Providing anticipatory guidance to children and adolescents.

Anticipatory guidance, a component of Bright Futures, refers to communicating with patients and caregivers to identify and provide information most needed. Providing reliable, appropriate, and culturally competent anticipatory guidance to children, adolescents, and their families at every visit is one of the most essential roles of a primary care provider. D etermining the right information for a specific patient can be quite challenging for a physician, given the large amount of information recommended by multiple agencies and various guidelines including those provided by Bright Futures [1]. Finding the best approach to providing anticipatory guidance for a patient and his or her family in a manner that respects their experience and knowledge is part of the art of medicine. It is not a skill learned quickly in an afternoon at a continuing medical education workshop. In my own practice, at every visit I ask every child and adolescent how they are doing in school. The most frequent response is " good, " with " fine " coming in a close second. I could easily write " good " in the note and move on. Because I know that school performance, and more important, changes in school performance and involvement, are markers for multiple health issues, I always follow up with the question " And what does 'good' mean in your family? " The question almost always opens up the conversation with both the patient and the family, allowing me to better understand the daily activities of the patient and to tailor anticipatory guidance to his or her specific needs. There are 2 essential steps in providing effective antici-patory guidance: talking with and listening to patients and families and taking the time to provide them with the information they need. Determining the needs of the patient and the family through questionnaires that they fill out before seeing you can be helpful. However, building the doctor-patient-family relationship through conversation is essential [2]. Conversations are based on open-ended questions. Too often, physicians instead want to move through a script for each visit. A direct observational study of 483 well-child visits with 52 providers using the Bright Futures guidelines demonstrated that fewer than half (38.9%) of the visits began with open-ended questions, and a quarter did not include any open-ended questions [3]. Although guidelines and questionnaires are of benefit, it is essential to view the well-child check as a conversation about the health of the …