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’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.

Why did Dr. Oz introduce Dr. Nemeh on his show today?

February 2, 2011

Well, with all the winter weather slamming the nation, I thought a picture to remind us of spring was in order…

Dr. Oz discussed healing through faith on the show today [http://www.doctoroz.com/videos/man-faith-healer-pt-1]. This is one of my favorite topics in health communication. Dr. Oz introduced Issam Nemeh who was very comfortable answering all kinds of questions. For example, “Couldn’t the lung mass have really been a virus that cleared up on its own?” “A biopsy showed it to be a mass… It was there and then it wasn’t.”

My favorite phrase used several times during the show by several people, including the host and the guest–“it isn’t ‘either’ — ‘or’. It can be both” They were referring to…healing through faith and Western medicine…working together.

In ‘Talking about health’, Tina Harris tells the story of her brother when he was young and the years that her family dealt with his breathing difficulties. Her brother had many hospitalizations and saw many doctors over almost five years. During all of that time, they prayed for a healing of Ken. Then, the family found a doctor who shared their faith. The family prayed with him. The comfort they had based on the shared faith guided them to feel comfortable with scheduling a surgery with the doctor, believing that God would use the doctor’s own faith and skill to improve their son’s health. Then, the miracle they had been praying for happened. Ken was healed. He no longer needed surgery…and as Tina said, her brother sings the Lord’s praises every week in church…

Tina and I have explored the topic of the role of religious faith for beliefs about genes and health. We find, of course, that some people do not believe in God. Religious faith is a strongly held value. In a nation founded on religious freedom and among citizens who largely claim to be religious, openly declaring one’s own lack of religious faith is not a declaration likely to be done with little thought behind it. But expressing belief in God is also not a declaration done with little thought, and finding a way to make a space for either in conversations about health is important…to health and healing…

How do we talk about pain?

January 18, 2011

Have you ever been asked, ‘On a scale of 1 to 10, where 10 is the most, how bad is your pain?’ I’ve been asked that question. I have heard others be asked that question. I have even seen it in prime time shows. Is it just me, or is that a hard question to answer?

I took a quick look online to see what kind of research there might be about ‘taling about pain.’ I found very little published research. There is research about pediatric pain and getting kids to use pictures of faces to tell about their pain. Then I found an article about developing a measure of neuropathic pain [http://www.meduniwien.ac.at/phd-iai/fileadmin/ISMED/Literaturhinweise/Bennett_LANSS_Pain_2001_92.pdf]. It has the kind of things that I would imagine being more helpful both for making treatment recommendations and to help a patient be able to answer. It asks whether the pain feels like pin pricks, for example. A doctor takes all of the patient’s answers to add up for a total pain score. This seems to be a good way to talk about pain when working to manage it…

Should we ask our doctors about antibiotics?

138_07301 February 27, 2010

On the ABC evening news this past week, Dr. Besser advised the audience, “Do not ask your doctor for antibiotics.” He provided the evidence to support the claim that asking for antibiotics greatly increases the chances that a doctor will prescribe antibiotics to a patient. He went on to explain that antibiotics are designed to treat bacteria. They do not treat a virus.

I would reframe this conversation. From the doctor’s side, if a patient asks for antibiotics to treat a virus, this seems like a great opportunity for the doctor to explain, “Antibiotics do not work to treat a virus, and your cold is caused by a virus.”

The advantages of this approach include the chance to improve a patient’s health literacy. We can increase our own understanding about health if our doctors take the opportunity to use these teachable moments to ‘teach’ us.

Another advantage is that we feel able to ask a question about our treatment without concern that our doctor might prescribe something unncessary. One likely unintended of Dr. Besser’s advice to not ask for an antibiotic is that it may lead us to wonder, ‘how often would a doctor prescribe something to me just because I asked for it?’

The medical research supports the conclusion that in the U.S., direct-to-consumer advertising leads patients to ask for tests and prescriptions that increases the likelihood that a doctor will order the tests and/or prescribe the medication. So, like in the case of antibiotics, when a patient asks — a doctor is more likely to prescribe.

But is this always a bad thing? We have decades of research to support the conclusion that the time demands on a doctor and the ever growing body of research about available therapies for various conditions = less chance to consider all options in each situation. To participate in our care, we should ask about treatments we may know about. Just asking may prompt the doctor to consider a path that wasn’t the one being considered. Just because it is considered doesn’t mean it should be selected. Sometimes, however, the doctor might judge it to be a ‘good idea.’

If each time a patient asks a doctor for treatment that is not a good match to the health condition, a doctor feels compelled to prescribe the treatment, it will lead to further waste in the health care system. We know that a doctor is not likely to follow the path a patient suggests if the doctor believes it will be harmful…at least, in the short term. But with antiobiotics as a case to illustrate, we want our doctors to think about our well-being in the long term. And if our request doesn’t make sense, take a minute to tell us why it doesn’t.

