The power of storytelling

My hometown newspaper The Milwaukee Journal-Sentinel ran a story today about the power of storytelling for patients and physicians. Letting patients talk longer and tell their story reveals more detail to physicians that can help them make a diagnosis. But it's not just talking to a doctor. Patients hearing the stories of other patients also helps them to think more about their own symptoms. The story and the studies it cites demonstrate the importance of communication in health care, not just doctors talking to patients, but doctors listening to patients and patients listening to peers.

Doctors lying to their patients

The Seattle Times and other outlets reported on the results of a physician survey published in Health Affairs this week that asks doctors about if and when they lie to their patients. According to the article, " Nearly 20 percent said they hadn't fully disclosed a medical mistake for fear of being sued. And 1 in 10 of those surveyed said they'd told a patient something that wasn't true in the past year."

The survey results point to the importance open communication by both doctors and patients. Doctors may feel they are ultimately helping the patient by lying or omitting information. Given that, it is particularly important for patients to be very clear about what and how much information they want. It is also important for physicians to realize that in order for patients to play an active role in their health care, they need honest and open information from their doctor.

Communication in the hospital

I have been away from the blog for a longer period than normal for a very difficult reason. My dad was in a serious motorcycle accident on August 3. He will recover but faces a very long recovery and rehabilitation.

I flew out to Portland the day I found out about the accident. I spent a little over a week with my mom at my Dad's bedside and witnessed physician communication, not in theory, but in practice. Two thoughts have stayed in my mind.

1. Be accessible. Perhaps I am naive, or perhaps it is because I work with primary care providers, but I was shocked, and at times annoyed, at how long we would go without even seeing a doctor. Now, I know the doctors are getting reports from nurses and residents and are aware of what is going on. I am also aware that if there was an immediate problem, the doctor would be right there. But I also know what a difficult situation my mother and I were in, and how many questions we had, and it was upsetting, at best, that we often had to chase down a physician to talk to someone about my dad's condition.

2. Be aware of timing when delivering difficult news. There has been some research on how physicians should break bad news, but I am talking more about timing and delivery. When we finally managed to get some face time with one particular doctor, a day after my dad had been transferred to a new facility, the doctor launched into a litany of possible problems and then dropped the bomb, "Oh yeah and he might be paralyzed. But we don't know yet." Paralysis is a very difficult thing for a love one to think about, especially a week after the accident when no one else has mentioned this possibility before. To just drop that into conversation, and try to say, "oh, but we don't know yet," is insensitive. But beyond that, it is ineffective communication because I can tell you my mom didn't hear much of the rest of what the doctor said after that. And I'm not saying he was wrong to say it. If that is a possibility, it should be discussed. But it could have been handled and communicated better.

Hospitals are there own world. Communication in this world is a particular challenge, given the anxieties, emotions and uncertainties. And as I have now seen firsthand, there is still room for improvement.

Communicating discharge instructions

An article in MedPage Today examines the importance of communicating discharge instructions to patients. Effective communication of discharge instructions can reduce readmission rates. Interventions and home visits can be especially effective in following up on discharge instructions. But the two studies featured showed low patient participation rates in follow-up programs are low.

It seems that the challenge is for physicians and nurses to communicate not one, but two things: 1. The importance of following discharge instructions, and 2. How follow-up plans can help with 1.

In addition to communicating clearly, physicians and nurses need to listen to patient and family questions and concerns in order to make discharge planning successful and reduce readmission rates.

Dumb things to do at the doctor's office

CNN.com's "Empowered Patient" feature had an article today about the dumb things patients do at doctor appointments. Seven of the 10 items on the list has to do with poor communication. Patients fail to state their real concerns, fail to ask questions and are afraid to speak up when they disagree with their doctor. So much health communication research focuses on what physicians should do to improve their communication with patients. This article is a nice reminder that communication is a 2-way street. Patients need to be strong communicators as well.

Doctors' struggle to show compassion

Dr. Manoj Jain, an infectious disease specialist in Memphis, reflects on the reasons physicians struggle to show patients compassion in an article in yesterday's Washington Post. But while there have been studies showing medical student losing compassion for patients in the course of their training, there is evidence that compassion can be effectively taught in physician training programs.

Compassion can perhaps be taught to physicians and health care providers in any number of ways. But compassion may ultimately come down to teaching physicians how to effectively communicate with patients in emotional circumstances. Doctors may feel compassion but may have a hard time expressing it. But training in compassionate communication, helping doctors come up with what exactly to say to a patient, may help them express the compassion they feel.

Soliciting questions

One of the most effective communication behaviors can engage in to assure patient understanding is to simply ask if the patient has any questions. There are a couple different techniques one could employ to accomplish this task, some of which more effective than others. The first is to simply ask: Do you have any questions? But this is what is called a close-ended question, one that can be answered with a yes or no. To solicit more than a one word answer, use an open-ended question: What questions do you have for me? An especially effective technique, though more time-consuming, is a request for teach-back, in which the physician asks the patient to repeat back what was just said, as a way of soliciting patient understanding and any underlying questions. "You may have to explain this result to your spouse or family members when you get home, just to make sure I did a good job explaining this, can you repeat back to me what we just talked about. Making the effort to encourage questions effectively engages the patient in the conversation and enables them to be an active participant in their own health care. Meanwhile, the Agency for Healthcare Research and Quality, contends questions are the answer.

