March 14, 2013

I am using a new text in my undergraduate health communication course. The text is edited by Maria Brann, a professor at West Virginia University. It is called, “Contemporary case studies in health communication” and is published by KendallHunt, 2011. The text has a unique approach that is working well to spark discussion in my diverse undergraduate classroom. Each case in the  book leaves out the conclusion to the case, so that the class can speculate on the possible endings. Then, as the instructor, I have access to the conclusions written by the case study authors and can share these with the class. We have lively debates about how a case is resolved versus other ways it might have gone. For example, the case that I will discuss with the class tomorrow was written by Dr. Jennifer Ohs, a professor at Saint Louis University.  The case discusses medical decision-making and uses the example of an older woman who is deciding whether to have sinus surgery. It is a case used to illustrate problematic integration theory, which is the theory we are discussing in class this week, a framework for understanding proposed by Professor Austin Babrow who is a faculty member at Ohio University. The theory explains why communication may cause us to form judgments that a good outcome is highly unlikely,  while a bad outcome is very likely. Other situations that are problematic to integrate with our experiences include situations in which communication makes two options seem to be equal, both in terms of how likely or unlikely they may be and/or how good or bad we judge outcome linked to the option. The case discusses how an older woman considers what her husband, son, and daughter have to say about the surgery, the role of prayer, a friend’s view, and the conversations that her usual doctor and the specialist who would conduct the surgery have with her. In the end, she decides not to have the surgery. It is a good decision for her as it turns out, because she later learns that she needs dental surgery, and having  that surgery resolves the issues she was having with her sinuses as well.  Of course, she did not know that when she made the decision. Rather she made her decision because her daughter did not offer to come and be with her, because she really wanted a second opinion and her husband would not like to have to drive to the city to see another specialist, and because her son had a similar surgery that did not improve his health much. These were weighed with the doctor’s advice to have the surgery and led to her choice. It will be interesting to see how the class views this case and the ideas they come up with for possible conclusions.

February 19, 2013

The World Health Organization — WHO — has long promoted hand-washing as an important way to reduce the risk of spreading infections.  While we all can reduce the risk by washing our hands, we may also assume that healthcare workers would be among the people most likely to practice hand-washing. Apparently not. A study designed to increase hand-washing among healthcare works cites evidence that compliance with the practice is just 25-40%.  The article appears online in PLOS ONE [ a publication of PLOS [ http://www.plos.org/] an organization designed to make peer-reviewed medical research accessible in less time and with less cost than more traditional approaches to publishing scientific results. The research led by Chrsitopher Fuller, “The Feedback Intervention Trial (FIT) — Improving Hand-Hygiene Compliance in UK Healthcare Workers A stepped Wedge Cluster Randomised Trial”, conducted the study in 60 locations that included 16 acute hospitals and 44 general medical wards or acute elderly care sites. All sites were already participating in the “Clean Your Hands” campaign. This campaign includes placing alcohol hand-rub at patient bedsides, using posters and other educational materials to encourage workers to clean their hands. an audit and feedback on compliance was cinluded at least once every six months, so workers knew that the behavior is expected and would be evaluated. The FIT focused on goal-setting for and rewarding of handwashing behavior as an additional compoment to the national campaign.

A significant increase in hand-washing occurred with the FIT, with more change in the 16 intensive therapy units than in the other sites — achieving 13-18% change versus 10-13% change, ranging about 60% to nearly 80% compliance. The improvement declined over time. There were difficulties associated with implementing the protocol, including that the trial place extra responsibilities on some ward staff, who did not receive additional training beyond the initial introduction to the intervention and were not monitored after the initial observation of their placement of materials bedside. To increase the likelihood that such a campaign would be successful over time, the authors recommend that the tasks be integrated into the role of some employees and audited regularly as part of job performance. As for me, I will be watching to be sure healthcare workers wash their hands. And I will do the same.

November 8, 2012

If you are like me, you imagine a time when you will be less ‘scheduled’. This has been a time of being over-scheduled in the past half dozen weeks. I have a pile of topics I want to discuss relating to communicating about health. And too little time to do so.

One of the topics that keeps coming through my piles relates to an article written by Stephen A. Sommers and Roopa Mahadevan that was commissioned by The Institute of Medicine–IOM–and published in October 2010. I came across it when preparing to talk about health literacy and health communication with my undergraduates last year. It has been shuffling about on my desk since then. Today is finally the day I will share my thoughts about it.

