Hear more about the research project I am on

Dr. Mike Farrell will be on Fox 6 Wake Up in Milwaukee on Monday October 2 to talk about his research project on improving physician counseling about newborn screening. So if you are in Milwaukee, and up at 6:50, tune in to channel 6 to learn more about this communication project. http://www.myfoxmilwaukee.com/

Empathy in communication

With physicians pressed for time, it can be difficult enough to effectively communicate with patients, let alone communicate with empathy. Most physicians realize it is important to speak empathetically, but many fail in their efforts.

One of the indicators of quality physician communication we are testing at MCW is empathy. One of the scales we looked at comes from Robert Smith, MD and his book The Patient's Story. Smith uses the mnemonic NURS to help physicians effectively empathize with patients.

Name the emotion: "That sounds sad for you."

Understand the patient's emotion: "I've never had this happen, but I can see how deeply it hurts."

Respect the patient's difficulties: "I like the way you've hung in there and kept fighting."

Support the patient and show this is a partnership: "I'm here to help any way I can. Together, you and I can get to the bottom of this."

Small steps can make a world of difference in making a patient feel confident in the words and actions of his or her physician.

Telling the patient's story

Jerry Brewer of The Seatttle Times has spent the last five months telling the story of an amazing little girl Gloria Strauss and her family. Gloria was fighting neuroblastoma, a vicious childhood cancer. The parents gave Jerry and The Seattle Times full access as they prayed for a miracle for their little girl. They wanted to tell their story. They wanted to share their faith that gave them strength, their hope, their love. Jerry Brewer kept a reporter's journal where he recorded his thoughts on telling this life-changing and career-changing story. http://seattletimes.nwsource.com/html/localnews/2003897807_gloria23.html

Brewer said, "I could have written this series many different ways. I could have focused on the medical side of this vexing disease. I could have focused on the suffering. I could have focused on how a father with a sick child, a wife with multiple sclerosis and six other children struggled as the family's only source of income.

But this had to be about faith.

If I had written about the experience any other way, I would have either ignored or de-emphasized the most pivotal part of the Strausses' lives."

Brewer captured what many families and patients want in their last days. They want their story told. They want to be heard with compassion.

And thanks to The Seattle Times and Jerry Brewer, we all got to share in Gloria's story.

I think I get it now

I have been in a number of health communication forums and seminars where the topic of conversation will come to public relations and the media. Many scientists and medical researchers have a contentious relationship with the media. They admire the idea of disseminating their research to the public, but they hate the way journalists oversimplify the significance of their findings. Journalists don't seem to appreciate nuance and degrees of change. Public relations officials don't fare much better. Medical schools and private foundations love to promote the life-altering research they fund, but the public relations people exaggerate and paint things in such a way to generate media buzz, and in the process lose the true meaning of the results found.

Given my own journalistic background, I always nodded sympathetically at these scientists' lament. But I tried to defend the journalists and p.r. professionals. "They are working with a limited amount of print space." "They have to get the readers attention." "Most newspapers aim for a sixth grade reading level."

But I think I get it now. I have been working on a community outreach event at the Medical College. Our goal is to bring community members in for an awareness event to get community leaders input on our upcoming project to improve communication with parents about newborn screening. But the p.r. hacks are more concerned about what we can do to get t.v. crews there. I don't really care about t.v. crews. I want to publicize the event to the public so that we can get some input and support from the people our project most affects. It's about the research effort and making a difference in the lives of patients. It's not about looking good for the camera.

I get the frustration now.

Why does a doctor need good communication skills?

One of the first things I did when I started my job at the Medical College was to check out the library's selection of books on communication. There were of course a selection of books on topics such health communication case studies and media campaigns as an important element of public health. But many of the communication books targeted at doctors make the argument that effective communication lowers the risk of malpractice lawsuits. It's true of course. People generally don't sue doctors they trust and people generally trust doctors who are effective and empathic communicators. But is that the reason we want and need doctors to be better communicators? Don't we want doctors to be better communicators so they will provide better care?