This approach means that doctors and patients can keep talking, and that their communication might benefit health in the short term and the long term, and the cost of health care as well.

Do we want doctors to tell us if we have advanced cancer?

117_1755 February 18, 2010

In 2002, Hisako Kakai published an article in the journal, Health Communication, about preferences for disclosure of a cancer diagnosis. Dr. Kakai indicates that in Japan, a direct communication style is usually preferred when it comes to disclosing one’s personal diagnosis of cancer. In other words, people want to be told they have cancer. However, an indirect communication style with no disclosure, or an ambiguous disclosure to the patient was preferred for a family member. The article raises many interesting communication and ethical issues.

A serious diagnosis raises the question, ‘how do we deal with uncertainty?’ Communication plays a big role. It points to the reality that we often are not good with dealing with uncertainty. We frame uncertainty as ‘bad’ and let uncertainty overtake everything good that might be going on in our lives. This relates to how we communicate about a serious health condition. It also relates to how we communicate about the economy, about security, and about an endless number of issues that equal being — human.

The message communicated often to us is, ‘work hard and it will pay off’ — with payoff crossing a spectrum from health, relationships, and wealth. The message, ‘life is uncertain. Work hard at your relationships and school and work, and take satisfaction in the fact that you worked hard’ — is communicated less often, if at all. And it shows up in our inability to deal with uncertainty, our obsession with …reducing the uncertainty.

Should the goal in communicating be to reduce uncertainty? When it comes to our health, that may not always be the best aim. If we can learn to manage the uncertainty of a diagnosis, we may be better able to live our lifes as someone living with cancer or heart disease or diabetes. If we make the diagnosis a more integral part of our being and identity, we may communicate in ways that define us to others as being disabled rather than living with a disability, diabetic rather than managing life while living with diabetes, and so on.

Even more surprising, when we focus on managing our uncertainty as a part of life, we may even discover that there are times when we communicate to increase uncertainty. Instead of being certain that our future, our health, our well-being are uncertain and that is a bad thing, we can use uncertainty as a way to promote hope. In our own research, Ben Cairns and I found that this was particularly important for people who have newly experienced spinal cord injuries and their family members. ‘Will she walk again? Will he be able to do things for himself? Can she sit up on her own? Can he feed himself?’ Not knowing offers people living with the injury and their families and friends the hope that they might do these things again.

Communicating to increase uncertainty about a diagnosis thus gives some time to adapt to a diagnosis. And that may be the best and more ethical way to communicate about an advanced cancer diagnosis as well. Not telling so that a patient does not know a true diagnosis may seem to offer a way to manage a serious diagnosis and thus to reduce uncertainty. Telling and acknowledging that the diagnosis is serious, even very serious, but that predicting exactly when the end-of-life will happen is uncertain may give some time to adapt to the diagnosis and some hope that important things that have not been said can be…

…a lesson in Dr. Maureen Keeley’s award-winning book, Final Conversations that has been shown to be so important for those who know that they are dying and the loved ones they will leave behind.

Why should we keep track of our use of vitamins and other supplements and who should we tell?

February 11, 2010

119_1917a Taking vitamins is the number one way that U.S. citizens ‘complement’ the formal health care they receive. This is a finding that has been consistent for some years and the 2005 Institute of Medicine Report about use of complementary and alternative medicine [ http://www.iom.edu/Reports/2005/Complementary-and-Alternative-Medicine-in-the-United-States.aspx] considers this reality as well.

Many debates about using vitamins, minerals, and other supplements — including garlic or herbs or cinnamon or ginger — focus on getting us to eat ‘healthy’ rather than depending on vitamins to make up for a diet that may be lacking. Other debates focus on the cost of ‘unproven’ therapies.

Whatever the debate, keeping track of use increases our ability to report use to our doctors. Talking to our doctors about use may make the difference between a therapy working or not. Many prescribed medications have been found to interact with different vitamins and other supplements, spices, and/or herbs. Sometimes, we need more or less of a medication based on use. So keep track and talk about use to avoid harmful effects.

What is a “competent” health communicator?

119_1944a February 9, 2010

I received a ‘smileworthy’ email from my friend and colleague, Ed Maibach, on Monday. He had received word that one of the articles we co-authored had been named to the 50 most read articles in the Sage journal, the American Behavioral Scientist. In fact, the article is #5 on the list, as you can see if you visit http://abs.sagepub.com/reports/mfr1.dtl

The article’s title, “Competencies for the health communication specialist of the 21st century,” gives some idea why it has been one of the most read publications. The importance of this area both theoretically and in application has been widely recognized. This has contributed to a surge in adding health communication classes to undergraduate and graduate programs around the world. And in adding these programss, the debate continues about the focus of education and training.

