Dealing with Anxious Parents While on Call

One of the hardest parts of pediatrics after the trauma of residency is trying to figure out patients you don’t know and can’t see at 3 a.m. when you’re on call from home. And among these stressful calls, one of the hardest is dealing with parents calling because they’re anxious.

Sometimes, they’re anxious because the child is really sick and, of course, that’s one of the scariest parts. You are anxious, too, not to miss sending to the emergency room a child who really requires it.

But what about the parent who is more anxious than their child’s illness warrants?

Sometimes, this is a child with a very complicated medical problem, and neither you nor the parents can really tell how sick they are. Children in that category include medically fragile children with a tracheostomy, or preemies and children with serious neurologic problems such as autism or profound mental retardation who react in idiosyncratic ways to illness and really can’t report their symptoms.

Sometimes, the problem is that the caller doesn’t know the child very well: their 4-day-old infant, or, worse yet, a preemie with complicated medical problems.

One of the most aggravating calls is from a person who doesn’t take care of the child very much – the new foster parent or a grandparent. It might even be the father, but he usually promptly hands the phone to the mother!

The newest anxious group is people who scared themselves silly by listening to the fear-mongering evening news or well-meaning friends or Dr. Google, and their nerves finally peak in the middle of the night. They need education, but we just wish they could hold their questions until the morning!

Like many practices around the country, I care for parents from myriad cultures. Different cultures historically view certain illnesses with more concern (diarrhea in Africa can kill), tend to be overly anxious about their children in general, or have different expectations of what they think the availability of doctors should be. In Russia, one gets care by showing up early and banging on the counter until being seen.

So why do they call at 3 a.m. – the worst possible time as it falls in the lighter early morning sleep cycles, effectively making it impossible to get back to sleep even if the case isn’t serious at all?

I’m hearing from parents who have just gotten home, and discover that their child is sick. They deal with their guilt for not being there by calling for advice.

Another newer trend in my practice is the parent who has to leave for work at 4 a.m. and needs to determine at 3 a.m. whether they should go to work that day or not. Some parents may not even be aware that you’re not sitting there awake at a desk waiting for their call!

But there are other reasons that people are up at 3 a.m. thinking about their child and his illness. One of them is that no one is there to help them stay calm and think rationally. The lonely silence of the night is scary for everyone.

But I think the most common reason for a call that turns out not to be urgent is that the parent is anxious by disposition. And one of the inherent characteristics of anxiety is a brain that rapidly goes to the worst-case scenario. It’s not only appropriate, but actually necessary to ask (tactfully) what it was about the child or their situation that made the parents call at that time. Rather than being reluctant to ask this potentially confrontational question, think of it as an important opportunity to gauge the severity of their concerns. When they say, "I thought she was handling the wheezing okay with the nebs, but now she looks like she is struggling," any disgruntlement you felt will disappear. On the other hand, if they say "The rash Dr. Jones said was from the virus spread down onto her stomach," you have a different task.

One of the biggest differences of dealing with an anxious parent when you are on call is that you probably don’t know her or her judgment abilities, and she doesn’t know you or have a history of trusting you.

So how do you quickly establish a relationship that allows you to both determine the child’s degree of illness and provide enough reassurance so that you can go back to sleep?

Of course, determining severity is a skill gained from clinical experience. Does it fit a pattern of illness? What illnesses are going around? If it were the worst case in your differential diagnosis, how bad could it be to make it wait? In the back of your mind might also be whether this sounds like someone who might sue you, which is another reason to make good notes while on call.

Several of the steps that allow you to successfully reassure the caller are the same as those you need to make a good assessment. I like to speak to the child himself, if he is old enough. Not only is this good medicine and reassuring to you when he says happily that he is just watching a little TV, but it also reassures the parent that you really care about what’s going on and are collecting all the relevant data.

Collecting more data is an important way to calm down an anxious parent, allow her to gather her thoughts, and also let her know that you’re taking her seriously. Her anxiety extends from fear of illness to fear that she won’t be able to get the care she thinks her child needs. Asking the parent to push around on the belly of the crying baby, time respirations, take the temperature, send a photo of the rash, or try a dose of ibuprofen and then call you back engages the parent in action that itself reduces anxiety.

