Talking About Health; Why Health Communication Matters

And when the shoe is on the other foot in health communication, so that a patient wants to reject treatment or medication, what then?

Jauary 17, 2012

Sometimes, life really is a race…

Here is my daughter pictured in a skull at the Head of the Charles rowing competition. Looking at it, I am thinking about how our discussion about conscience clauses ignores the other side of the story.

I was reminded of our right to refuse treatment based on our values and morals when I once more searched to find published research about how doctors, especially pharmacists, talk about these issues with patients when it means that a doctor/pharmacist is not going to provide medication or treatment.

Orr and Jensen conclude in the Journal of Medical Ethics,

“How should the clinician respond when a patient or family requests “inappropriate” treatment based on religious beliefs? As in all situations where there is disagreement about treatment options, good communication is the most important step towards resolution. The patient or family must clearly understand the medical situation. This may require repeated discussion, conversations with consultants,viewing of x-rays or other clinical data, or other efforts familiar to most clinicians. A management conference, which includes the patient/family, primary physician, consultants, bedside nurses and others from the care-team, is often the best way to ensure that such communication happens.” (1993, p. 145; http://jme.bmj.com/content/23/3/142.full.pdf+html)

The article’s title? “Requests for “inappropriate” treatment based on religious beliefs.”

I think the suggested course of communication in the decision-making scenario is a great model for how to talk about decisions when the shoe is on the other foot, so to speak…and the focus is conscience clauses and the provider’s religious beliefs.

What might happen when a pharmacist uses a conscience clause?

January 16, 2012

A conscience clause — when might a pharmacist feel conflicted about filling a prescription? The most commonly discussed event is birth control. Birth control pills, the morning after pill… these medications cause feelings of conflict between values related to pro-life and anti-abortion, and dispensing the medications.

The store, Target, supports a pharmacist’s rights not to fill these prescriptions. However, a pharmacist must direct a consumer to another Target store where the prescription can be filled. I can find no research that has been done to see how such conversations might take place or what happens when — as in the town where I live — there is one Target store. I don’t know if there is more than one pharmacist there. I don’t know if any of them object to filling these prescriptions. But if they do, what happens? How would I know? Who would tell me?

What is a conscience clause and how does it affect health communication?

January 14, 2012

Do you remember the first time that you heard the word ‘conscience’? I grew up in a household where my parents used the word and shaped my ‘conscience’ — my sense of right and wrong. And as an adult, I feel the twangs of my conscience guiding my decisions. I would hate to have a job where someone told me that I could not follow my conscience. It is hard enough to work in a job where and live in a world where not everyone shares my ‘conscience’. But at least I am able to behave based on my moral code, even if it doesn’t always reward me to do so.

Health care providers face challenges to their ability to act based on their conscience in some situations. Efforts have been made to adopt policies to allow health care providers to act based on their conscience. These ‘conscience clauses’ aim to allow doctors and pharmacists and other health care providers to choose not to provide some services because to provide the service would go against their conscience. Watch this video and we’ll talk more about this issue in the coming week.

Consumer Reports and Apple Juice: Why Did Dr. Besser Apologize to Dr. Oz?

December 11, 2011

Not long ago, near the end of September, I reflected on the debate that took place between Dr. Besser and Dr. Oz about apple juice. It was a chance to consider the meaning of evidence when reports appear about the safety of food or other substances. I noted that I would have appreciated it if Dr. Besser had spent more time talking about why the evidence was of poor quality and less time attacking Dr. Oz.

Well, new data is in. Dr. Besser apologized to Dr. Oz and aimed his criticism at the FDA where data about arsenic in applie juice had been piling up for a number of years. A new study released by Consumer Reports added to that data. Dr. Oz gives tips about the amount of apple juice that should be safe for children at different ages to drink. It is clear that all of us need to keep asking for answers to the question: how did the science reach that conclusion? When we ask, someone just might listen and try to give a more valid answer…

I guess it’s time to get a new dentist…

October 27, 2011

I don’t have good luck with dentists. I do my best to get recommendations. Things go along OK for awhile. Then I start getting advised to do things that don’t make sense to me. I ask questions. But I don’t get satisfactory answers.