As I looked back at the lessons learned to develop the article, I realize that many of these competencies are ones that we all need in order to successfully navigate the health information that might only be described as overwhelming in quantity and sometimes questionable in quality. One of the competencies that health communication specialists may choose as a focus focuses on gaining access to and using various electronic databases. As we’ve discussed on this site before, we all need to harness the skills to do this. One of the most important issues remains the ability to identify the sources of these messages in order to consider the validity of their claims.

The emphasis in the article reflects the importance of understanding the role of both media and interpersonal communication on our health habits. To continue the conversation from yesterday, we too often do not seek formal health care because our family or friends don’t support doing so. And we frequently substitute care from our support networks for formal health care. In fact, one of the roles that many faith-based organizations assume relates to providing support to members sruggling with illness or recovering from events that limit their well-being. This may include injuries on the job or the death of a loved one.

Perhaps one of the most surprising and least considered areas of health communication competence relates to impression management. This, too, flows from the knowledge generated from research and practice in interpersonal communication. I reflect on my own hesitation to reveal my failure to behave in ways that I know I should. I want others to form a positive impression of me and to like me. And it carries over into health realms. Besides wanting to present our own best image, we often–with little thought–help others project their own best image. So we may fail to ask our doctor about something we thought we would be talking about in our appointment because we are thinking that to do so might seem to imply that we are ‘criticizing’ our doctor.

Other competencies related to the 21st health communication specialist that we identified more than 15 years ago that all of us will benefit from include media literacy skills associated with understanding gatekeeping relating to content. As discussed in the former post, media stories about medical research likely appear far ahead of therapies to benefit our well-being related to the research findings. Understanding that media seek to give us novel content supports our ability to reflect on the gap between a story and its translation to our care.

So a competent health communicator likely begins with our intention…to understand, to reflect, and to participate in making decisions about our health in informed ways guided by our efforts and experiences. 119_1914

What is race-based medicine?

Winter afternoon January 31, 2010

Medical research has shown that there are some patterns linked to racial group categorization in how some medicines work. Some medicine may metabolize faster or slower for some racial groups–in general. Lower does of some medicne may be required for treatment of members of some racial groups–in general. Similar patterns have been observed when comparing how men and women respond to some medications or therapies–in general.

What’s wrong with talking about race-based medicine?

First, stereotypes emerge from communicating about any group as if every member of the group behaves and responds in the same way to anything. Not everyone in the group will respond as suggested.

Second, it may seem to suggest that others who are not members of the racial group are less at risk for a condition. If we are a member of a different group, we may distance ourself from feeling at risk for the condition and socially distance ourselves from those who are at risk. This may happen because communicating the medical research that finds members of a particular group seem likely to respond in a particular way may seem to suggest that anyone not mentioned is not at risk. If, for example, efforts are made to commmunicate about a particular group’s response to treatment for heart disease becomes the focus of advertisements aimed at selling the treatment to members of the group, the unintended message may be, ‘They aren’t talking about me so I have less risk for heart disease.’ When communicating about therapies for men, for example, women may have long assumed that they were not a risk for heart disease, and that, of course is not true.

Third, communicating about race-based medicine may unintentionally contribute to the formation of stereotypes. As shorthand, classifying someone as a member of a group reduces our uncertainty about how we expect he or she will ‘be.’ As a result of such communication, we may, for example, form views that all members of a particular racial group are at risk for a particular health condition.

Finally, stereotypes of others and our own feelings of social distance from them often forms the foundation for stigma…our feelings of stigma about people and conditions, and our behavior toward those we consider to be members of a stigmatized group.

In sum, communicating about race-based medicine must be done with care to achieve valuable health outcomes and to limit harmful social outcomes.

Why don’t we ask doctors to clarify information when we don’t understand it?

January 15, 2010

I’ve done it. Have you? Walked out of the doctor’s office scratching your head, telling your waiting family member or friend, or running to the nearest computer to get online…and figure out what the doctor was talking about. Why don’t we just ask?

First, it is a bit embarrassing if the doctor says something and doesn’t ask us if we have any questions. It seems like we should know what is going on. So, we don’t ask because we feel embarrassed that we don’t understand. These days, I try to ask myself, “Do I literally want to ‘die’ from embarrassment?” If I don’t understand and I don’t ask a question, what are the chances I could…fail to follow advice, fail to understand my diagnosis, and well—harm my health…

Second, we have to admit to ourselves that we don’t quite understand what’s going on. Cholesterol called good cholesterol and bad cholesterol…what does that mean? Isn’t it all bad? If I at least ask the doctor to spell it or write it out, I find that most of the time, I get more information and I get it reinforced in writing.

…two ways to help myself out when I don’t understand……