I imagine I am not the only communication scholar who feels conflicted about this. We know that many physicians are kind empathic people who want to do what is best for patients. And physicians want their patients to understand what they need to know to improve their own health. But let's face it, in this era of managed care and our litigious society, the best way to get a physician's attention is to say "Hey, do this, be a better communicator and you'll have less of a chance of getting sued!" Besides, these books do offer some practical tips, if a bit simplistic. Anything that gets physicians to think twice about their communication skills should be welcomed.

The next generation of doctors

Our Toastmaster's club was invited to give a presentation today to a group of medical students about improving your public speaking skills. The group that invited us to speak was the Asian Pacific American Medical Student Association, so we were expecting the crowd to be quite a few non-native English speakers, but we were impressed by how many American students were there. They seemed to realize that public speaking skills are important to their profession and that they need to build those skills and were willing to give up their lunch hour to learn more (though the fact that the club had food helps).

Ellen, a seasoned Toastmaster, started things off by talking about getting over the fear of public speaking. My assignment was to talk about impromptu speaking, which is relevant to these soon-to-be doctors because they will often find themselves in an impromptu speaking situation when a patient asks an unexpected question. I tried to integrate research about physician-patient communication into my talk, including the 1984 Annals of Internal Medicine study which found that doctors usually only wait on average 18 seconds before interrupting a patient who is talking (JAMA replicated the study in 1999 and they had improved to 23 seconds). The students seemed receptive and appreciative of the presentation. I even got a few brave souls to practice an impromptu speaking exercise.

When I told my boss what I was doing today, he said: "Tell them the two most important things are to think before you speak and to listen. Some students, and even some doctors, never seem to get that." It made me feel good to see that perhaps the next generation of doctors will keep trying to improve communication skills.

Making difficult decisions in the genetic age

A colleague at the Medical College told me about this article that ran in the Sunday New York Times about the difficult decisions patients sometimes are faced with in the era of genetics http://www.nytimes.com/2007/09/16/health/16gene.html?ex=1347681600&en=ead2468f0794dcd8&ei=5124&partner=permalink&exprod=permalink.

As researchers continue to identify the genes linked to particular diseases, ordinary people are left with some extremely difficult decisions. If you know you have a family history of a disease, do you get yourself tested for the gene? What will you do if you find out you do have the gene for a disease? Are you ready to subject yourself to life-altering surgery to prevent a disease you found out you have a 60 percent chance of developing in your lifetime? What if it was a 90 percent chance? What if you find out you carry the gene for a disease for which there is no cure? Then what?

The article also shows the family dynamics of a genetic disease. If someone finds out he or she is a carrier for a disease, it potentially impacts the members of his or her family, even if the family member never wanted to know. These lead to difficult family discussions as family members struggle to come to terms with their shared family history and how the decisions one family member makes can impact the whole family.

Presented with the option of knowing your risk for a disease makes it all the more important to have a doctor you feel comfortable talking to and asking questions. Having a doctor to answer your questions can help you make a well-informed decision and prepare you to face the consequences, whatever the results may be.

Numeracy in health care

Many scholars who study physician communication are concerned about the words physicians use and whether patients can understand those words. Indeed, words are important, but an often over-looked part of communication is how physicians use, and patients interpret, numbers.

One of the doctors in my department at the Medical College of Wisconsin has just received a grant from the NIH to develop a measure of health numeracy. Numeracy is one of the concepts the Institute of Health highlights in its definition of health literacy, but is often overlooked in traditional health literacy research. How patients interpret numbers is important in everything from understanding doses of medicine to the assessing riskiness of a surgical procedure. And I imagine, not many doctors stop and think about how the patients understand the numbers they hear in the course of a visit.

The topic reminded me of a pair of books by John Allen Paulos: Innumeracy: Mathematical Illiteracy and its Consequences and A Mathematician Reads the Newspaper. These are both great books to make you think about the consequences of a society that doesn't comprehend numbers. And it's not just about simple math, but being able to use and apply mathematics in situations such as risk and probability. It is an important alarm that we all need to sharpen our numeracy skills. And physicians need to take the time to make sure their patients are numerically literate.

Health news at the New York Times

Here's another web site aimed at the active health care consumer. The New York Times Health Section http://health.nytimes.com/.

