Talking About Health; Why Health Communication Matters

When is reading a mammogram like looking for a polar bear in a snowstorm?

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.

When the rubber meets the road and a health message includes numbers

February 8, 2012

I am reading some research about how math anxiety leads us to avoid doing things that might have math or numbers included. I read one study where it all came rushing back to me. I was a freshman at the University of Michigan and taking the first of three classes in calculus. I didn’t quite understand some of the homework, so I visited the graduate teaching assistant’s office and was told, “If you don’t understand this, you better get out while you can ‘cuz it only gets harder.” I wasn’t feeling anxious about math until that meeting. In fact, I have always loved math and have a high aptitude for math. But worry and anxiety washed over me. There was no one to ask about this that I knew. It was my second week at a huge university with 10s of thousands of students. The TA must know what he was talking about. I dropped the class. Only to pick it up again and complete the three calculus courses with success later.

Still, I read the research conducted by Jackson and colleagues and that experience came flooding back, as the researchers found that at the college level, especially freshman year, “Students were told to leave class if they did not understand the material.”

Perhaps such experiences and our own love for math and science leads us to spend time with our granddaughter and grandson doing math. Making it a game more often than not, with me playing with my grandson–who will be 4 years old in the next week–counting and arranging and rearranging.

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?

Can you set the table please?

March 30, 2011 GUEST BLOG POST by Melissa VanAlstyne

“I have work to catch up on”, “I’m not hungry”, “I’m going out”, we have all heard these excuses when it comes to sitting down to a family meal and often it seems easier to just forgo it all together. However, research is proving just how big of an impact family meals do have. Not only is sitting down to a family meal a good way to keep the family connected but it also has a number of health benefits as well, one of which is promoting healthy eating habits among adolescents.

According to a journal article in the Journal of Adolescent Health [full citation below] having a family meal can help to detect early signs of disordered eating as well as help prevent disordered eating from ever beginning. Having a family meal allows adolescents to see their parents engaging in healthy eating habits and therefore model their own eating habits after them. In addition, eating together allows parents to monitor their children’s diet which allows them to detect signs of disordered eating earlier.

While simply prioritizing sitting and eating together is good in and of itself, family meals should be times that parents and children value and find enjoyable. This means keeping discussion at the meal free from conflict around food or other issues, thus making the meal something the family looks forward to each day.

While life is undoubtedly extremely stressful and busy and finding time to sit down and eat together may seem a daunting task, the benefits of making sure to prioritize this family time cannot be overstressed. Adolescents who report more frequent and enjoyable family meals have been repeatedly found to be at a decreased risk for engaging in unhealthy weight control behaviors. So find a time that works for your family, sit down, pass the chicken and enjoy!

Fulkerson, J. Neumark-Sztainer,D. Story, M. Wall, M.(2004).Are Family Meal Patterns Associated with Disordered Eating Behaviors Among Adolescents? Journal of Adolescent Health,35. 350-359

How do nurses cope with the emotions of caring for terminal patients?

March 26, 2010 GUEST POST by Jason Bankert

It is the common belief that nurses are the care givers and thus are more compassionate than physicians who are often perceived as hard and emotionless. The Intensive Care Unit (ICU) can be emotionally draining as many patients are in critical condition or are terminal. The care of terminally ill patients is called end of life care or EOLC. How do health care professionals, such as physicians and nurses cope with the emotional burden of terminal illness in the ICU and how do there perception, treatment and communication involving terminal ill patients differ? These different perspectives impact physician-nurse collaboration as well as their satisfaction with the quality of EOLC (Hamric and Blackhall 2007).

In a recent study conducted in the ICUs of a rural hospital in Southwestern Virginia and an urban hospital in Eastern Virginia, investigators examined these questions to provide an insight on how these different perspectives on EOLC ultimately impacts patient care and what interventions can be taken to reduce moral distress and improve physician-nurse collaboration (Hamric and Blackhall 2007). The study, based on survey responses, showed that RNs experience more moral distress during EOLC than do physicians, even though both groups identify the situation as morally distressful (such as aggressive treatment as requested from a family member when both groups feel the treatment is unnecessary (Hamric and Blackhall 2007). As a result, these nurses are less content with their environment or the perception of the quality of care given to the terminal patient. This higher emotional burden on nurses may be the result of their job. It is the nurses who provide the majority of the bedside care during EOLC and are in contact with the patient more often than physicians. Also, nurses lack finally authority over the treatment options implemented by physicians. Even though nurses may disagree with the way physicians communicate prognosis and diagnosis, they feel that they have no say in the final decisions regarding patient treatment during EOLC.

The emotional environment is more important for nurses who are in contact with the patient more often than physicians, providing most of the daily beside care tasks (Hamric and Blackhall 2007). Therefore, it is necessary to improve this environment to ultimately improve the overall quality of patient care. The best care in the ICU occurs when nurses are active participants in diagnosis and treatment decisions and are active in communicating with patients and families alongside physicians (Hamric and Blackhall 2007). In order to provide a environment where nurses can be proactive in the patient care, special attention and policy needs to be implemented to increase physician awareness of the extra emotional burden experienced by nurses and respect their input in regards to EOLC. Equally important is the improvement of physician-nurse collaboration. This may be accomplished by promoting open communication about the different perspectives of EOLC through team meetings, individual meetings with chief staff members and conferences involving staff and specialists from other institutions.

