presentation

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CHAPTER 4 Provider–Patient Communication

For the purpose of this text, we are going to use the following as working definitions:

■ Active listening: Showing the other person in an interaction that you are listening through nonverbal cues like nodding, eye contact, and/or lean- ing toward the speaker; and by giving verbal feedback (restating what was heard, or by asking questions to assure accuracy)

■ Audience analysis: Assessing the other person in an interaction to deter- mine his or her first language, literacy, and education level—both ver- bal and written—in order to properly tailor a message to meet that person’s needs, expectations, and abilities to assimilate the information communicated

■ Closed-ended questions: Queries intended to gain specific responses, “How long have you had a cough?” or “Are you coughing up some- thing?” or “How high was your fever?” Generally used to limit the feed- back from the respondent and to obtain specific information sought by the communicator

■ Empowerment: Providing patients with information they can use to par- ticipate in their health care decision making

■ Narratives: The stories patients respond with in answer to open-ended questions, such as, “How are you doing?” or “How are you feeling today?”

■ Open-ended questions: Inquiries that encourage narratives—expanded responses—not short answers

■ N A R R A T I V E S

In American culture we use storytelling—narratives—to make sense of the world. We begin by reading and telling stories to infants about their parents, siblings, the family history, and so forth. We use oral histories and photos from

C o p y r i g h t 2 0 1 7 . S p r i n g e r P u b l i s h i n g C o m p a n y .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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66 Health Communication for Health Care Professionals

books to inform and engage. Throughout all aspects of American life, stories are used make sense of our lives. One of the major uses of narratives is discuss- ing health issues with friends and family.

Reflection 4.1. Think of a recent sickness, an upper respiratory illness (URI), sometimes called a “cold,” or a sore throat, and so forth. When you were discuss- ing how you felt and how your life was impacted (work, school, plans, etc.) with a friend or family member, how did you describe what you were experiencing or had experienced? Be as detailed as possible in your recounting of your part of the conversation.

Reflection 4.2. Think about the last time you went to a health care provider for an acute illness or injury. What happened when you tried to tell your story/narrative? Did the provider allow you to describe it as you wanted? Or did he or she stop you (interrupt) with questions? If the latter, how did the interruptions make you feel about the information exchange with your provider?

So, the narrative discussion of your signs and symptoms is typical of most interpersonal communication between individuals in a dyadic discussion. For example, it generally is not atypical to hear two friends discuss an illness as follows:

Jill: “Hi, how are you doing? I missed you in calculus today.”

Jean: “I am so sick.”

Jill: “What’s up?”

Jean: “I woke up last night soaked in sweat, I felt like I was burning up. And my throat hurt so bad when I swallowed that I couldn’t even drink water.”

Jill: “Did you go to the health center?”

Jean: “No, I took some Motrin and some throat things my mom had packed for me when I moved in, they helped, and I got some sleep—didn’t even wake up until after class. I don’t think I have a fever, but my throat is still sore and my nose is all plugged up. Think I should go to the health center?”

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4 Provider–Patient Communication 67

In this example, Jean is telling her story, Jill only interrupts to inquire whether she has sought medical care—an interpersonal, empathic- listening query about her friend’s illness. However, Jean not only wants to tell her story, she wants to explain more about her situation to try to allay her friend’s concerns and seek some advice. These types of narratives are typical in American culture, espe- cially as they relate to people’s desires to share stories about their health and use these narratives to continue to build relationships with close friends and/ or family. At the same time, these communicators are trying to gather feedback and input for their own health care assessment and decision making.

If narratives are so expected/important in our culture, how do you think patients feel when they do not get to tell their stories? In 21st-century health care, because of time constraints and the biomedical model, many health care providers use a disease-centric approach. For example, let’s assume Jean goes to the health center and, after waiting to see a provider, has the following exchange:

Provider: “Hi, what can I do for you today?”

Jean: “I’m not feeling good.”

Provider: “Okay, so do you have a fever?”

Jean: “Yes, and …”

Provider: “How high?”

Jean: “I don’t know, I don’t have a thermometer in my dorm. But I woke up all sweaty and …”

Provider: “Well, your temp is normal here, are you coughing?”

Jean: “A little, mostly when I lay down. But it’s my throat.”

Provider: “You sound like your nose is congested, so it’s likely a postnasal drip that is causing your cough when you lay down, which irritates your throat, and then you’re probably mouth breathing with a stopped up nose, so that would also contribute to your throat irritation. We’ll do a strep test to rule out a strep throat, but without a fever, it’s likely a virus and you’ll need a decongestant, some fluids, and rest. Let me examine you quickly and then we’ll get that throat swabbed.”

How would you analyze this conversation? Did the provider get the information needed to make a diagnosis? How would you assess the pro- vider’s communication from the patient’s perspective? If the provider is working from a biomedical approach, he or she is striving to find the cause of this patient’s illness and fix it. Using our health communication lens we can assess the provider’s behaviors in this example. The provider:

■ Gathered information from the patient

■ Compared the patient’s signs (temperature and vital signs) and symptoms (cough, sore throat, nasal congestion)

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68 Health Communication for Health Care Professionals

■ Analyzed findings against an algorithm for viral versus bacterial infections and other possible etiologies based on the patient’s complaints

■ Decided on a likely course of action/treatment based on questions, physical exam, and strep test

From the provider’s goal-attainment perspective, we could argue that he or she got the information needed to arrive at a working diagnosis in a fairly brief amount of time. However, this approach is disease- and provider-centric. It is about what the provider needs to diagnose and treat the illness. However, it does not recognize that the patient may have needs/goals that are not disease/ provider focused.