As a last resort, you might ask to speak with someone (less anxious) who was there earlier when the symptoms began or who just isn’t so upset.

So, I know what you’re thinking at 3 a.m. – or at least I know what I’m thinking. How can I get off the phone as quickly as possible?

As an experienced clinician, you may know in the first second, hearing that barking cough in the background, what the problem is. But giving advice at that point often backfires because the parent thinks you are brushing him off.

Believe it or not, one of the best, most efficient ways to reassure an anxious parent is to take an exhaustive history of the illness, moment by moment. This is important because it reassures the parent that you’re taking his concerns seriously. Otherwise, he feels compelled to repeat and rephrase or raise other concerns until he is convinced that you understand. This technique has actually been measured to take only 2 minutes or so and to be faster than responding to individual questions.

After you’ve heard the story, it’s best to provide "echoing" or active listening, reflecting back the key items of content, but also to gauge the parent’s emotions. "When he coughs so hard that he vomits, it can make you worry that he might stop breathing" might be an example of wording. This does not plant new fears (he already owns all of the worst ones), but instead, if you have guessed wrong about the extent of his concern, he will reassure you!

Asking what she’s afraid might happen and also what other people are saying about the symptoms or have told her to do, can be the key to a satisfied caller. Often, there’s a grandparent in the background who is spreading worry around, suggesting folk remedies or criticizing the parent, and the call is really for a second opinion or back up for the decision the parent has already made.

The next step is to go over your differential diagnosis so that she knows that you thought about the bad stuff that’s in the back of her mind, be it appendicitis or Lyme disease. Explain your reasoning for the course of action you propose she take between now and the morning. Be sure to make a plan that includes what she should be looking for to determine whether things are getting better or worse. Reviewing the details of what she should do, even coaching her to write it down, is also a way to keep her from calling you back 45 minutes later when you finally fall back to sleep!

Finally, there sits Pandora’s Box. It’s very important to ask, "Is there anything else you are worried about right now?" when anxiety seems to be out of proportion to the symptoms she is describing. Unexplainable anxiety sometimes indicates domestic violence, suicidal ideation, or child abuse about-to-happen that could be prevented. A call about a child’s symptoms is the only way some people know to cry for help.

Always offer anxious parents the option of going to the emergency department. Some families may be afraid that you’re blocking their access or won’t approve an ED visit to their insurance. As long as they are worried about that, they will hype up their complaints to make sure that they have that opportunity.

But what to do about the fact that it is 3:15 a.m. and now you are angry? Anger not only interferes with your judgment, but is likely to keep you awake for the rest of the night. It helps me to remember that people call because they’re either scared or lacking information about child health or both.

To address gaps in knowledge, after you’ve come up with a plan, it’s reasonable to tactfully educate the parent about alternatives to ringing up the on-call doctor. The message that parents hear on our after-hours call number includes a reminder to check our practice website for answers, if it all possible, before paging us. There are instructions on the website about common illnesses, basic care, and guidelines for when to call. Introducing those supports has greatly reduced the number of calls we get at night.

Keep in mind that both the parent’s strong emotions and yours come from a dedication to taking good care of the child. And in cases in which the child isn’t the real reason for the call, they likely have another very significant problem making them raise an alarm.

Sometimes, we physicians don’t do a good job taking care of ourselves in the service process. If you have a lot of trouble being exhausted from being on call, consider negotiating a better call schedule, such as being off the next morning or simply spacing out your call nights in a different way.

Some other things that you can do to experience less distress about anxious parents in the middle the night is to look in the record, if it’s a patient from your practice, or contact their primary care doctor to find out more about the family and why they might have made a call when it didn’t seem warranted. That may or may not make you more sympathetic but will definitely make you better prepared next time you’re on call when you’re pretty likely hear from them again.

Debriefing aggravating calls with a colleague also can be helpful in several ways. Just having a chance to ventilate can relieve stress. Sometimes, a colleague will see things in the case that you didn’t. In any case, it will help prepare them for that same anxious parent the next time they are on call!

Finally, follow up with the family to find out how the illness turned out. You may even hear an apology for that 3 a.m. call or, better yet, a thank you!

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert for Frontline Medical Communications. E-mail her at pdnews@elsevier.com.