Many patients are becoming more engaged in seeking health care information. And the Internet is filled with information, some, of course, of dubious quality. But the NYT section impressed me with its 3,000+ article archive of news stories about health topics, in a useful search database. It also offers stories on health care policy and health care financing, as one would expect from The New York Times.

Nothing can replace dialogue with a trusted physician, but it is always good to have an additional source of information.

The Mystery of Breathing

I was suprised to see a novel about a competitive neonatal physician at an elite academic hospital described as a "psychological thriller." But that is exactly what The Mystery of Breathing by Perri Klass is. The novel delves into the life of Dr. Maggie Claymore, a gifted neonatal physician in line for a coveted promotion, when an annonymous hate campaign threatens to derail her career. She works in a higly competitive world and the hate campaign not only causes her colleagues to quietly question her credentials, but the events shake Maggie's own deepest sense of her self.

The novel takes the reader between the events unfolding in Maggie's life to the defining events in Maggie's childhood and young adulthood that brought her to where she is. The author manages to articulate the combination of childhood events, adult ambitions and human emotions that mold our very being. And our ability to control who we are and how the world perceives us is fragile indeed.

I was not at all suprised to see that Perri Klass is a practicing pediatrician. You just can't make up the intricacies and oddities of academic medicine. Because of that insight, and the searing look into a women's ambition and soul, The Mystery of Breathing is indeed a gripping psychological thriller.

Distrust and communication in health care

It seems that at least some of the problems with communication in health care come down to distrust. Some people may not disclose information to their doctor because they feel like they can't trust their doctor. If the patient withholds information, the doctor may not have all the information they need to make a diagnosis. If a doctor senses a patient is not being being honest, he or she may be more guarded with the information he or she shares with the patient. And the communication problem perpetuates.

This is even a larger problem when it comes to medical research. Because of past medical research atrocities, such as the Tuskegee syphilis studies, many African Americans are inherently distrustful of medical research. I am now in the process of beginning some outreach efforts for our communication research project at MCW and because it involves sickle cell trait, we have to be even more deliberate in our efforts to reach out to the community. In the past, some have used sickle cell disease and even sickle cell trait as a reason to discriminate against African Americans for certain jobs, so it is easy to see why some people may potentially question our motives for wanting to talk to people about sickle cell disease.

This distrust of the medical establishment is ultimately one of the reasons why physician-patient communication research is so important. Better communication and better understanding can lead to greater trust between patients and physicians.

The Facebook/ MySpace of Health Care

From the same people who brought you Wikipedia, we have Wikidoc http://www.wikidoc.org/index.php/Main_Page. They call themselves the Facebook/ MySpace of Health Care.

When I was teaching I ranted at my students about the evils of Wikipedia, but I have since softened a bit. It is of course not a legitimate primary source, but Wikipedia and Wikidoc are powerful examples of the potential of the Internet as a portal for sharing information. And Wikidoc offers a compelling set of health information for those in the medical profession and lay people seeking information for their own health.

Wikidoc does have more stringent guidelines for editors than Wikipedia, requiring prospective editors to submit a CV. It will be interesting to watch how much they get in contributions, since doctors and academics are usually more worried about publishing in peer-reviewed journals than open-source web sites.

Talking with a white coat

For a lay audience, doctor-patient communication is not some abstract academic concept. It is real life. It is sitting in a stranger's office in a paper gown in an unladylike position and this stranger is using lots of big, unfamiliar words. Even the best-educated, most well-intended among us can get flustered in such a situation.

So for a recent speech at Toastmasters, I offered some tips for how to effectively talk to your doctor. The speech was well-received and I even won best speaker for the evening.

Talking with a white coat

At Toastmasters, we like to think we are all reasonably intelligent and articulate people. But even the most articulate person can be reduced to babbling when confronted with the prospect of talking to a doctor.

Let’s face it: the long wait times and embarrassing questions make many people dread having a one-on-one conversation with a virtual stranger about the most personal of issues: your own health and well-being.

Well no more. Today I will be sharing some strategies for how to successfully and effectively talk to you doctor so you can be an active partner in your care.

We’ll start with some strategies before you even get to the doctor, then some effective ideass for what to do and say once you get to the doctor’s office, and then we will talk about strategies for effective follow-up.