If we assess the provider–patient interaction from Jean’s perspective using a health/interpersonal communication lens, we can deduce that the patient was:

■ Prevented from communicating her narrative as she would in other parts of her life

■ Interrupted numerous times, demonstrating the provider’s power and the patient’s limited role in the relationship

■ Diagnosed, at least provisionally, with minimal information

■ Regarded, nonverbally and verbally, differently than she would be in almost any other context in American culture

Therefore, it would not be surprising that the provider’s unwillingness to allow Jean to tell her story negatively impacted their provider–patient relationship and consequently lowered Jean’s level of trust in the provider’s diagnosis, treatment plan, and prognosis. Providers should perceive the simple act of allowing a patient to share his or her narrative, not as a waste of time, but as both information-gathering and relationship-building opportunities. The uninterrupted communication of the patient’s symp- toms permits him or her to feel that the provider respects him or her and that the common act of narrative sharing extends to health communication as well. Furthermore, the patient’s ability to share his or her narrative also communicates a provider’s willingness to share power vis-à-vis listening, not just controlling the conversation via provider-focused, disease-centered messages.

■ L I S T E N I N G V E R S U S T A L K I N G

As discussed in Chapter 3, listening is critical to effective interpersonal and health communication. However, not only is listening different from hearing, active listening and empathic listening can also be used to build a

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4 Provider–Patient Communication 69

relationship, encourage a speaker to share more information, and assure the speaker that the listener is assimilating the material and cares about him or her. For health care providers, especially those who follow a biomedi- cal approach to health care delivery, gathering specific information—related to an algorithm or a disease/injury focus—often leads to providers talking more than listening.

Furthermore, in order to gather the information they want/need, many health care professionals tend to interrupt patients frequently, which is not only the opposite of patient-centered listening, but is typical of masculine-gendered behavior. As well as contributing to a paternalistic per- ception by patients, interruptions frequently limit patients’ interests in shar- ing and/or opportunities to communicate additional information.

For the most part, in American culture, communicators prefer not to be interrupted. Instead one person likes to complete his or her narrative before the other person speaks/interrupts. However, in a disease- focused, provider- centric health care system, the patient’s communication needs/desires are often overlooked or undervalued. Furthermore, when a person feels his or her messages/narratives are less important than the other communicator in the dyad, the patient is less likely to want to share information but also less likely to want to engage in interpersonal communication or to develop/ maintain an interpersonal relationship. Although it is true, that providers cannot allow patients to endlessly tell their stories, for the most part waiting a minute or two for patients to complete their narratives about their signs (temperature, increased pulse, lump, etc.), symptoms (pain, feeling, nausea, etc.), or events allows them to feel that they shared the information they felt was important and, if the provider truly listens, many, if not most, of the pro- vider’s questions will often be answered. And, if not, closed-ended questions

Research Exercise 4a. Try a little social science research project: Start  a conversation with someone and every time the other person starts to expand on something, interrupt with a question. Pay close attention to the person’s nonverbal behaviors and your verbal cues. In the space here, discuss what you observed about the other person’s behaviors (verbal and nonverbal) and what you were feeling while doing this.

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70 Health Communication for Health Care Professionals

(How high was your fever? or, When did the vomiting start?) can be used to gather more detailed data for diagnosis and treatments. However, using an open-ended question (Tell me why you came in today? or simply, How are you doing?) without interruption will help maintain the larger culture’s interpersonal communication expectations for patients. In addition, using open-ended queries to initiate a conversation allows providers to build a relationship by demonstrating the importance of patients’ narratives in the provider–patient interaction. Furthermore, the simple act of using an unin- terrupted open-ended question to seek information serves to equalize the power in the relationship versus using a paternalistic/autocratic, interroga- tive interrupting style that nonverbally communicates the provider’s power. The value of open-ended, uninterrupted initial information-seeking behav- iors still must be tempered with a clear understanding of the patient (and/or family member) and his or her needs, expectations, and abilities.

■ A U D I E N C E A N A L Y S I S : A C R O S S T H E L I F E   C Y C L E

In the field of communication, few things are as important as a careful anal- ysis of the audience. Typically, we think of audience analysis more in public speaking, mass communication, or written communication—health care is again very different in interpersonal communication/interpersonal relation- ships because of the diversity of potential communicators a provider may encounter—from neonates to comatose individuals and from minimally educated to MD/PhD-prepared adults. In consequence, the demographic variations of patients and/or family members differentiate health communi- cation further from typical interpersonal communication interactions.

For example, in terms of how you communicate, if you are going to talk to an 8-year-old child, does it matter if he or she has a cold or a tumor? Or

Reflection 4.3. Consider your close friends and family—those you have inter- personal communication/relationships with (know well and share common goals with). How would not knowing how educated they were or what their prior expe- riences in a similar relationship might have been impact how you communicate with them?

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4 Provider–Patient Communication 71

will you speak with the child the same way regardless? Similarly, if you are speaking with an adult patient who does not have a college education, how would that impact your conversation? As you likely have noticed, the possi- ble differences between patients and/or family members are as diverse and expansive as the U.S. population. The specific impact of health literacy and stereotyping will be discussed later in this chapter, but let’s focus our thoughts on the value of audience analysis related to several other key patient demo- graphic areas:

■ Age

• Pediatric

• Adolescent

• Adult

• Geriatric

■ Education

• Speaking

• Reading

• Assimilating

■ Sex

■ Gender

■ Socioeconomic status (SES)

■ A G E

One of the many aspects of health care that differentiates it from most other aspects of our lives in terms of interpersonal communication has to do with the differences in demographics between providers and their patients. Few adults have interpersonal communication/relationships with young chil- dren (except with their own); however, in many health care roles and profes- sions it is not uncommon for providers to need to communicate with children of all ages. And depending on the context for the child’s illness/injury/visit, he or she may be the most important source of information. Therefore, it is critical to analyze how to best communicate with the child patient and/or parent. If possible, it is wise to acknowledge the patient/child first, then the parent. Too often, for speed, or ease of information gathering, the parent is the focus of the provider’s communication and attention. When this approach is taken by pro- viders, especially in emergency departments (EDs) and nonpediatric practices, the context takes on more of a veterinary exam with the child being there for the exam and the parent being the source of almost all information. A few sim- ple steps can help the child be more trusting and want to share in the process.

