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?

When words, and friends, fail

An essay in The New York Times today highlights the difficulty of going through a health crisis and having friends seemingly disappear. Psychologists are beginning to explore what people experience when they are witness to other's traumas. Part of the difficulty, is that words fail, and friends don't know what to say to a sick friend or how to help. The other difficulty is not so much a lack of empathy, but too much empathy. When a healthy friend can picture herself or her child as sick as the sick friend, it may give them cause to pull away from that friend in need.

Sometimes the right words and the right actions don't come naturally. But knowing our own fears and vulnerabilities may help us think twice and reach out to those in need.

The challenges of psychosocial research

An article in the New York Times today highlights some of the particular challenges of psychosocial research. The article discusses the challenges of personality analysis, specifically as it applies to research of generations. Is it possible to analyze and assess a collective generational personality? Are there flaws in how researchers try to measure personality, behavior and attitude?

Measuring attitude is a difficult task, because even at its best, you have what the participant says and some sort of scale or means of interpreting what it means. There is a lot of room for error: the participant may just say what he thinks the researcher wants to hear, the participant may says what is socially desirable, the researcher may interpret the responses incorrectly or the researcher may think he is measuring one thing when he is actually measuring something else. This is why different mechanisms for validating behavioral scales are so important. The work is extremely valuable in that it can teach us something about ourselves and how we approach our world. But it is indeed a challenge.

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.

Taking the patient into consideration when planning the medical home

Dr. Pauline Chen's article this week in the New York Times shows what happens when doctors and health systems make plans, but fail to consider the patients needs or even the patients reactions. The article examine the concept of the "patient-centered medical home," a team-based, comprehensive approach to preventative care, facilitated by electronic medical records. It sounds like an efficient system. But some practices implementing the system have found that patients do not understand and even dislike the system that was put in place to center around the patient. Now practices are playing catch-up by setting up patient advisory panels and other mechanisms for patient feedback.

The findings of the early medical home models demonstrates the importance of patient buy-in to any type of medical practice reform. Without patient buy-in, medical care comes to a sudden halt.

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.