One of the hardest parts of pediatrics after the trauma of residency is trying to figure out patients you don’t know and can’t see at 3 a.m. when you’re on call from home. And among these stressful calls, one of the hardest is dealing with parents calling because they’re anxious.

Sometimes, they’re anxious because the child is really sick and, of course, that’s one of the scariest parts. You are anxious, too, not to miss sending to the emergency room a child who really requires it.

But what about the parent who is more anxious than their child’s illness warrants?

Sometimes, this is a child with a very complicated medical problem, and neither you nor the parents can really tell how sick they are. Children in that category include medically fragile children with a tracheostomy, or preemies and children with serious neurologic problems such as autism or profound mental retardation who react in idiosyncratic ways to illness and really can’t report their symptoms.

Sometimes, the problem is that the caller doesn’t know the child very well: their 4-day-old infant, or, worse yet, a preemie with complicated medical problems.

One of the most aggravating calls is from a person who doesn’t take care of the child very much – the new foster parent or a grandparent. It might even be the father, but he usually promptly hands the phone to the mother!

The newest anxious group is people who scared themselves silly by listening to the fear-mongering evening news or well-meaning friends or Dr. Google, and their nerves finally peak in the middle of the night. They need education, but we just wish they could hold their questions until the morning!

Like many practices around the country, I care for parents from myriad cultures. Different cultures historically view certain illnesses with more concern (diarrhea in Africa can kill), tend to be overly anxious about their children in general, or have different expectations of what they think the availability of doctors should be. In Russia, one gets care by showing up early and banging on the counter until being seen.

So why do they call at 3 a.m. – the worst possible time as it falls in the lighter early morning sleep cycles, effectively making it impossible to get back to sleep even if the case isn’t serious at all?

I’m hearing from parents who have just gotten home, and discover that their child is sick. They deal with their guilt for not being there by calling for advice.

Another newer trend in my practice is the parent who has to leave for work at 4 a.m. and needs to determine at 3 a.m. whether they should go to work that day or not. Some parents may not even be aware that you’re not sitting there awake at a desk waiting for their call!

But there are other reasons that people are up at 3 a.m. thinking about their child and his illness. One of them is that no one is there to help them stay calm and think rationally. The lonely silence of the night is scary for everyone.

But I think the most common reason for a call that turns out not to be urgent is that the parent is anxious by disposition. And one of the inherent characteristics of anxiety is a brain that rapidly goes to the worst-case scenario. It’s not only appropriate, but actually necessary to ask (tactfully) what it was about the child or their situation that made the parents call at that time. Rather than being reluctant to ask this potentially confrontational question, think of it as an important opportunity to gauge the severity of their concerns. When they say, "I thought she was handling the wheezing okay with the nebs, but now she looks like she is struggling," any disgruntlement you felt will disappear. On the other hand, if they say "The rash Dr. Jones said was from the virus spread down onto her stomach," you have a different task.

One of the biggest differences of dealing with an anxious parent when you are on call is that you probably don’t know her or her judgment abilities, and she doesn’t know you or have a history of trusting you.

So how do you quickly establish a relationship that allows you to both determine the child’s degree of illness and provide enough reassurance so that you can go back to sleep?

Of course, determining severity is a skill gained from clinical experience. Does it fit a pattern of illness? What illnesses are going around? If it were the worst case in your differential diagnosis, how bad could it be to make it wait? In the back of your mind might also be whether this sounds like someone who might sue you, which is another reason to make good notes while on call.

Several of the steps that allow you to successfully reassure the caller are the same as those you need to make a good assessment. I like to speak to the child himself, if he is old enough. Not only is this good medicine and reassuring to you when he says happily that he is just watching a little TV, but it also reassures the parent that you really care about what’s going on and are collecting all the relevant data.

Collecting more data is an important way to calm down an anxious parent, allow her to gather her thoughts, and also let her know that you’re taking her seriously. Her anxiety extends from fear of illness to fear that she won’t be able to get the care she thinks her child needs. Asking the parent to push around on the belly of the crying baby, time respirations, take the temperature, send a photo of the rash, or try a dose of ibuprofen and then call you back engages the parent in action that itself reduces anxiety.