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72 Health Communication for Health Care Professionals

For example, you might want to sit at the child’s level, ask about school, pets, or siblings to try and demonstrate your interest in what she or he has to say. Be just as cognizant of your nonverbal behaviors with pediatric patients as you are with adults; if the child is old enough, offer to shake his or her hand, ask before touching/examining the patient, and explain what you are going to do before you do it. Try to learn about the child’s prior health communication experiences—did he or she have ED visits, hospitalizations, or other unusual or “traumatic” health care experiences? Remember, communication is contin- uous, so you want to make this as positive an experience as possible (for the current as well as future encounters with you and other providers). At the same time, recognizing and acknowledging a past problematic or painful health care experience up front and trying to explain how this visit will be different is an effort toward easing some of the patient’s and parents’ concerns and may pos- sibly change the dynamic from fear and mistrust to a willingness to contribute to the success of the interaction. However, not unlike many other aspects of the life cycle, providers must be aware of how easy it is to ignore or minimize input from older patients as well.

Research Exercise 4b. Why not try to apply this approach to pediatric interactions and do a brief research project. Find a child, a 5- to 10-year-old, not a member of your family or a patient and, with his or her parent’s per- mission, introduce yourself and ask the child to tell you about school, toys, books, whatever he or she wants to discuss and listen to what the child says and see how easily you can begin to have a conversation about the topic. In this space, describe what you learned about communicating interpersonally with a child and how that might be useful to you in your professional role when examining/treating/caring for a pediatric patient.

Rather than move chronologically in our discussion of the role age plays in effective health communication exchanges, let’s discuss the oppo- site end of the life cycle. How do you see interacting with geriatric patients being similar to or different from pediatric patient communication? Not unlike health care visits with children, many providers tend to communi- cate with family members or caregivers rather than with elderly patients. With our aging population, adults older than 60 now make up a large portion of the patient population. Therefore, it is much more common to see 80-, 90-, and 100-year-olds in both acute and chronic care settings, not just in long-term care facilities. As a consequence, audience analysis

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4 Provider–Patient Communication 73

for advanced-aged patients should include their level of acuity (both for communication and clinical perspectives) and, whenever possible, the pro- vider should be elder-patient focused and not family member/ caregiver- centric. As in pediatric interactions, the provider needs to determine the best nonverbal and verbal actions to utilize to demonstrate his or her inter- est in communicating with the geriatric patient; overall a few approaches to consider include:

■ Nonverbal behaviors

• Paralinguistic cues

■ Volume—may need to be higher than usual, depending on the patient’s hearing acuity

■ Tone—conversational, not paternalistic or condescending

■ Speed—may need to slow down your talking

• Careful attention to patient’s feedback/assimilation

• Haptics—as with others, touch appropriately and with permission

• Kinesics—try to sit at eye level, pay more attention to the patient than to the computer or family member/caregiver

• Proxemics—consider sitting closer to the patient if that improves his or her hearing/assimilation/exchange of information

• Written communication—language (educational and ethnic) appro- priate, font size as needed for patient’s visual acuity, and with clear instructions for how to follow up with unanswered questions (phone, e-mail, office visit, etc.)

■ Verbal behaviors

• Interpersonal—strive to use expected communication messages

■ Introductions

■ Goal setting

■ Feedback

■ Next steps

■ Educational, mental acuity, and appropriate language choices

Although end-of-life discussions are important throughout adulthood, based on the context of the geriatric patient–provider interaction, it is important to discuss advance directives and living-will issues with senior citizens. If they have already made these decisions, it will only take a few minutes to determine that, but if they have not, this is a critically important educational opportunity for providers talking with geriatric patients. As this may be an emotionally charged issue, the patient may want a family mem- ber present to also hear the information, and it is critically important to have written material for the patient and family member/caregiver to take with

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74 Health Communication for Health Care Professionals

them to review later in a less intense context. Until the provider is certain that the patient has been fully informed and able to reach a decision about living-will and/or advance directive issues—this topic should be a part of all follow-up interactions. Although there are similarities in the communica- tion challenges associated with provider–patient interactions with pediat- ric and geriatric individuals—there are also concerns related specifically to adolescent and adult health communication.

Although the issues related to health communication with pediatric and geriatric patients may seem more obvious, many providers have nearly as many interpersonal communication/relationship difficulties with adolescent and/or adult patients. As you may have surmised, for a variety of reasons (emotional, hormonal, social, etc.), adolescents present a unique set of potential commu- nication-related problems. Adolescents frequently do not want to discuss or feel uncomfortable discussing personal issues with adults (parents and health care providers). Similarly, many providers feel awkward having health-related conversations with adolescents. The fact that these young men and women are literally in between childhood and adulthood makes them both emotionally sensitive, hormonally challenged, and physically evolving. As a consequence, from a communication perspective, it becomes a question of when to treat them as adults (verbally and nonverbally)? For example, at what age should the patient decide whether a parent should be in the exam room for nonlife-threatening, provider–patient interactions? When does a provider need a chaperone and should that be part of the office/hospital/clinic staff’s job or the parent’s?

Reflection 4.4. Think back to when you were 14 or 15, how did you feel about communicating when you went to see your health care provider? Did you want to have a dyadic interaction or did you want a parent involved? How about when it came time for the examination? Did you want your parent present or not? How do you think these feelings impacted your willingness to communicate with the provider (ask/answer questions, gather information, etc.)?