Your preparations for your doctor’s visit begin long before you arrive in the parking lot of your doctor’s office. To begin, make a list of all your questions and concerns. From that list, you are going to prioritize and then create a summary statement. This summary statement is a summary of your main, driving reason for coming the doctor’s office that day. You want to be able to state your primary concern in one or two sentences. Your statement should be specific, be clear, and be brief. For example, “Doctor, I am here today because I have has worsening heartburn over the last two weeks and over-the-counter medications do not seem to be helping.” The reason why it is important to be specific, clear and brief is because communication scholars have found that doctors, on average, usually only wait about 18-23 seconds before interrupting a patient who is talking. So you want to use that time wisely and make sure your primary concern is heard.

If you are going to you doctor to discuss a serious issue, consider bringing a family member or trusted friend with you. The reason for this is cognitive psychologists have found that people who are hearing stressful news may not actually hear everything that is being told to them. That’s why it can be helpful to have someone else also listening to the doctor with you who you can talk to again after the initial shock has worn off. If you do not have someone who can come with you, ask your doctor’s permission to use a personal tape recorder to record the conversation, so you can refer to the tape again later.

And of course, anytime you do to the doctor, you should always bring a list of all your medications and the doses, because if your doctor doesn’t have this information already, he or she is going to want it.

The day of the big doctor’s appointment arrives, and first things first, you need to follow the rules. Arrive on time, if not a little bit early. If you absolutely need to cancel you appointment, give your clinic 24 hours notice, or whatever the policy is for your clinic. The reason this is important is it conveys your respect to the doctor and shows you are serious about playing an active part in your medical care. Also, make sure you have everything you need for your visit, including your list of medications and your insurance cards or any forms you need you doctor to fill out.

Have realistic expectations of your doctor. Your doctor is not a miracle worker, and there is no magic pill to treat every ill. Sometimes it takes time to come to a diagnosis and effective treatment plan. So be patient and be realistic.

Don’t say things that set up barriers to communication, such as: “Doctors never listen” or “All you doctors are pill-pushers,” or “Those HMOs are just out to screw the little guy.” These kind of statements may just make your doctor defensive and will not encourage him or her to be open and honest with you and engage you as an active partner in you health care. He or she will just be in a bigger hurry to get you out of the office.

Be clear about your major concern – what is bringing you in today. Use your summary statement that you prepared ahead of time. Be brief and be clear. Remember the 23 second average; you may not have a lot of time, so you want to use it well.

When you doctor speaks, listen carefully. Taking notes may help. Cognitive psychologists have found that for some people, the act of writing information down can help people process information more than just listening. Plus, you will have a reference for later.

Repeat back key points that your doctor says to make sure you understand. For instance, you may say, “OK doctor, I’m hearing you say this…” If you are correct, the doctor will say so. If you do not repeat it back correctly, the doctor will correct you and perhaps rephrase the information so you can better understand what he or she is saying.

When your doctor asks questions, be honest. Your doctor needs as complete a picture of your health as possible. And to be an active and engaged partner in your health care, you need to be open and honest. While it may be tempting to be idealistic when it comes to questions such as how often you exercise or how many vegetables you eat or how much you drink, it is more important to be honest than idealistic.

Before you leave, make sure you understand what your doctor expects you to do next. If your doctor needs you to get lab tests, make sure you know when and where to get them. If you need a new prescription, make sure you understand the dose and when and how you should be taking it.

If you don’t think you can follow the regimen your doctor has prescribed, speak up before you leave. For example, if you don’t think you will be able to remember to take a medicine three times a day, say so. The doctor may be able to help you come up with another solution. It’s better to let your doctor know that you don’t think you will be able to follow through with a regimen than to just not do it, which can create barriers to the future of your relationship with your doctor.

After you get home from your doctor’s appointment, your work is not quite done yet. Review your notes or tape recording right away. If possible, review your notes with another person. Cognitive psychologists have found that teaching a piece of information to another person can help you retain and understand the information better.