My current dentist knows that I came to him several years ago. Not because I was just moving to the area. But I wasn’t feeling good about how talk with my former dentist was going. So, this dentist seemed great for awhile. But last year, he recommended that I get a crown in a tooth where it seemed to me that we should start with a filling. I should have gotten a second opinion because instead, I put off doing anything, built up resentment that the dentist couldn’t explain why a crown was needed. “It will just be better in the long run” doesn’t tell me anything. I guess we could just put crowns on all my teeth and it would be better in the long run if what that means is that my natural teeth wouldn’t be wearing anymore.

OK, I should’ve gotten a second opinion last year. I didn’t. I have all the same excuses everyone has. I didn’t have time. I didn’t want to offend my current dentist. I didn’t know how to go about finding another dentist and asking for a second opinion. Yikes.

Well, this week I had my first scheduled cleaning since the crown. The technician asked me how it was going and I told her that it hurt to chew a steak on that side where the crown is… “I don’t eat much red maet,” I said, “But when I do, it hurts.”

She said, “That’s nornal. It’s new.” I should’ve known right then that things were not gonna go my way. She took exactly 12 minutes to clean my teeth and then went for the dentist. He took 15 minutes to appear. When he appeared, the technician said, “He’s Mr. Funny man today.”

He took a look and a poke and announced, or mumbled I should say, something to the technician. She said, “So you want to do the four now?” Four what, I wondered.

“Let’s do all six.” Six what, I panicked.

“Six what?” I asked.

“Fillings.”

“What?!” Mind you, I had been to the dentist six months ago. I didn’t have any new x-rays done at the current appointment. What was different today from six months ago?

“Well, you have some wear in the enamel on the top of some of your teeth. The dentin is about to be exposed in some places. I just want to prevent that.” I guess I looked skeptical as he said, “I can show you.” He handed me a mirror. I opened my mouth. He pointed to one of my incisors. “See?” I looked and, yes, I could see a dip in the enamel. Nearly six decades of living might do that, don’t you think? That’s a lot of chewing and, well, grinding my teeth–a bad habit of mine. I must have looked skeptical still as he said, “I could show you the others, but you might have to stand on your head to see them.”

“I see what you mean,” I said to the technician. “He really he is a ‘funny man’ today. What are you going to do? Why?”

“I will just put a bit of filling in there to protect the tooth. It won’t take much drilling at all. But I’ll still numb you up real good.”

I checked out. Literally and figuratively. I didn’t ask any more questions. But I didn’t make the appointment for the fillings. I have been looking and can find no research or recommendations relating to taking this action. I do find some discussions that lead me to believe that the dentist will have to etch my tooth to make the filling stick–my lay term. And that it is the first step toward the filling not sticking and then needing–a crown.

I would love to be wrong about this. I want to trust the health care professionals I pay for my care. But I need them to explain why their recommendations make sense and to respect my decisions about actions labeled ‘preventive’ care. I don’t feel either of these exists in this situation. And so, I guess it’s time to get a new dentist.

Would you like to have a copy of the book, ‘Moral problems in medicine’, edited by Samuel Gorovitz and colleagues?

October 7, 2011

It happens. My library at home and in the office spills over onto the floor in my office. The floors at home. In the library. And the bedroom. There is the chair beside the TV. Oh and the table in the library. There is the tactic of placing a few books here and a few books there. All in the name of ‘decorating’ with books. But it reaches a critical mass and is just…too much. So I have selected some to part with. Before just dumping them into the local book drive box, I thought I would give you a chance to say that you would like to have this book. I will tell you a bit about it and how to have it [book jacket in tact and all] for your own.