From a communication perspective, it would seem ideal if the patient (ado- lescent) could decide whether his or her parent was in the conversation and/or exam with the provider. However, until children are 18 parents legally have the right to be involved in all aspects of their children’s care. Therefore, a provider may want to explain to both the parent and the adolescent child at the first visit that because the patient is getting older he or she may want to have a bit more privacy with the provider. If you are going to use a chaperone (especially

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4 Provider–Patient Communication 75

for exams) you would want to make that clear as well. Then let the parent and child negotiate whether the parent stays or not—this way the adoles- cent knows that the provider recognizes her or him as more an independent adult than a pediatric patient. From an interpersonal communication/relation- ship-building perspective, it should help establish the provider’s intention to treat the adolescent as much like an adult as possible. Consequently, regard- less of whether the parent remains or leaves, the provider needs to be patient- centric in his or her communication and only include the parent as needed for clarity, or as demanded by the mother or father. It is important to constantly remind yourself that the nonverbal communication of disinterest and limited verbal responses are typical for adolescent–adult interactions regardless of the context. However, the more your verbal and nonverbal behaviors demonstrate your interest in the adolescent and helping him or her stay healthy vis-à-vis your verbal and nonverbal behaviors, the more likely you are to eventually build a trusting interpersonal relationship and increase the opportunity for information sharing and mutual goal attainment. One of the key opportu- nities for adolescent–provider health communication is often also a for- midable challenge—assuring patients are educated about sexual behaviors, pregnancy risks, and sexually transmitted diseases. Providers need to assess what their adolescent patients know about these critically important health communication topics and evaluate the most effective way to help educate and empower these young adults. Although face-to-face (F2F) discussions and feedback are generally ideal, age-, language-, and literacy-appropriate writ- ten communication/handouts are often a good way to encourage a dialogue. Providing the materials and allowing some time for the adolescent to read them before having a discussion is ideal, but this may not always be practi- cal. Therefore, providers need to analyze the adolescent and the context to determine the best way to educate the patient and use feedback to determine assimilation, confusion, and/or misperceptions. However, providers should ask adolescents what they know about sex, where they got their information, and correct any misinformation—as well as encourage these patients to always feel free to discuss the topic at any time they have questions or a health con- cern. Assuring them of confidentiality will likely be another opportunity to build trust and an interpersonal relationship. Conversations about sex and a patient’s sexual history are just one aspect of the provider–patient interaction from adolescence through adulthood.

As patients age, especially if they have continuity of care from adolescence into adulthood, it will be easier to maintain and enhance an interpersonal relationship. As with any relationship over time, generally there is an increase in trust and in health communication a heightened exchange of informa- tion and patient self-disclosure. Therefore, it is important for providers to use effective interpersonal and gendered communication (see Chapter 3) in an effort to further the relationship and improve information sharing, power sharing, and empowered decision making. As will be discussed further, it is critically important for providers to recognize the problems associated with

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76 Health Communication for Health Care Professionals

stereotyping (addiction, sexual orientation, etc.) and how such behaviors limit information exchanges, analysis, and effective health communication/ outcomes. However, providers also need to recognize that audience analysis needs to also include demographics beyond age, such as the patient’s educa- tion level.

■ E D U C A T I O N

Although some demographics are more obvious, or even documented (sex or age), a person’s education may not be as clear. For example, according to the U.S. Department of Education and the National Institute of Literacy, nearly 15% of adult Americans cannot read, and over 20% cannot read at the fifth- grade level. Therefore, consider many of the communication behaviors we treat as commonplace today: filling out health care forms, following preoperative/ postoperative ins tru ctions, understanding educational pamphlets/brochures, or even prescription labels. How do you think these educational deficiencies might impact the provider–patient information exchange?

Reflection 4.5. If your patient reads at less than a fifth-grade level, how do you think that will impact your ability to partner with that person and improve his or her health/wellness? What are some ideas for helping you assess the patient’s reading level without embarrassing him or her?

And literacy, though often categorized solely by reading, from a health com- munication perspective really does include not just verbal, written, and reading aspects, but assimilation ability as well. Health literacy will be discussed in more detail later in this chapter, but it is important for providers to recog- nize the interdependent nature of these disparate but interrelated behaviors. For example, if a patient cannot read a health form, she or he will likely not relate all the information the provider needs. In addition, if the patient cannot verbally communicate effectively and/or is unable to assimilate the provider’s messages because of literacy issues, the interaction will not only be frustrating for all, but may in fact, be useless or, in the worst possible scenario, danger- ous as the patient misunderstands the treatment plan, instructions, and so on. The importance of analyzing patients’ abilities to read, assimilate, and com- municate/share information are critical to the communication/collaboration of patients and providers. And the very troubling reality is that if someone speaks a foreign language it is generally easy for a provider to recognize that and seek

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4 Provider–Patient Communication 77

a professional translator. However, if the patient seemingly speaks the same language as the provider, without some careful analysis, it may be very difficult for the provider to determine not only the patient’s education level, but his or her verbal, reading, and assimilating abilities. Although the analysis of a patient’s education (reading, speaking, and assimilating) often needs careful scrutiny, the role of sex in provider–patient communication is more obvious, but still frequently underassessed and/or underappreciated.

■ S E X

Although age has a breadth of communication-related issues that need to be analyzed by a provider, the patient’s sex and how it impacts the delivery of health care needs to be similarly assessed. Much has been made about the differences in the communication styles of males and females, especially in health care settings. Again, providers need to be aware of this potential but not consider it a stereo- type. Therefore, because it has been postulated that males tend to provide less information and ask fewer questions than females, providers need to make sure that they are seeking feedback and using a variety of formats (verbal and nonver- bal/written) to try to gain information from patients of both sexes. The provider needs to use effective interpersonal communication to build relationships with patients regardless of their sex and to assure that the patient is given time to not only share his or her narrative, but ask questions, clarify misperceptions, and/ or be encouraged to fully discuss his or her health/illness/injury issues. Similar to assessing the patient’s sex in terms of health communication approaches, the provider should also consider the patient’s gender.

■ G E N D E R

As discussed in Chapter 3, gender communication is often difficult to analyze but critically important to how individuals communicate. Therefore, it is essen- tial for providers to not stereotype patients based on their sex (male = masculine and/or female = feminine), but to analyze their gendered behaviors to enhance the information sharing and interpersonal communication/relationship possi- bilities. Clearly, a person’s gendered communication often makes a difference in how he or she not only shares information, but seeks care, follows up, and/ or trusts the provider.