Managing anxiety when talking about clinical research

I am looking forward to presenting later this month on the topic of communication and informed consent at the Association of Clinical Research Professionals Global Conference. I am going to be presenting on several different communication behaviors and theories, but I think one aspect of my presentation that may initially be surprising, though I hope will resonate, is the idea of Anxiety-Uncertainty Management. Anxiety-Uncertainty Management is actually an intercultural communication theory that examines communication between members of a given cultural group, and a "stranger" to that culture. Anxiety-Uncertainty Management contends that communication is effective when someone is able to effectively interpret the words and actions of the other person. But when a person is a stranger to the culture, they may not understand the words and actions of the other person, and thus may become anxious and unable to process the new information that they are receiving. A little bit of anxiety can be OK, and it may in fact be helpful. But when anxiety becomes overwhelming, communication suffers. It is pretty easy to see how this might play out in clinical research encounters. A potential research participant, who is new to the world of clinical research, may not be able to interpret the words and actions of the research coordinator, and because they do not understand what is going on, they may become so anxious, they are unable to process new information, such as an informed consent discussion. So what can research coordinators do? In order to create an environment where effective communication can take place, coordinators should help potential research participants manage their anxiety. They can do that by explaining who people are, what their jobs are, and what's going to happen. Take the mystery out of the clinical research experience. Because if they are able to manage their anxiety about the situation, then they will be able to have an effective conversation about participating in research.

Fear of colon cancer screening

The New York Times Well blog had a post today about the reason many people do not get recommended colon cancer screening: fear. The fact that so many cite fear as a reason for not getting or putting off the test presents a communication opportunity for physicians talking to their patients about colon cancer screening. Physicians should not downplay a patient's fears. but rather anticipate and validate emotions the patients may be feeling about the screening test. Take a few minutes to explore the emotion: is it fear of finding cancer or fear of complications from the test or something else? Communication can be the difference between a patient getting a needed test and not getting it.

Meanwhile, here's what Dave Barry had to say about getting a colonoscopy.

Communicating about religion in the hospital

An article in The New York Times Health section featured an article today about an article in the Journal of Medical Ethics, considering Muslim religious beliefs and how those beliefs may impact the delivery of health care. Muslims differ in adherence, but maintaining modesty is an overriding ethic, and may even cause some to delay care if they cannot get in to see a physician of the same gender.

While it may not always be possible to accommodate all religious requests, respect and communication can go a long way to facilitate trust between the physician and patient. It starts by the physician simply asking, either in person or in an intake form, what their religious concerns are and what can be done to make them more comfortable. Those conversations can be a good starting point for discussing what can be accommodated and what is necessary. A conversation, rather than a directive, will help the patient feel heard and cared for.

Communication through touch

The New York Times Well blog has an interesting discussion today about a recent JAMA essay. In the JAMA essay, a medical student contemplates even and when it is appropriate to hold a patient's hand. Some of the Well commenters were mystified that a medical student would even need to ask if it is appropriate to hold a patient's hand and show compassion. But in the current medical culture, students are taught to be very aware of how actions, even as simple an action as holding a hand, may be viewed.

It is the reality of physician-patient communication, that the physician may always have some level of concern about communication being misconstrued. And this fear has the real potential to limit high-quality communication between physician and patient. All communication involves some risk, the risk of being misunderstood. But a physician taking a risk and offering a hand to a patient at a difficult moment can mean the world to a patient.

Battlefield humor and patient-physician communication

Dr. Michael Khan explores the pervasiveness of "battlefield humor" in this week's New York Times Cases section. Beyond being dehumanizing, and just plain rude, demeaning humor used to describe patients may have a direct impact on communication with the patient and ultimately on patient care. If a physician automatically assumes that a patient's behavior is because of some character flaw, or because the patient is a "whale" or the patient's "crazy," the physician may miss a real symptom or indication. And the humor certainly creates a barrier to building a trusting relationship between physician and patient.

Physicians certainly work in a stressful environment and certainly not all of their patients are pleasant. But what are some alternative that physician might consider to this battlefield humor? How can communication scholars demonstrate the affect this humor has on patients?

Should you read your doctor's notes?

The Los Angeles Times had an interesting blog post today about the notes that physicians write in patient's charts. The patient's chart ultimately belongs to the patient, and so one hospital system is starting a new project where patients can access the notes in their chart by a secure Internet portal. But will being able to read these notes cause more harm than good? Will physicians be as candid in their notes if they know the patients will read them later? But, the notes can give patients insight into their illness and how the physician is approaching it.

It is an interesting discussion and it is one that will only continue as more clinics and hospitals convert to electronic medical records.