First, let me just say that Penn State has approved a dual title degree program in bioethics, with Communication Arts & Sciences being one of the departments within which a student might elect to pursue this degree http://live.psu.edu/story/54735. I have always been fascinated and engrossed in debates about health, health care, and ethics. Not the least of these is the continuous discussion about whether access to health care paid for by insurance ’causes’ individuals to use more care–the moral hazard linked to insurance. It is because of my interest in this area that I’ve read hundreds [yes, ’tis true] of books dealing with the topic on all kinds of levels in all kinds of nations. And I own a lot of books on this subject–broadly speaking. Which brings me to this book.

Regarding the book itself, it is listed in this bibliography: http://www.qcc.cuny.edu/SocialSciences/ppecorino/SS640/bibliography.html regarding “General works in medical and bioethics.”

The book was reviewed positively in the Journal of the American Medical Association shortly after publication. http://jama.ama-assn.org/content/236/25/2906.1.short Notably, the reviewer comments on the fact that the book does not limit the topic to any one field but provides varied views from contributors in a number of fields. At any rate, if the topic interests you and you want this book, tell me so in the comment section. I will select someone to receive the book and go out of the blog to get your mailing information via email. Then the book will soon be traveling your way…

Weighing in — what’s the debate about Dr. Oz and the apple juice story really tell us?

September 21, 2011

All has been quiet on the talking about health front. I am in the midst of teaching the undergraduate class about designing health messages at Penn State, so it is odd that I don’t find my way here more often. But in the fury of the debate over the Dr. Oz show about apple juice. [go here to read and listen to the debate if you want more information: http://www.doctoroz.com/videos/arsenic-apple-juice], I had to make time to add a few thoughts.

First, in favor of Dr. Oz — his show entertains us and informs us at the same time. We do have to remember that someone has to pay the bills for the show, so the entertainment quality has to be there. It is that simple.

The positive things about a show like Dr. Oz is that it can arouse public passions about scientific issues and lead to health advocacy. It may increase healthy behaviors and improve our vocabulary when it comes to talking about health and the science of health.

But on the negative side–it can be confusing and contribute to inaccurate understanding. It may arouse public passions but these can be misdirected.

The apple juice show and related debate illustrates both. The headline for the page above and the text beneath illustrates this reality. What is an “extensive national study”? According to the text, it means “dozens of samples” from “three different cities”. That is neither extensive nor a nationally representative sample.

How was the study conducted? Even with the several dozen samples, there is much room for the approach to vary. Did the tester shake the apple juice before drawing a sample? That might be important in terms of how the contents in the apple juice are distributed through the liquid. Did the tester take a sample from the bottom of the juice container or the top? Did the tester take more than a single sample of juice from each of the containers tested? Inquiring minds want to know…

But instead of focusing on specific and direct questions to guide our understanding, the backlash focused on name-calling. Skimming the contents of various letters from companies represented on the show and the Food & Drug Administration–FDA–“irresponsible” might be the most frequently leveled charge. Dr. Besser calls the Dr. Oz show “fear-mongering”. Watch this exchange:

I give credit to Dr. Oz for remaining calm and answering the charges.

But I wanted to know more about organic and inorganic arsenic levels, and other issues such as I raised above. I wanted to know less about Dr. Besser’s “upset”…

What interesting bit of information did I learn on the Rachael Ray show?

September 8, 2011

Imagine my surprise when I was listening to Rachael Ray’s cooking show and one of the guests was a female doctor who talked about a number of important health issues and took some questions from audience members. I was surprised that this guest was on a cooking show. But then I was surprised by some of the information she discussed.

Along the way, she told the audience that they should refrain from sexual intercourse for 24 hours before having a pap smear to screen for cervical cancer. The reason for doing so is to increase the accuracy of the test results. I always receive written guidelines about preparing for my annual mammogram, including such things as not to wear deodorant or powder or lotion. But I have never received any guidelines about preparing for a pap smear. Not on an appointment reminder card. Not face-to-face with the person checking me in. Not from my doctor. Not in passing in conversation with other women.