Generally speaking, feminine-gendered individuals (male or female), tend to ask more questions, share more detailed information, seek feedback, and interrupt less than masculine-gendered communicators (male or female). Therefore, it should not be surprising that individuals who want to provide detailed information and discuss their feelings, not just their signs and symp- toms, are often perceived as potential hypochondriacs or hormonally imbal- anced. In fact, it may be that many of these patients were feminine gendered and wanted to provide more information, encourage a discussion, participate

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78 Health Communication for Health Care Professionals

and collaborate in their treatment decision making, and so forth. Similarly, males are often characterized, even stereotyped, as not wanting to go to health care providers, offer much information, or ask questions and yet many of those masculine-gendered behaviors are the same ones that are not only expected but are praised in professional organizations. The more competitive, inde- pendent, and aggressive the professional, regardless of the career, the more he or she attempts to be in control, self-serving, and taking a leadership role. Therefore, health care providers must seek ways to encourage patients—based on their gendered behaviors/communication—to not only seek information, but share it, and participate in the decision making, treatment plans, and thus enhance their health/wellness outcomes. Although a patient’s age, education, sex, and gender can and should be analyzed in terms of communication effec- tiveness, the impact of similar or different SES on provider–patient interactions needs to also be analyzed and addressed.

Reflection 4.6. What are some of the communication behaviors you can observe in order to help analyze a patient’s gender? How might you use your findings to enhance your interaction with the patient if the patient is masculine versus feminine gendered?

Research Exercise 4c. Consider two people you know but prefer- ably with whom you are not “close friends” who behave the opposite of what might be expected in this culture from a gender perspective; a male who communicates with a more feminine-gendered style and a female who has a more masculine-gendered communication behavior. Independently, ask each to tell you a story about his or her childhood ( anything they want) and try to note not just the content of the story, but the amount of detail, the interest in sharing it with you versus any reluc- tance or even refusal, and so forth. What did you learn about how gender impacts information sharing and how stereotyping gender based on sex might be problematic for you as a health care provider?

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4 Provider–Patient Communication 79

■ S O C I O E C O N O M I C S T A T U S

The role of SES in provider–patient communication is somewhat different than the other demographics that providers analyze. Understanding the potential impact of SES on patient–provider interactions is very important. Humans frequently use their perceptions of similarity with another com- municator to determine how much they are alike and therefore the more comparable they may be in values and beliefs. Consequently, many patients assess providers based on their SES and how similar/dissimilar they are. Therefore, in U.S. culture, it should not be surprising that most patients will assume that providers are quite different from themselves—educationally, economically, and socially. Although providers clearly cannot change their SES based on the patient, being aware of the potential impact of SES on pro- vider–patient communication, relationship development, and trust building can help you use interpersonal communication that minimizes the differ- ences between you and your patient and maximizes your desire to partner with him or her and attain the goal of improving/maintaining his or her health/wellness.

The point of assessing the role SES differences might have in provider– patient communication is to help you further understand that just because the provider asks a question, or communicates what may be a very carefully con- sidered plan of action, does not mean it will be similarly perceived that way by another communicator. For example, if you think a patient needs to lose weight, eat a more healthy diet, and exercise more—those may all be very accurate assessments and plans to improve the patient’s health. However, a health care provider who likely is in the upper middle or upper class in American culture generally is not perceived to have any problem purchasing food or shelter. That economic assumption is part of the SES that creates conflict for many patients. Eating healthier, for example, is a wonderful plan—as long as someone can afford it. But if a patient only has $1.50 for dinner, a fast-food burger or taco is going to be the most likely choice. Therefore, although providers have been

Reflection 4.7. Recall a time when you felt someone (preferably not a health care provider) you were communicating with had a different socioeconomic status (SES) than you—perhaps as a student with a professor, or as a college intern, or with a summer employer, and so forth. How did that difference in SES, the dissimilarity you perceived between yourself and the other person, impact how you felt about him or her and your willingness to communicate any more than was required?

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80 Health Communication for Health Care Professionals

trained in nutrition, exercise physiology, and weight control, these topics are of very little importance to a patient who is making decisions about whether to eat or pay rent, or eat or buy prescriptions.

SES analysis then is important in helping providers recognize how they can best help their patients—not just provide accurate information, but collaborate in developing plans that can be realistically managed by the patient based on his or her social and economic situation. By not assuming that all patients can manage their health equally from a SES perspective, providers demonstrate to their patients that they may not share the same status, but recognize the differ- ences among all Americans and the desire to find ways to provide health care options that are appropriate given the patient’s current SES. However, part of this awareness of the role SES plays in health care delivery and provider– patient communication requires that providers not stereotype patients based on their artifacts (clothes, hairdo, jewelry, body art, etc.). Like SES, stereotyping can create more barriers to effective health and interpersonal communication and relationship development.

■ S T E R E O T Y P E S A N D M A R G I N A L I Z E D P O P U L A T I O N S

As previously mentioned, stereotyping and a provider’s potential bias toward marginalized populations (e.g., addicts, the homeless, grossly obese, mentally impaired, and elderly) can markedly limit effective health and interpersonal communication. Clearly, there is a likely relationship between stereotyping and marginalized populations that can be increased based on the provider’s prior experiences, social and psychological biases, and pro- vider–provider/peer pressure. It is very important, however, for health care professionals to analyze not just the communication needs of patients who might be perceived from a stereotypical or marginalized perspective, but also intrapersonally—from the provider’s perspective. Although experience

Reflection 4.8. Picture a 35-year-old patient in your emergency department (ED) who just crashed his motorcycle; he is complain ing of pain from his broken right foot and badly abraded left forearm. From a psychological/sociological perspective, what do you see when you look at him? Be as detailed as possible. What do you hypothesize is his profession and why?

