate selective memory.

Pay special attention to dressings. If possible, let the child pick the color of the dressing before surgery, then make the dressing as bulky as possible.

"If you do a biopsy on an adult scalp, you might just need a little bit of antibiotic ointment," she said.

But with a child, "I'll often use a much larger dressing [than is needed], because this can be helpful in enforcing postoperative activity restrictions. There is generally not much discomfort or pain, so you kind of [need to] remind them that there's something there," Dr. Metz advised.

An oversized dressing also can help ensure that the child's experience is not minimized, Dr. Metz pointed out, adding that many children will need a note excusing them from physical education classes and after-school sports.

"It's also helpful to give them printed-out postoperative instructions," she added.

Dr. Metz said that 2-octyl cyanoacrylate tissue adhesives such as Dermabond also can be used to close wounds that would otherwise require up to a 5–0 suture.

These types of adhesives are especially beneficial for squirmy children and toddlers, and there is no need for a follow-up visit.

The wound can also get wet.

On the other hand, she cautioned that the cost—approximately $30 per vial—and the fact that it can be picked off or inadvertently dissolved by petrolatum-based products, are drawbacks.

Dr. Metz pointed out that the resilience of children is not to be underestimated.

"I'm surprised every time at how quickly kids bounce back after a procedure," she said.

"It may have gone terribly, but afterward they just bounce back. It really makes postoperative care a breeze," she commented.

WASHINGTON — Simple techniques can smooth the dermatologic surgery experience and outcomes for children, Dr. Brandie J. Metz said at the annual meeting of the American Academy of Dermatology.

For instance, while it may seem obvious to explain a procedure as thoroughly as possible without scaring the child, it's also important not to lie about any aspect of the procedure, to remain especially "bright and friendly" throughout the discussion, and to engage the child in discussion as much as possible.

Sitting at or below the level of the child can also help put him or her at ease, the dermatologic surgeon said.

Dr. Metz, of the University of California, Irvine, also recommended having the child's parent sit at the head of the table during a procedure and obscuring the child's view of the surgical tray and any blood-soaked gauze.

When it comes to injections, slow infiltration is less painful than rapid infiltration, she said.

It can also help to use topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA) or 4% liposomal lidocaine (ELA-Max) to numb the area before injection. Technically, topical anesthetics do not need to be occluded, but "it doesn't seem wise to put a big glob of cream on a kid and then let [him] run around without occluding it," Dr. Metz said.

A nurse—not a parent—should be the one to restrain the child if he or she is squirming or very frightened.

"A lot of [children's] impressions of pain and anxiety are based on past experiences," she said. So for more extensive procedures in young children, "consider doing them under general anesthesia," even if that means referring the child to a pediatric dermatologist or a plastic surgeon.

After the operation is over, Dr. Metz said, "No matter how disastrous it was, always praise the child."

Also, reward the child with stickers, lollipops, or other treats to facilitate selective memory.

Pay special attention to dressings. If possible, let the child pick the color of the dressing before surgery, then make the dressing as bulky as possible.

"If you do a biopsy on an adult scalp, you might just need a little bit of antibiotic ointment," she said.

But with a child, "I'll often use a much larger dressing [than is needed], because this can be helpful in enforcing postoperative activity restrictions. There is generally not much discomfort or pain, so you kind of [need to] remind them that there's something there," Dr. Metz advised.

An oversized dressing also can help ensure that the child's experience is not minimized, Dr. Metz pointed out, adding that many children will need a note excusing them from physical education classes and after-school sports.

"It's also helpful to give them printed-out postoperative instructions," she added.

Dr. Metz said that 2-octyl cyanoacrylate tissue adhesives such as Dermabond also can be used to close wounds that would otherwise require up to a 5–0 suture.

These types of adhesives are especially beneficial for squirmy children and toddlers, and there is no need for a follow-up visit.

The wound can also get wet.

On the other hand, she cautioned that the cost—approximately $30 per vial—and the fact that it can be picked off or inadvertently dissolved by petrolatum-based products, are drawbacks.

Dr. Metz pointed out that the resilience of children is not to be underestimated.

"I'm surprised every time at how quickly kids bounce back after a procedure," she said.

"It may have gone terribly, but afterward they just bounce back. It really makes postoperative care a breeze," she commented.

WASHINGTON — Simple techniques can smooth the dermatologic surgery experience and outcomes for children, Dr. Brandie J. Metz said at the annual meeting of the American Academy of Dermatology.

For instance, while it may seem obvious to explain a procedure as thoroughly as possible without scaring the child, it's also important not to lie about any aspect of the procedure, to remain especially "bright and friendly" throughout the discussion, and to engage the child in discussion as much as possible.

Sitting at or below the level of the child can also help put him or her at ease, the dermatologic surgeon said.

Dr. Metz, of the University of California, Irvine, also recommended having the child's parent sit at the head of the table during a procedure and obscuring the child's view of the surgical tray and any blood-soaked gauze.

When it comes to injections, slow infiltration is less painful than rapid infiltration, she said.

It can also help to use topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA) or 4% liposomal lidocaine (ELA-Max) to numb the area before injection. Technically, topical anesthetics do not need to be occluded, but "it doesn't seem wise to put a big glob of cream on a kid and then let [him] run around without occluding it," Dr. Metz said.

A nurse—not a parent—should be the one to restrain the child if he or she is squirming or very frightened.

"A lot of [children's] impressions of pain and anxiety are based on past experiences," she said. So for more extensive procedures in young children, "consider doing them under general anesthesia," even if that means referring the child to a pediatric dermatologist or a plastic surgeon.

After the operation is over, Dr. Metz said, "No matter how disastrous it was, always praise the child."

Also, reward the child with stickers, lollipops, or other treats to facilitate selective memory.

Pay special attention to dressings. If possible, let the child pick the color of the dressing before surgery, then make the dressing as bulky as possible.

"If you do a biopsy on an adult scalp, you might just need a little bit of antibiotic ointment," she said.

But with a child, "I'll often use a much larger dressing [than is needed], because this can be helpful in enforcing postoperative activity restrictions. There is generally not much discomfort or pain, so you kind of [need to] remind them that there's something there," Dr. Metz advised.

An oversized dressing also can help ensure that the child's experience is not minimized, Dr. Metz pointed out, adding that many children will need a note excusing them from physical education classes and after-school sports.

"It's also helpful to give them printed-out postoperative instructions," she added.

Dr. Metz said that 2-octyl cyanoacrylate tissue adhesives such as Dermabond also can be used to close wounds that would otherwise require up to a 5–0 suture.

These types of adhesives are especially beneficial for squirmy children and toddlers, and there is no need for a follow-up visit.

The wound can also get wet.

On the other hand, she cautioned that the cost—approximately $30 per vial—and the fact that it can be picked off or inadvertently dissolved by petrolatum-based products, are drawbacks.

Dr. Metz pointed out that the resilience of children is not to be underestimated.

"I'm surprised every time at how quickly kids bounce back after a procedure," she said.

"It may have gone terribly, but afterward they just bounce back. It really makes postoperative care a breeze," she commented.