I wonder how many dollars we would save if women knew to avoid sexual intercourse for 24 [the recommendation in the attached summary says 48] hours before an appointment for a pap smear and followed this advice. Apparently, sometimes the test result will show something that seems to be a problem but isn’t because a woman has had sexual intercourse.

I looked online and found some guidelines at http://womenshealth.about.com/cs/papsmears/ht/preparepapsmear.htm. I guess I will make it a goal to check whether there are things I should do to prepare for screening tests I have from now on. I suspect if you are like me, getting these things done on the prescribed timetable is hard enough. Too easy to procrastinate. I sure don’t want to have to them again just because I wasn’t prepared properly the first time.

How do you communicate to children about cancer?

April 5, 2011 GUEST BLOG POST by Joey Debernardis

Since cancer has such a huge impact on many people’s lives, I thought it would be a very important topic to talk about. More specifically, the study below considered how to talk to children about cancer. This specific study was done at ‘Three Principal Cancer Treatment’ in the United Kingdom.

The study was based of 38 participants at different levels of their cancer journey. The groups broke down as follows: young children (4-5 years), older children (6-12years), and young people (13-19 years).

Some of the results that were found were quite interesting. As a young child, the cancer patients were not able to voice their preferences. They just did not have the ability to do so. Children also worried about the permanence of symptoms. Older children were unhappy about their parents leading communications with the health professionals.

The children aged 4-12 years reside in the background of information sharing with health professionals until they gain autonomy as the young people (roughly 13 years). They then moved in a foreground, and their parents transition into a supportive background role. In this way, younger children begin to realize their abilities to voice their preferences. Parents and the professionals, in turn, can learn to develop their supportive background roles…

Gibson. F. (2010). Children and young people’s experiences of cancer care: a qualitative research study using participatory methods. Pubmed. http://www.ncbi.nlm.nih.gov/pubmed/20430388

How can we really understand informed consent?

April 3, 2011 GUEST BLOG POST by Aimee Hilton

You are told you have a left clavicle contusion and your face just screams “What?” You go home to research and find you simply have a bruised collarbone, i.e your shoulder is going to hurt for a little while. Doctors may forget that they spent eight plus years in education learning the medical jargon that most of their patients do not understand. So when the patient has an important decision on the line, like whether or not to participate in a clinical trial based on their illness, how do we organize the information to make an informed decision? When we can’t understand words like randomization and placebo, how can we really understand the informed consent?

A study performed by Jefford et al. (2009), looked at how well patients understood the clinical trial they recently enrolled in. 102 patients who signed up for a clinical trial concerning cancer within the last two weeks participated in the research. The most important results showed that doctors needed to ask specific questions pertaining to the patient’s understanding of the trial, instead of simply “Do you understand”. Using a method known as “the teach back method” allows the patient to understand and develop questions. As a patient, if making a decision about a clinical trial, be sure to restate the clinical trial process and informed consent to your doctor. It will make sure you understand and they know you understand.

Patients should also receive written information and a recording of the conversation discussing the clinical trial. This allows the patient to go back and look over any information they found confusing or did not comprehend. Doctors also should be sure to discuss the standard treatment and other possible treatments in the trial. Patients should be aware of all options and possibilities throughout the trial.

It may seem that clinical trial information is overwhelming. However, if the doctor presents the information in an organized process, the patient will be more likely to understand and receive enough information to understand the informed consent they need to sign. Clinical trials are very important for the advancement of science and treatments. If doctors can help patients have a better understanding of the trial, hopefully more patients will be willing to participate.

Jefford, M. Mileshkin, L. Matthews J. et al. Satisfaction with the decision to participate in cancer clinical trials is high, but understanding is a problem. (2009) Support Care Cancer, 19, 371-379.