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can inform the provider’s decision making and information sharing as well as diagnosis and treatment plans, it is important to remember that just because a prior patient(s) behaved a certain way, does not mean that all patients with similar problems, behaviors, needs, and so forth should be treated like the prior patient(s). Spending less time communicating with a patient because of conclusions the provider has made based on stereotyping or marginalized population biases is not only unfair to the individual patient, but unethical, and, on some level, is likely dangerous (medically and/or legally). The more providers can analyze the health care problems, needs, expectations, and communication behaviors/messages of the individual patient he or she is interacting with in a social vacuum, the more effective the information exchange is likely to be and the more potentially beneficial the interpersonal communication/relationship will be for both communicators. This approach is not to suggest that the experi- ences and knowledge of the provider should not help inform the commu- nication and collaboration with the patient, but that is far different than dismissing the patient as lazy, unwilling to work, an addict who has no desire to change, or hopeless. Taking a quick minute to analyze not just the patient, but your own response to the patient will provide invalu- able information for not only your communication, but also your ability to actively listen, assimilate, and assess the patient’s situation based on the data, not on bias or presumption. This notion of not assuming/presum- ing is important to avoid stereotyping and bias against marginalized pop- ulations, but also to assessing the health literacy of your audience/patients.

■ H E A L T H L I T E R A C Y

Although most patients do not attempt to hide their sex, or even their age and education, patients with lower health literacy may either not realize it, or be unwilling or embarrassed to admit it. Therefore, it is often best to assume that patients have limited health literacy and be sure that your verbal and written messages are not only communicated in non–health care terms, but also at fifth- or sixth-grade reading levels. However, as mentioned earlier, the only way to be sure that patients are able to understand your messages, assimilate the information, and use it to make decisions is to use feedback via questions to assess what the other communicator heard, read, and comprehended. Analyzing your patient’s health literacy would also be aided by asking him or her to read a few sentences or a short paragraph, to determine his or her literacy in general, as well as the patient’s ability to interpret the message. Finally, you could also include a typical prescription text (e.g., take one tablet every other day; avoid alcohol and citrus fruit) and ask the patient to tell you what specific days he or she will be taking the medicine and what else the patient needs to do according to the

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82 Health Communication for Health Care Professionals

prescription—remember, this is not about repeating the words on the prescri ption, but how the patient interprets the meaning of those words. For example, what does the patient think “avoid alcohol” means (e.g., just liquor, or also wine and beer, or does he think “rubbing alcohol”)? And can the patient tell you which fruits are “citrus”? These simple cognitive tests can become a standard part of your evaluation, in which case you are assess- ing literacy and comprehension as part of your mental health and neuro- logic exam—not to embarrass the patient but to help gather data about the patient’s overall wellness and health. For example, you could use a fifth- grade-reading-level example from a credible source, like this one from the North Carolina State University, William & Ida Friday Institute for Educational Innovation, and ask the patient to read it aloud:

Hurricanes

Hurricanes are large tropical storms that develop in the oceans of the world. Hurricanes gather heat and energy from the warm ocean water. The heat from these warm currents increases the power of the hurricane. Hurricanes that remain over warm water usually get bigger and stronger, but they weaken once they get over land. Hurricanes are storms that are given names, and a new list of names is created each year. The first hurricane name starts with the letter A, like Ashley, and the names move through the alphabet as more hurricanes form. (North Carolina State University, 2006)

Research Exercise 4d. Ask a variety of friends and strangers to explain to you what the term avoid alcohol (liquor, beer, wine, combinations of any of these) means to them. Then ask them to name as many “citrus fruits” (grapefruit, lemons, limes, oranges, tangerines) as they can? How did your data collection confirm or conflict with your hypotheses about who would be able to most effectively answer these questions? And how does that relate to audience analysis, stereotyping, and health literacy?

After the patient reads the paragraph, you could ask the patient to tell you how hurricanes are named, where they develop, or how they are formed. In this way, you can both listen to the patient’s ability to read at a fifth-grade level, but also assess his or her comprehension of the material to assure not just reading ability, but literacy/understanding.

This chapter has focused on many aspects of provider–patient communi- cation. It is important to remember that the goal of this text is to help pro- viders become more effective interpersonal and health communicators by

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taking a patient-centric, relationship-building approach to provider–patient interactions. Therefore, in this chapter we have discussed the value of narratives, listening versus talking, and audience analysis across patients’ life cycles. In addition, the value of recognizing the impact of various demographics, SES, and health literacy on health communication effectiveness and relationship building cannot be overemphasized.

R e f l e c t i o n s ( a m o n g t h e p o s s i b l e r e s p o n s e s )

4.1. Think of a recent sickness, an upper respiratory illness (URI), sometimes called a “cold,” or a sore throat, and so forth. When you were discussing how you felt and how your life was impacted (work, school, plans, etc.) with a friend or family member, how did you describe what you were experiencing or had experienced? Be as detailed as possible in your recounting of your part of the conversation.

When most Americans describe a life event, it is not done with a bulleted state- ment but instead a detailed narrative that includes both factual and emotional data. For example, if you were telling a friend or parent about a recent URI, it would likely be similar to this scenario:

You: “Mom, I think I have some kind of cold or flu. I woke up during the night and my bed was soaked; I just hurt all over. My legs ached so bad, I didn’t know if I could stand up. And then I got back to sleep, but when I got up this morning my nose was stopped up and my throat hurts, and I am so tired.”

This narrative is not just a list of symptoms:

■ Sweat

■ Myalgias (muscle aches)

■ Nasal congestion

■ Pharyngeal irritation (sore throat)

■ Malaise (tired)

but instead a detailed discussion of both physical complaints and emotional feelings. Although most health care providers want the symptoms, bulleted previously, the brief extra verbiage in a narrative provides the same data, but just in the patient’s normative information-sharing/conversational/interper- sonal communication style. It would be very beneficial for providers to rec- ognize the value of narrative use by patients—who feel they were able to “tell their stories” in their usual way—and through which providers get information that they can further refine via closed-ended questions.

4.2. Think about the last time you went to a health care provider for an acute illness or injury. What happened when you tried to tell your story/narrative? Did the pro- vider allow you to describe it as you wanted? Or did he or she stop you (interrupt) with questions? If the latter, how did the interruptions make you feel about the infor- mation exchange with your provider?