Two important aspects of communication

Our research team, even while plugging away on two population-scale communication research projects, is thinking about the future and how we can build on the projects we have already done. Our conversations led us to consider two important, but different, aspects of communication: content and conduct.

• Content is the "what" that is communicated.
• Conduct is "how" it is communicated.

It is especially important to consider both content and conduct when considering physician communication with patients. Is the physician giving correct information? Is the information appropriate for the stage of the conversation? But even if the content is correct, it is not enough if it is not communicated effectively. Does the physician use words the patient is likely to understand? Does the physician check in with the patient to see if the patient understands what is being said? Does the physician consider the patient's emotional reaction?

And so physician-patient communicators continue to seek way to measure and improve both the content and conduct of physician communication.

How hard should you try to convince a patient to do something?

The Wall Street Journal Health blog reported last week on an editorial in the Journal of the National Cancer Institute. The editorial considered whether it might be more worthwhile to invest money into improving cancer screening technologies such as mammograms, rather than spending that money on getting more patients to get existing, imperfect tests. Some patients may have a rational, logical and well thought-out reason for turning down an imperfect screening test. No amount of education campaigns is likely to change that decision.

The article points to a larger discussion of what the goal of physician counseling should be. Is the physician's goal to convince the patient to do what he or she wants the patient to do (i.e. get the screening test)? Or should the physician's goal be to simply counsel and educate the patient, and then let the patient make a decision? It is easy to say that the goal should be the latter, but in practice, this is difficult for both the physician and the patient. Physicians face the reality of practice standards and pay-for-performance schemes that say what tests a patient should get and when. And patients may not be willing to make difficult decisions or may make poor decisions no matter how much evidence is given to them. The task of counseling does not have any easy answers. But it seems that if 71% of women are getting a screening test, the reason the other 29% are not is not as simple as a lack of discussion.

A tangible piece of the conversation with your doctor

Things have been buzzing with our physician-patient communication research group. A new topic of interest is the use of brochures and handouts, a tangible piece the patient can take away from the conversation. Specifically, we are interested in looking at how brochures and handouts can be used to aid in the conversation. Perhaps brochures can help prompt comments from both the physician and the patient, as they read through the brochure together. And when the physician or the patient actually writes something on the brochure, it may help prompt recall of the conversation later.

What do you think? What makes a brochure or handout from a doctor useful? And what make it go straight in the garbage?

The problems patients have with reporting symptoms

The New York Times reported on a New England Journal of Medicine article about how patient-reported data about drug side effects can be a tremendous source of information. But physicians and patients often have trouble discussing potential side effects because of limited time in consultations and limited understanding of what side effects and their causes may be.

So we have a great potential source of data about emerging drugs. But we have a communication gap in getting that information from patients to doctors to researchers. Many hope that opening new lines of communication for patients to report symptoms they are unsure about to others may help facilitate the reporting process. Information coming directly from patients will increase understanding of new and emerging drugs and technologies. And giving patients another means of expressing their concerns helps the patients be heard as they pursue their own health care.

What doctors and patients are NOT talking about

The New York Times Well blog had an interesting article today about the issue that physicians and patients appear to not be talking about: a patient's weight. It is a difficult, but important, conversation to have. Weight plays a pivotal role in so many health issues. But physicians seem to not be bringing it up with their overweight patients. Some physicians may be embarrassed or may feel ill-equipped to make proper recommendations for weight loss. Some may just be discouraged that the advice will fall on deaf ears. Whatever the reason, failure to bring up this important health issues can have a real impact on the clinical relationship between physician and patient, as well as the interpersonal relationship. Patients know when they are overweight and if a physician doesn't bring it up or help discuss strategies for weight loss, the patient may feel like they are not getting the care they need. The weight-loss conversation may be difficult, but the alternative is worse.

Different priorities

The New York Times had an article this week about a paper in the Journal of General Internal Medicine examining what is sometimes a great disparity between physicians and patients: medical priorities. Physicians and patients often have different priorities for medical encounters, as well as different priorities for care of chronic conditions. The article is concrete evidence of the many anecdotes of failed patient-physician encounters. Physicians are failing to communicate with patients about the broader implications of symptoms and illnesses. Patients are failing to communicate their concerns and the reasons for their concerns. There is no easy answer to this dilemma, other than increased listening. But we all know, that is no simple task - for doctors or for patients.

Putting off difficult discussions

The New York Times had an article earlier this week about the difficulty physicians have with discussing end-of-life care treatment with terminal patients. The conversations are difficult, but important, and include such decisions as aggressiveness of treatment, resuscitation and hospice. Guidelines dictate that such discussions take place when the patient has a year left to live, so the patient can make decisions along with their families. But many physicians fail to have those conversations until much later. It is easier to suggest more treatment than to have a difficult conversation with a patient about his or her impending death. But failure to have those conversations may result in more aggressive treatment than a patient desires and death in a hospital when a patient would have preferred the comforts of home. While the conversations are difficult, physicians who learn to have these conversations help their patients live their last days as they wish.