First, the relationship between health literacy and health communication that I discuss with my undergraduates in a ‘designing health messages’ course is two-fold. On the one hand, low levels of health literacy, meaning the audience is unlikely to understand many health and science terms or be able to use math and statistics to make decisions–suggests that health communicators, whether they are public health program planners or medical doctors, should adapt their communication so that it will be understood, and informed decisions can be made based on an accurate understanding. A great deal of health communication message design research and practices focuses on this effort, working to assure that knowledge gaps do not become wider between more and less educated audiences, for example.

The second issue related to health communication and health literacy relates to efforts to improve health literacy. In other words, how could we communicate to motivate someone with low levels of health literacy to become excited about learning more vocabulary and applying more statistics in making choices about health?  

Addressing both health literacy issues in health communication is the ethical thing to do. Knowing that someone does not understand health vocabularies or may be embarrased to ask questions when they do not understand places a responsibility on the health communicator to adapt. Knowing that high levels of health illiteracy uniformly exist in the U.S. suggests that health communicators ought to be involved with improving the situation across the many contexts for talking about health.

Stephen A. Sommers and Roopa Mahadevan open their paper with the statement that the Affordable Health Care Act does not address low health literacy directly. BUT–they assert–the law cannot be successful unless national efforts strive to address low health literacy. Health literacy is mentioned in the ACA in relation to research dissemination, shared decision-making, medication labelings, and workforce development. “All four suggest the need to communicate effectively with consumers, patients, and communities in order to improve the access to and quality of health care” (p. 6).

So there we have it. If we are to achieve the aims associated with the ACA, including improving the population’s health and bringing health care costs under control, we will only achieve these aims through communication that adapts to and accommodates low levels of health literacy while motivating citizens to improve their health literacy.

September 14, 2012

Today is my daughter’s birthday. What a wonderful way to spend some time… reflecting on her years of growing up and the strong, healthy woman she is today. In the midst of thinking those lovely thoughts, I am clearing some desk clutter. I came across a glossy brochure from my health care organization. It says it is ‘exclusively’ for Health Advocate Members. I didn’t know that I was a member, but I guess I am. I opened it up and found five member wallet cards. A phone number is the highlight of the card, together with information about what HealthAdvocate does: healthcare help, EAP [employment assistance program], find the right doctors, and untangle insurance claims. Interesting. The brochure itself elaborates on each of these topics. For employee assistance, for example, the topics include stress and anxiety, work conflicts, anger and grief, as well as drug and alcohol abuse.

The brochure tells me that the way this all works is, I call the number which is toll free and I will get to talk to a counselor. Or, I can go online and access services. I’m not sure how well this all works. I’m not sure about a counselor communicating about so many health topics. Maybe the information is more general and the goal is to redirect a call to a more specific resource. It is interesting. I’ll check at the online resource and let you know what I think.

August 25, 2012

“BONIVA has not been proven to stop and reverse bone loss in 9 out of 10 women and is not a cure for postmenopausal osteoporosis”  [http://www.stategazetteftp.com/mags/parade/Pg_07.pdf]. This message has appeared in numerous magazines and newspapers. Have you seen or heard it?

I wonder how Sally Field feels about that. She appeared in ads to endorse the product and she read the script that said the research had shown that BONIVA reversed bone loss…  I will track down the research and see if we can find what the published research  really found. For now, I am reflecting on how many of us heard Sally’s ad versus how many of us have seen or read about the FDA’s retraction. And I am enjoying having the strength, including my bones, to pick up my 4 year old grandson and wrestle him into my lap for a family gathering at a restaurant after church on a warm Sunday afternoon.

August 9, 2012

When you have dense breast tissue… at least, that is what some physicians say [go here, for more:  http://www.womentowomen.com/breasthealth/densebreasttissue-mammograms.aspx ].

It has been 15 years since my annual mammogram led to a callback from the doctor for more x-rays and then a needle biopsy and finally ‘the all clear’ — no sign of cancer pronouncement. But it happened again last week. I got my annual mammogram on my way out of town to go to Atlanta for a visit with my daughter and granddaughter and son-in-law. And the day after I had the screening, I got a message on my home machine to call for a return visit…

Things have changed in the last 15 years, of course. Now, digital mammography makes some things more likely to be seen on the x-ray compared to film. Go here for a comparison: http://www.umm.edu/breastcenter/digital_mammography.htm?gclid=CNbCiKu_27ECFUlnOgodsH4A_A  

At any rate, I returned to the imagery center for more x-rays. Here is how the communication went. First, it was nearly impossible to understand the message on my answering machine. My husband and I listened to it a half dozen times. We looked up the phone numbers of the imagery center, and none of them matched what we thought we were hearing. Nonetheless, I wrote what we thought they were saying and tried the number. It rang out to a message saying that it was long distance. Not likely then to be what I needed to call. Next, I tried calling the number using the first 3 numbers that all the numbers online for the imagery center used. And the last 4 numbers we thought the caller was saying that appeared nowhere in the online listing. Success. I got a nurse who checked and said, “When can you come in?” And I made an appointment for the day after I would return from my visit, which was a week after the first mammogram.