As a last resort, you might ask to speak with someone (less anxious) who was there earlier when the symptoms began or who just isn’t so upset.

So, I know what you’re thinking at 3 a.m. – or at least I know what I’m thinking. How can I get off the phone as quickly as possible?

As an experienced clinician, you may know in the first second, hearing that barking cough in the background, what the problem is. But giving advice at that point often backfires because the parent thinks you are brushing him off.

Believe it or not, one of the best, most efficient ways to reassure an anxious parent is to take an exhaustive history of the illness, moment by moment. This is important because it reassures the parent that you’re taking his concerns seriously. Otherwise, he feels compelled to repeat and rephrase or raise other concerns until he is convinced that you understand. This technique has actually been measured to take only 2 minutes or so and to be faster than responding to individual questions.

After you’ve heard the story, it’s best to provide "echoing" or active listening, reflecting back the key items of content, but also to gauge the parent’s emotions. "When he coughs so hard that he vomits, it can make you worry that he might stop breathing" might be an example of wording. This does not plant new fears (he already owns all of the worst ones), but instead, if you have guessed wrong about the extent of his concern, he will reassure you!

Asking what she’s afraid might happen and also what other people are saying about the symptoms or have told her to do, can be the key to a satisfied caller. Often, there’s a grandparent in the background who is spreading worry around, suggesting folk remedies or criticizing the parent, and the call is really for a second opinion or back up for the decision the parent has already made.

The next step is to go over your differential diagnosis so that she knows that you thought about the bad stuff that’s in the back of her mind, be it appendicitis or Lyme disease. Explain your reasoning for the course of action you propose she take between now and the morning. Be sure to make a plan that includes what she should be looking for to determine whether things are getting better or worse. Reviewing the details of what she should do, even coaching her to write it down, is also a way to keep her from calling you back 45 minutes later when you finally fall back to sleep!

Finally, there sits Pandora’s Box. It’s very important to ask, "Is there anything else you are worried about right now?" when anxiety seems to be out of proportion to the symptoms she is describing. Unexplainable anxiety sometimes indicates domestic violence, suicidal ideation, or child abuse about-to-happen that could be prevented. A call about a child’s symptoms is the only way some people know to cry for help.

Always offer anxious parents the option of going to the emergency department. Some families may be afraid that you’re blocking their access or won’t approve an ED visit to their insurance. As long as they are worried about that, they will hype up their complaints to make sure that they have that opportunity.

But what to do about the fact that it is 3:15 a.m. and now you are angry? Anger not only interferes with your judgment, but is likely to keep you awake for the rest of the night. It helps me to remember that people call because they’re either scared or lacking information about child health or both.

To address gaps in knowledge, after you’ve come up with a plan, it’s reasonable to tactfully educate the parent about alternatives to ringing up the on-call doctor. The message that parents hear on our after-hours call number includes a reminder to check our practice website for answers, if it all possible, before paging us. There are instructions on the website about common illnesses, basic care, and guidelines for when to call. Introducing those supports has greatly reduced the number of calls we get at night.

Keep in mind that both the parent’s strong emotions and yours come from a dedication to taking good care of the child. And in cases in which the child isn’t the real reason for the call, they likely have another very significant problem making them raise an alarm.

Sometimes, we physicians don’t do a good job taking care of ourselves in the service process. If you have a lot of trouble being exhausted from being on call, consider negotiating a better call schedule, such as being off the next morning or simply spacing out your call nights in a different way.

Some other things that you can do to experience less distress about anxious parents in the middle the night is to look in the record, if it’s a patient from your practice, or contact their primary care doctor to find out more about the family and why they might have made a call when it didn’t seem warranted. That may or may not make you more sympathetic but will definitely make you better prepared next time you’re on call when you’re pretty likely hear from them again.

Debriefing aggravating calls with a colleague also can be helpful in several ways. Just having a chance to ventilate can relieve stress. Sometimes, a colleague will see things in the case that you didn’t. In any case, it will help prepare them for that same anxious parent the next time they are on call!

Finally, follow up with the family to find out how the illness turned out. You may even hear an apology for that 3 a.m. call or, better yet, a thank you!

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert for Frontline Medical Communications. E-mail her at pdnews@elsevier.com.