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84 Health Communication for Health Care Professionals

If your health care provider was utilizing a biomedical approach to information gathering, as many practitioners in this country do, then he or she likely asked a question and as soon as you provided a symptom, the provider interrupted your answer and began using closed-ended questions to gain data that could be used for the algorithm needed to determine your most likely diagnosis/ problem. So fever, sore throat, nasal congestion equals URI/virus versus strep throat/bacterial infection with posterior pharyngeal irritation from a postnasal drip as the most likely etiology. Although a series of closed-ended questions to rule out pneumonia, sinusitis, bronchitis, and so forth will be used, the pro- vider relies on the patient’s initial information to help determine the organ sys- tems that appear to be impacted by an illness or injury and what algorithm to use in analyzing the etiology, diagnosis, and treatment plan. The key is to recall that the more you can make the patient feel he or she is contributing to/collab- orating in the process and sharing the information he or she feels is important for the provider to know, the more effective the communication exchange and interpersonal relationship development will be perceived.

4.3. Consider your close friends and family—those you have impersonal communi- cation/relationships with (know well and share common goals with). How would not knowing how educated they were or what their prior experiences in a similar rela- tionship might have been impact how you communicate with them?

The more we know about a person, the more it enhances an interpersonal pla- tonic, professional, or romantic relationship. For example, if you do not know a person’s education level you may use language he or she does not understand or appear condescending in your explanations. Similarly, not knowing a per- son’s education level could create conflict if you assume the person can read at a certain level and that is untrue. One of the realities of American relationships is that we tend to associate with people who we perceive as similar to us— related to age, education, and SES. Therefore, part of the general relationship development process is learning about the other person’s background, family, education, and so forth. But this process generally takes place over a prolonged time frame, days, weeks, months, even years. However, in health care, providers and patients generally have minutes to learn about the other person and for patients there is often very little or no opportunity to discover much about the provider’s background except from diplomas on the wall or by his or her profes- sional title/degree. As a consequence, the more a provider can try to learn about a patient’s education and SES background, the more information the provider will have to analyze how most effectively to communicate with the patient.

4.4. Think back to when you were 14 or 15, how did you feel about communicating when you went to see your health care provider? Did you want to have a dyadic interaction or did you want a parent involved? How about when it came time for the examination? Did you want your parent present or not? How do you think these

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4 Provider–Patient Communication 85

feelings impacted your willingness to communicate with the provider (ask/answer questions, gather information, etc.)?

Generally, adolescents are reluctant to talk openly with adults and some would prefer to have their parents present while talking with providers and others would prefer to speak independently with their health care profes- sional. Therefore, it would be best if the patient could decide; however, par- ents are legal guardians and have the right to be present if they so desire. Consequently, although a provider can suggest that an adolescent decide who is present—it is ultimately up to the parent. Regardless, providers should try to make the adolescent the focus of the conversation and seek to encourage a dialogue and information sharing with the patient, not the parent, if possible. The more an adolescent trusts a provider, the more likely he or she will feel comfortable discussing health care issues, asking questions, and participat- ing in his or her treatment plans. And although it is likely wise, ethically and legally, to have a chaperone during physical exams of patients of the opposite sex, providers should certainly be aware of the importance of having a chap- erone during an adolescent’s examination and have the patient determine (if possible) whether he or she prefers a parent or a health care provider.

4.5. If your patient reads at less than a fifth-grade level, how do you think that will impact your ability to partner with that person and improve his or her health/well- ness? What are some ideas for helping you assess the patient’s reading level without embarrassing him or her?

As discussed earlier, a patient’s reading level impacts his or her health and communication in a number of ways. First, if patients have reading difficul- ties, they may not be able to appropriately complete the basic office/hospi- tal forms—consequently, the information, even the demographics, could be inaccurate. Second, if patients are embarrassed about their reading literacy, they may not want to disclose that and may even lie to keep it hidden from the provider. Third, if patients have a low literacy level, they will likely have low health literacy as well. Consequently, providers may not be able to use their standard educational handouts, pre- and postprocedure instructions, or prescription labeling. The impact of diminished literacy (reading and health) on health communication information exchange is enormous and can only be improved by providers taking the time to assess a patient’s liter- acy and providing appropriate materials for the patient’s reading and health literacy levels. Finally, the provider can use a reading sample (see example given earlier) as part of the patients’ exams, to assess their reading levels, as well as their abilities to assimilate and analyze what was read.

4.6. What are some of the communication behaviors you can observe in order to help analyze a patient’s gender? How might you use your findings to enhance your inter- action with the patient if the patient is masculine versus feminine gendered?

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86 Health Communication for Health Care Professionals

Patients can be observed to determine how they use communication to demonstrate their aggressiveness, independence, competitiveness, or how they want to participate, collaborate, or contribute. Armed with this informa- tion, a provider can assess how much to encourage a patient to tell his or her narrative—for more feminine-gendered individuals, or seek more information if a more masculine-gendered patient is averse to discussing his or her pain, problems, and concerns with a provider.

4.7. Recall a time when you felt someone (preferably not a health care provider) you were communicating with had a different socioeconomic status (SES) than you—perhaps as a student with a professor, or as a college intern, or with a summer employer, and so forth. How did that difference in SES, the dissimilarity you per- ceived between yourself and the other person, impact how you felt about him or her and your willingness to communicate any more than was required?

Often when a person has a different SES from another, especially in an inter- personal relationship, like student–professor, employee–employer, or pro- vider–patient, it will directly impact how comfortable the lower SES person is with information sharing. It may be hard for that person to identify with the higher SES person’s role, lifestyle, and so forth. For example, in a conver- sation with a professor about where to eat off campus, many students might feel awkward because the professor has a higher SES and can choose from a much wider offering of restaurants, from economic, ethnic, and geographic perspectives. Consequently, students would likely not choose to engage with the professor about where to eat, as they don’t want to be reminded of the dif- ferences in their SES. Similarly, patients may be reluctant to discuss problems or treatment options with providers if they feel the differences in their SES will make it impossible for the provider to understand their predicament—for example, the patient cannot afford time off work, more nutritious meals, or the price of certain medications. Providers need to recognize the potential patient issues related to SES differences in order to not appear elitist, aloof, or uncaring.