I went to the imagery center, this time with my husband coming in. The volunteer greeted me with, “Oh. I am so sorry.” Yikes. Not what you want to hear. She remembered me from the week before because we had a long chat about my height. At any rate, I would venture to say–”so sorry” is not quite the right expression in this situation. Perhaps “sorry you have to come in for more tests” if ‘sorry’ is to be used at all. The expression and her empathy were, however, unsettling.

Once I was in the room with the x-ray technician, I encountered the other end of the spectrum. The communication was reactive rather than proactive regarding what she wanted me to do. “Put your arm up and grab the handle? I did. “No. Turn this way. Face the machine.” Her tone was irritated. Wow. It is 9:30 in the morning. Why is she so grumpy? I am the one getting my boob smashed again.    

She sighed. Letting out a clear expression of annoyance, she said. “Stick your bum out.” Who talks like that? “No. Look at me– Like this–” she said as though talking to someone she regarded to be extremely stupid. Finally, she was satisfied.

Time for another image. She turns me a bit and I try to enact what I have learned. I stick my bum out. “No.” she says harshly. “Stand up straight.” My arm began to quiver. Unavoidably uncertain about what I was doing wrong. Several more images and abrupt commands later, we were done.

“Will the radiologist come in here to discuss these with me?” 

“No. Wait in the waiting room. I will get you when he is ready for you.”

I asked the volunteer if she would get my husband when I got called to the radiologist meeting. She told me to ask the technician to do it. So, when the technician came to get me, I asked her. And she did. No attitude. Wow!

And then there was the radiologist. I don’t think he could have been nicer or clearer. He put two pictures up on a screen and pointed to a small round dark spot about the size of a pellet for a BB gun. “This is what we’re looking at that’s different,” he said. “All this is your muscle and dense breast tissue.” It all looked like a lot of snow to me but I could see the BB…

“We’re going to do an ultrasound to see what we can learn about that spot.”

“What will the ultrasound tell you?”

He launched into a helpful answer that I will summarize as, ‘if the sound waves go through the mass, it’s a cyst. If they don’t it may be something we need to take a look at.’

The sound waves showed no mass. He spent plenty of time making sure that it did not appear in any direction. And then he announced, “I believe it’s a cyst. I will call this ‘normal’ and you won’t need to return for a year. Unless, of course, you see or notice changes that should be checked. Any questions.”

Hip Hip Hooray…. But I wish someone  would give me a satisfaction survey to fill out about the volunteer and x-ray technician. I have a few thoughts about how their communication could be improved.

July 23, 2012

Doctors often recommend blood tests to help them diagnose our condition or to check our health status. For example, I have an underactive thyroid condition. As discussed in my book ‘Talking about health’ — my ‘normal’ numbers fall outside the range of a healthy ‘normal’ [see for a discussion http://www.denvernaturopathic.com/news/TSH.html]. I was diagnosed with this condition in my 20s and have taken daily medication to address it since that time. My mother was diagnosed with the condition in her 20s as well. I go to see my internist annually, and he puts in an order for a TSH [thyroid stimulating hormone] test [http://www.endocrinology-online.com/Content/For%20Patients/TSH.htm] that I go to the lab for several weeks before my scheduled appointment. This test is considered to be very sensitive–but what does that mean? It is the probability that a person having a disease will be correctly identified by a clinical test. However, a careful reading of the article at the link shows that the results may depend on the time off day you were tested–a reason why the test is given in the morning after fasting.

But aren’t all medical tests highly sensitive? Otherwise, why do them?

The answer to the latter is ‘because that is the best that can be done’. The answer to former is ‘no’. 

Take the CA 125 test, for example. The test was hoped to be a valid indicator of ovarian cancer. However, the test indicates the presence of other disease as well. So a positive CA 125 test validly indicates the presence of ovarian cancer sometimes but often does not:

“The result of a Ca-125 test is interpretable only by considering the context in which it was ordered. When you order a Ca-125 test you will have to estimate your patient’s risk for having ovarian cancer. If your patient can be put in a group in which the likelihood of cancer is high then a positive test is probably correct and a negative test wrong. If your patient can be placed in a low risk group then the positive test is probably wrong and the negative test meaningless. Furthermore, there is no way to evaluate a positive test. You can repeat the test and pick the best 2 out of 3; 3 out of 5; 4 out of 7, etc. Otherwise, she will be heading for surgery” [http://www.gynoncology.com/ca-125/].