One of the hardest parts of pediatrics after the trauma of residency is trying to figure out patients you don’t know and can’t see at 3 a.m. when you’re on call from home. And among these stressful calls, one of the hardest is dealing with parents calling because they’re anxious.

Sometimes, they’re anxious because the child is really sick and, of course, that’s one of the scariest parts. You are anxious, too, not to miss sending to the emergency room a child who really requires it.

But what about the parent who is more anxious than their child’s illness warrants?

Sometimes, this is a child with a very complicated medical problem, and neither you nor the parents can really tell how sick they are. Children in that category include medically fragile children with a tracheostomy, or preemies and children with serious neurologic problems such as autism or profound mental retardation who react in idiosyncratic ways to illness and really can’t report their symptoms.

Sometimes, the problem is that the caller doesn’t know the child very well: their 4-day-old infant, or, worse yet, a preemie with complicated medical problems.

One of the most aggravating calls is from a person who doesn’t take care of the child very much – the new foster parent or a grandparent. It might even be the father, but he usually promptly hands the phone to the mother!

The newest anxious group is people who scared themselves silly by listening to the fear-mongering evening news or well-meaning friends or Dr. Google, and their nerves finally peak in the middle of the night. They need education, but we just wish they could hold their questions until the morning!

Like many practices around the country, I care for parents from myriad cultures. Different cultures historically view certain illnesses with more concern (diarrhea in Africa can kill), tend to be overly anxious about their children in general, or have different expectations of what they think the availability of doctors should be. In Russia, one gets care by showing up early and banging on the counter until being seen.

So why do they call at 3 a.m. – the worst possible time as it falls in the lighter early morning sleep cycles, effectively making it impossible to get back to sleep even if the case isn’t serious at all?

I’m hearing from parents who have just gotten home, and discover that their child is sick. They deal with their guilt for not being there by calling for advice.

Another newer trend in my practice is the parent who has to leave for work at 4 a.m. and needs to determine at 3 a.m. whether they should go to work that day or not. Some parents may not even be aware that you’re not sitting there awake at a desk waiting for their call!

But there are other reasons that people are up at 3 a.m. thinking about their child and his illness. One of them is that no one is there to help them stay calm and think rationally. The lonely silence of the night is scary for everyone.

But I think the most common reason for a call that turns out not to be urgent is that the parent is anxious by disposition. And one of the inherent characteristics of anxiety is a brain that rapidly goes to the worst-case scenario. It’s not only appropriate, but actually necessary to ask (tactfully) what it was about the child or their situation that made the parents call at that time. Rather than being reluctant to ask this potentially confrontational question, think of it as an important opportunity to gauge the severity of their concerns. When they say, "I thought she was handling the wheezing okay with the nebs, but now she looks like she is struggling," any disgruntlement you felt will disappear. On the other hand, if they say "The rash Dr. Jones said was from the virus spread down onto her stomach," you have a different task.

One of the biggest differences of dealing with an anxious parent when you are on call is that you probably don’t know her or her judgment abilities, and she doesn’t know you or have a history of trusting you.

So how do you quickly establish a relationship that allows you to both determine the child’s degree of illness and provide enough reassurance so that you can go back to sleep?

Of course, determining severity is a skill gained from clinical experience. Does it fit a pattern of illness? What illnesses are going around? If it were the worst case in your differential diagnosis, how bad could it be to make it wait? In the back of your mind might also be whether this sounds like someone who might sue you, which is another reason to make good notes while on call.

Several of the steps that allow you to successfully reassure the caller are the same as those you need to make a good assessment. I like to speak to the child himself, if he is old enough. Not only is this good medicine and reassuring to you when he says happily that he is just watching a little TV, but it also reassures the parent that you really care about what’s going on and are collecting all the relevant data.

Collecting more data is an important way to calm down an anxious parent, allow her to gather her thoughts, and also let her know that you’re taking her seriously. Her anxiety extends from fear of illness to fear that she won’t be able to get the care she thinks her child needs. Asking the parent to push around on the belly of the crying baby, time respirations, take the temperature, send a photo of the rash, or try a dose of ibuprofen and then call you back engages the parent in action that itself reduces anxiety.