Follow up with your doctor right away if there is something you don’t understand. Sometimes people are embarrassed to call so soon after their appointment. They don’t want to be seen as a nuisance or a bother. But you and your doctor are partners in achieving your best health, and you need to understand the information your doctor has given you if you are going to be an active partner in your care. When you call, often times, there is a nurse or doctor on call who may be able to answer your question over the phone. If not, they will be able to get a hold of your doctor, who can answer your question. So if you find something you do not understand or remember a question you forgot to ask, don’t hesitate to call.

So the next time you get a little reminder postcard in the mail reminding you it’s time to make a doctor’s appointment, or a change in your health you can’t ignore causes you to finally make the call to see your doctor, you don’t need to be intimidated about that conversation with the man or woman in the white coat. With proper preparation, a clear and brief summary of your health concerns, careful listening and immediate follow-up, you can speak effectively and confidently with your doctor, as you work together to achieve what you both want: your good health.

Patients and direct-to-consumer prescription drug advertising

In continuing with my introduction from last night, tonight I am sharing the abstract of a research project I conducted in 2004-05 while a graduate student at Marquette University. This paper won the faculty/MA student symposium best paper competition in 2005. http://www.marquette.edu/comm/grad/symposium_papers.shtml

Patients exerting control with their physician: Bringing direct-to-consumer prescription drug advertising into the conversation

Introduction - With the burgeoning of direct-to-consumer prescription drug advertising, patients can bring in more information from outside sources to the conversation with their physician than ever before. My study examines the potential impact of direct-to-consumer prescription drug advertising on the relationship between patients and physicians.

Theory - The study was guided by relational control theory, which says that conversation partners assert control through patterns of conversation. Relational control stems from the notion that interactional partners assert control through patterns of conversation indicating who is in charge.

Hypothesis - It is expected that patients who bring information about a specific drug to the conversation will exert more control during the conversation. It is expected that patients, who realize the advertisements are produced by the pharmaceutical companies and not government health agencies, will use that information as part of the conversation by asking more questions about their health care.

Data analysis - I examined my hypothesis by analyzing data from a 2001-02 Harvard Medical School survey on the public health impact of prescription drug advertising. I specifically examined responses that indicated that a prescription drug advertisement had caused a respondent to take some action and their satisfaction with the outcome.

Discussion – Patients are indeed asking their physicians questions based on prescription drug advertisements and those questions are not just limited to asking about a specific drug. Satisfaction with the interactions about a drug is relatively high and indicates that patients are satisfied with how their physicians handle their health concerns.

Nurse religiosity and relational control

As a means of introduction to my new blog, I am posting the abstract of the poster I will be presenting next month at the International Conference on Communication in Healthcare http://www.aachonline.org/programs/internationalconference/ I will try to post a pdf of the poster itself once it is finalized.

The impact of nurses’ religiosity on their willingness to relinquish relational control in conversations with patients about end-of-life care

Introduction - Nurses and physicians are taught to approach communication in the clinical setting in a task-oriented manner, but discussions about certain topics such as end-of-life care may bring up personal religious values. The study attempts to examine how religious beliefs may influence patterns of communication in the clinical environment. The study was grounded by relational control theory, which says that conversation partners assert control through patterns of conversation indicating who is in charge. Previous studies indicate it is helpful for patients to have some control of conversations, but medical providers do not always relinquish control.

Hypothesis – It is hypothesized that nurses that are higher in intrinsic religiosity will be more willing to relinquish control. Clinician empathy is expected to be an intervening variable, diminishing the impact of intrinsic religiosity on willingness to relinquish control.

Method – An online census survey was administered to the graduate students in the school of nursing at a Midwestern university. The survey was designed to measure: relational control, as measured by the subscales of dominance and task orientation in Burgoon and Hale’s scale of relational communication; clinician empathy, as measured by the Jefferson scale of clinician empathy; and intrinsic and extrinsic religiosity, whether religious views are held for deep personal reasons or social reasons, as measured by the Maltby and Lewis scale, designed for religious and non-religious samples. Data were analyzed using multiple regressions and one-way ANOVAs.

Results and Implications – Intrinsic religiosity and empathy were both associated with the willingness to relinquish relational control in certain contexts. Many clinicians with intrinsic religious beliefs are willing to let patients guide their own care. Some respondents struggled with the language used on the relational control scales, so future research should consider different methods and language sensitive to the clinical culture to measure relational control in clinician-patient interactions.