So if your doctor orders a CA 125 test, remember that the results should be discussed. This is true of all medical tests.But when a test that has been ordered is not highly sensitive, it is really important to discuss the meaing of the test result. If the test comes back positive and is not highly sensitive, have a conversation and ask: ‘What’s next to rule in or rule out the condition you were testing for?’ AND ‘What other conditions could the positive test result suggest I may have? How will we rule out whether I do or do not have them?’

June 12, 2012

I am trying to imagine how my medical doctors perceive me. I tend to ask a lot of questions. I even bring — surprise surprise — information to an appointment and want to discuss it. I find that asking questions and sharing information leads my doctors to use vocabulary with me that I don’t understand and have to ask to have explained. And I am OK with that. But I cannot remember a time when I worried that my doctor, or my childrens’ doctors, or doctors treating my husband would label me ‘difficult’ because I asked lots of questions. But others do have these concerns.

A study published in Health Affairs conducted by Dominick Frosch and collaborators used focus group discussions to learn what barriers limited efforts to share decision-making with their doctors. They learned that participants wanted to be more involved in considering treatment and care options, but concerns that doctors would label them ‘difficult’ kept them from doing so. This suggests to me that doctors may need to make more explicit efforts to invite participation in shared decision-making, thus reducing the perception that participation will make an unfavorable impression.

Read more at: http://content.healthaffairs.org/content/31/5/1030

May25, 2012

After a brief hiatus to complete those piles of undone tasks [which are still not all complete but I'm making progress!], I wanted to share how communicating about health in my family may have helped my vision. I use ‘may’ because it appears to be the case, but I am not a medical doctor and can only tell you my personal experience–with a focus on how talking about health worked in this case.

First, setting the stage, I have low vision. For those of you who have low vvision, you know what this means. For others,  it means that limits related to my ability to see are significant. For example, I cannot drive… I see a low vision specialist at least every six months and more often if I feel the need based on some symptom. At any rate, in addition to impaired peripheral sight in both eyes and practically no vision in the left eye, at the last visit–my low vision doctor announced that a cataract had begun to develop. And it was in my so called ‘good’ eye. When I told my parents, my dad asked me if I was taking Lutein. He takes it for his vision. So this  family conversation started me on a path.

I looked online at google scholar and found quite a few published scientific articles about cataracts and lutein. Here is a link to one example: http://www.nutritionjrnl.com/article/S0899-9007(02)00861-4/abstract I went to Wal Mart and found lutein in the 20 mg size with zeaxanthin…which some studies specifically mentioned as being important with lutein. I took it 3 or more times each week. And this week, my visual acuity was significantly improved and the start of the cataract waas reversed…not there. Hmm. Sure am glad I talked to my dad…

Interestingly, the doctor wanted to know what I was doing differently because the change was a positive and clinically significant one. I told her. And she said, ‘the National Eye Institute at the National Institutes of Health have found that taking lutein improves eyesight…” She went on with more details but I was lost in the thought that ‘she knew this but she didn’t tell me. My dad told me…’ I have several follow-up questions for the doctor but did not ask them at the time. Why didn’t she tell me? Did she doubt the results? Did she think I wouldn’t take the supplement? She could’ve advised me to eat more fruits and vegetables with the lutein and zeaxanthin. I do eat a lot of these though and probably wouldn’t have changed my eating habits. Brussel sprouts is included in this list, as well as some others. See   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1722697/

But in the end, she didn’t say anything. I sure am glad my dad did…

April 4, 2012

In the research I discussed in my last post, I noted that there are different styles, so to speak, for predicting how we might want to communicate about our health. The personal control folks believe that their personal behaviors determine how genes relate to health. The participants who fit this style did not want to much communicate about their health. In fact, they were least likely to want to talk about their conditions. Perhaps they believe they have everything under ‘their control’. But what if not talking means that they miss a chance to prevent a poor health outcome?

Here is an example. On Dr. Oz today, he was giving advice about reducing fat in various parts of the body. He advised in one case to use red clover tea. He did not add that it should NOT be used if you are taking Coumadin/Warfarin–a blood-thinning medication. It interacts with the medication and can cause excessive bleeding. Someone in the facebook exchange about the advice noted this important fact.

Others noted that no one should take anything suggested by Dr. Oz without  first consulting a physician. And so, the idea of personal control does not mean we should NOT talk about our health. In fact, in trying to have control over our health, we need to be sure that the advice we think makes sense for us fits based on our pesonal health history and current medications and therapies.