As a last resort, you might ask to speak with someone (less anxious) who was there earlier when the symptoms began or who just isn’t so upset.

So, I know what you’re thinking at 3 a.m. – or at least I know what I’m thinking. How can I get off the phone as quickly as possible?

As an experienced clinician, you may know in the first second, hearing that barking cough in the background, what the problem is. But giving advice at that point often backfires because the parent thinks you are brushing him off.

Believe it or not, one of the best, most efficient ways to reassure an anxious parent is to take an exhaustive history of the illness, moment by moment. This is important because it reassures the parent that you’re taking his concerns seriously. Otherwise, he feels compelled to repeat and rephrase or raise other concerns until he is convinced that you understand. This technique has actually been measured to take only 2 minutes or so and to be faster than responding to individual questions.

After you’ve heard the story, it’s best to provide "echoing" or active listening, reflecting back the key items of content, but also to gauge the parent’s emotions. "When he coughs so hard that he vomits, it can make you worry that he might stop breathing" might be an example of wording. This does not plant new fears (he already owns all of the worst ones), but instead, if you have guessed wrong about the extent of his concern, he will reassure you!

Asking what she’s afraid might happen and also what other people are saying about the symptoms or have told her to do, can be the key to a satisfied caller. Often, there’s a grandparent in the background who is spreading worry around, suggesting folk remedies or criticizing the parent, and the call is really for a second opinion or back up for the decision the parent has already made.

The next step is to go over your differential diagnosis so that she knows that you thought about the bad stuff that’s in the back of her mind, be it appendicitis or Lyme disease. Explain your reasoning for the course of action you propose she take between now and the morning. Be sure to make a plan that includes what she should be looking for to determine whether things are getting better or worse. Reviewing the details of what she should do, even coaching her to write it down, is also a way to keep her from calling you back 45 minutes later when you finally fall back to sleep!

Finally, there sits Pandora’s Box. It’s very important to ask, "Is there anything else you are worried about right now?" when anxiety seems to be out of proportion to the symptoms she is describing. Unexplainable anxiety sometimes indicates domestic violence, suicidal ideation, or child abuse about-to-happen that could be prevented. A call about a child’s symptoms is the only way some people know to cry for help.

Always offer anxious parents the option of going to the emergency department. Some families may be afraid that you’re blocking their access or won’t approve an ED visit to their insurance. As long as they are worried about that, they will hype up their complaints to make sure that they have that opportunity.

But what to do about the fact that it is 3:15 a.m. and now you are angry? Anger not only interferes with your judgment, but is likely to keep you awake for the rest of the night. It helps me to remember that people call because they’re either scared or lacking information about child health or both.

To address gaps in knowledge, after you’ve come up with a plan, it’s reasonable to tactfully educate the parent about alternatives to ringing up the on-call doctor. The message that parents hear on our after-hours call number includes a reminder to check our practice website for answers, if it all possible, before paging us. There are instructions on the website about common illnesses, basic care, and guidelines for when to call. Introducing those supports has greatly reduced the number of calls we get at night.

Keep in mind that both the parent’s strong emotions and yours come from a dedication to taking good care of the child. And in cases in which the child isn’t the real reason for the call, they likely have another very significant problem making them raise an alarm.

Sometimes, we physicians don’t do a good job taking care of ourselves in the service process. If you have a lot of trouble being exhausted from being on call, consider negotiating a better call schedule, such as being off the next morning or simply spacing out your call nights in a different way.

Some other things that you can do to experience less distress about anxious parents in the middle the night is to look in the record, if it’s a patient from your practice, or contact their primary care doctor to find out more about the family and why they might have made a call when it didn’t seem warranted. That may or may not make you more sympathetic but will definitely make you better prepared next time you’re on call when you’re pretty likely hear from them again.

Debriefing aggravating calls with a colleague also can be helpful in several ways. Just having a chance to ventilate can relieve stress. Sometimes, a colleague will see things in the case that you didn’t. In any case, it will help prepare them for that same anxious parent the next time they are on call!

Finally, follow up with the family to find out how the illness turned out. You may even hear an apology for that 3 a.m. call or, better yet, a thank you!

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert for Frontline Medical Communications. E-mail her at pdnews@elsevier.com.