4.8. Picture a 35-year-old patient in your emergency department (ED) who just crashed his motorcycle; he is complaining of pain from his broken right foot and badly abraded left forearm. From a psychological/sociological perspective, what do you see when you look at him? Be as detailed as possible. What do you hypothesize is his profession and why?

Working in an ED and seeing injuries from motorcycle accidents, providers have to guard against stereotyping every person who rides a motorcycle as being careless, a risk taker, or a member of a motorcycle gang. Lots of peo- ple are in automobile accidents and for the most part they generally are not judged as reckless or in a gang based on their choice of a car for transportation. Stereotypes only serve to bias the provider, limit the information exchange,

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4 Provider–Patient Communication 87

and potentially alienate the patient and/or negatively impact his or her care. Instead of trying to judge a patient’s behaviors, it would be more productive and patient centered to focus on the injuries, diagnosis, information exchange, and treatment plan. It is very important to remind yourself that health care providers, judges, lawyers, and countless other professionals ride motorcycles. Therefore, it makes no sense to stereotype everyone who rides a motorcycle as a gang member, risk taker, and so forth. The more providers can avoid judg- ing patients based on their behaviors and work to share information, power/ control, and decision making the more effective the communication exchange will likely become.

S k i l l s E x e r c i s e

In a conversation with a friend or loved one that lasts more than a couple of minutes, see whether you can focus on his or her eyes the entire time you and your friend are talking. Try to ignore the background, electronic devices, even an itch. When you’re done, how did the experience feel—was it routine and the way you always talk with people? Or was it different for you and how did that difference impact your perception of the interaction? Ask the other person first whether he or she noticed anything different about the conversation? If he or she mentions the eye contact, ask how it made him or her feel about the conversation and about you as a friend/family member/lover?

Video Discussion Exercise Analyze the video

■ Philadelphia (1993)

Interactive Simulation Exercise Pagano, M. (2015). Communication case studies for health care professionals: An

applied approach (2nd ed.). New York, NY: Springer Publishing Company.

■ Chapter 6, “Bad News” (pp. 55–66)

■ Chapter 12, “I Understand” (pp. 123–132)

■ Chapter 16, “I’m Feeling Better, But . . .” (pp. 161–172)

Health Care Issues in the Media Health literacy and prescriptions https://iom.nationalacademies.org/~/media/Files/Report%20Files/2004/ Health-Literacy-A-Prescription-to-End-Confusion/healthliteracyfinal.pdf

How to improve doctor–patient communication http://www.wsj.com/articles/SB10001424127887324050304578411251805908228

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88 Health Communication for Health Care Professionals

H e a l t h C o m m u n i c a t i o n O u t c o m e s

As discussed in this and prior chapters, provider–patient communication is interpersonal and, in American culture, more often than not is based on both parties using narratives in order to share information. However, for providers who communicate using a biomedical, provider-centric, disease/ injury- focused approach it is much more common to utilize closed-ended questioning as the way to gather patient information. Although this approach could make the interaction more focused and perhaps quicker than open- ended queries with a more narrative structure, the detective-like approach minimizes the opportunities for patient collaboration, trust building, shared decision making, and relationship development. In addition to the importance of providers using a more patient-centered communication style that encour- ages narratives and shared information, providers can nonverbally illustrate their interest in the patient vis-à-vis listening more than talking. By resisting the urge to dominate the conversation, providers can minimize the percep- tion of themselves as paternalistic and authoritarian and instead nonverbally demonstrate their efforts to be collaborative and share both the power as well as the decision making in the relationship. Furthermore, providers need to carefully analyze their patients and use communication (verbal and nonverbal) behaviors that are appropriate based on the patient’s demographics (age, sex, gender, education, literacy level, etc.). However, it is also essential that pro- viders strive to avoid using stereotypes or treating patients differently based on their demographics, illness, behaviors, artifacts, and so forth. By resisting the urge to stereotype patients, providers have a much better opportunity to assimilate the information gathered in an unbiased manner and collaborate with patients regarding their health care decision making. Finally, the criti- cal importance of recognizing the role literacy plays in effective interpersonal health communication cannot be overstated. Providers need to remind them- selves that they speak a different language than their patients, using unique terminology. As a consequence, just as they would not try to communicate with an American-English speaker using an ethnic language the patient did not understand, the same logic applies to avoiding health care language/ terminology with patients.

■ R E F E R E N C E

North Carolina State University. (2006). Improving reading comprehension using metacognitive strategies: Fifth grade reading passages. Retrieved from https:// www.ncsu.edu/project/lancet/fifth_grade/hurricane5th.pdf

■ B I B L I O G R A P H Y

Deber, R., Kraetschmer, N., & Irvine, J. (1996). What role do patients wish to play in treatment decision-making? Archives of Internal Medicine, 156, 1414–1420.

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4 Provider–Patient Communication 89

Gawande, A. (2007). Better: A surgeon’s notes on performance. In Afterword: Suggestions for becoming a positive deviant (pp. 249–257). New York, NY: Picador.

National Center for Education Statistics. (2015). National assessment of adult literacy: Overview. Retrieved from http://nces.ed.gov/naal/estimates/ Overview.aspx

Osborne, H. (2013). Health literacy from A to Z: Practical ways to communicate your health message (2nd ed.). Burlington, MA: Jones & Bartlett.

Vernon, J., Trujillo, A., Rosenbaum, S., & DeBuono, B. (2007). Low health literacy: Implications of national health policy. Retrieved from http:// s p h h s . g w u . e d u / d e p a r t m e n t s / h e a l t h p o l i c y / C H P R / d o w n l o a d s / LowhealthLiteracyReport10_4_07.pdf

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