Hamric, A. B., L.J. Blackhall. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Critical Care Medicine, 35, 422-429. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/17205001

What’s wrong with these questions?

February 12, 2011

“What are you doing in your free time?” “What do you guys eat?” “Do you have a problem eating healthy?” “Why is tanning so important to you?” “Do you have an eating disorder?” “Do you think you have a problem with eating healthy?” “Do you choose white or whole wheat bread?” “How were you raised?”

Each of these questions has the potential to seem critical. Asking someone what they do with their free time…could be a friendly rapport-building question in the mind of the person asking the question. But it also has a risk related to seeming to imply that there might be a right or a wrong answer. And if that is true, if you ask me the question, I am going to want to appear to be the kind of person who spends my free time doing things that fit my sense of self. I don’t think of myself as “lazy” and so if I tell you that I like to watch “Survivor” or “American Idol”–will it seem like I am lazy?

And asking me what I eat–when, yesterday, today, over the holidays, when I eat alone, when I am at work? Again, there are so many ways to think about that question and how my answer may say something about me that I don’t want it to say. So, how about if I just say, “It depends,” is that helpful in suggesting how to guide my eating habits?

And what about tanning? I heard that you need some sunlight to get enough vitamin D to help avoid osteoporosis. So why shouldn’t tanning be important to me?

The questions and our answers are likely to be linked to telling us to change our behavior, and we have some instinct about that as well. Most of us like to make smart choices. So a little bit of coaching can go a long way toward helping… But, just telling us “to stop tanning,” or “don’t eat junk food,” or” find more time to exercise…” –well, we’ve heard it all before.

When we talk about health, it helps to think about the fact that most of want to be liked by others or at least to have a chance to show how what we do matches who we think we are…most of the time.

What is the meaning of uncertainty when it comes to illness?

April 21, 2010

Communication and uncertainty go hand-in-hand. Many of our theories in communication focus on uncertainty as a reason to communicate. In these cases, we usually focus on communicating to reduce uncertainy. We talk about how we use cues from others–such as how they dress, the hair style they wear, the way that they gesture, and even how fast or slow they talk and their accent–to decide how much we are like another person. In these ways, we are using nonverbal information to reduce our uncertainty about talking with someone.

In already established relationships, we also experience uncertainty. Relational uncertainty may happen because we don’t know if our friend or family member is being ‘honest’ about whether they think we should take the job, go back to school, or in a million little day-to-day situations–like what to wear, what to eat, or what to do with our free time. We often try to reduce our uncertainty in these sitautions as well by communicating. ‘What do you want to do?’ ‘What are you doing to wear?’ ‘Do you think I should take this job?’ ‘What about the fact that we can’t sell the house right now?’ ‘They didn’t offer me any moving costs–can we afford it?’ So relational uncertainty emerges in a thousand different ways as part of having relationships. And it is a challenge to imagine how to balance the relationship needs and well, live our lives. So what happens when into the mix we introduce illness?

A diagnosis, whether it is terminal or not–as suggested by one of the participants in my last post–may spark the motivation to communicate. The diagnosis might be for a chronic condition such as heart disease, high blood pressure, high cholesterol, diabetes, or even HIV. It might be a broken leg or a sprained neck. Into each and every one of these and possibly thousands of other diagnoses enters uncertainty. “Illness uncertainty” is a big part of the uncertainy. But “relational uncertainty” is introduced into a diagnosis as well. To improve our communication about health, keeping both kinds of uncertainty in mind may help.

A diagnosis often leads us to want to reduce illness uncertainty about such things as ‘what is it,’ ‘what does it mean for my life,’ ‘how long will it last,’ ‘how will we treat it,’ and a host of other questions that may lead us to seek information to reduce our illness uncertainty. Sometimes, there will be no answers as we seek information, and so we have to “manage” our illness uncertainty by knowing that we have done what we could to answer our questions and perhaps by joining support groups online or in other ways putting ourselves in a position to keep up-to-date with any new information. What we don’t often think about is that in some situations, “increasing” our illness uncertainty may offer the most hope. As an emotion, hope let’s us look forward to a future that is a positive one and where we see ourselves able to achieve important goals. When we do not have certain information about our illness, that may provide a path toward hope if we frame it based on such comments as, “the doctor told me, ‘I don’t see any expiration date on you'”,–meaning that there is no answer to a question framed as, ‘how long do I have to live’.

In some of my past research, I have talked about the acute phase following a spinal cord injuury. During this phase, patients and families often are most reassured by communication that increases their uncertainty about the course of the diagnosis. Doctors not knowing whether a patient will walk again is a hopeful thing. At the same time that the patient and family experience hope related to increasing their illness uncertainty, they may experience sadness and fear and anger about a sense of increasing relational uncertainty. This is a case where friends and family may be very supportive in the beginning but seem to be less so over time. Communication may need to be more direct to reveal what is happening. If a friend asks, ‘what can I do for you?’ and the ansswer is always the same–‘nothing’–the friend may quit asking and quit coming around. There are many reasons that we don’t ask for help–and we can discuss those in the coming days–but if we remember that it may increase a friend’s uncertinaty about the relationship if we say ‘nothing’ and we obviously need help. And their lack of helping when we obviously need help may in turn increase our uncertainty about them. And both may contribute to illness uncertainty in negative ways–relating to a lack of tangible and emotional support–perhaps we can stop the spiral and communicate about our health and our relationship in more fruitful ways… not always to reduce uncertainty… but at least in ways to manage it.