Patient-Provider Communication and Health Information Seeking

Cheryl's Situation

• Cheryl, halfway through her sophomore year, felt overwhelmed and woke up with symptoms: sore throat, throbbing head, achy body, and a fever of 103.

• She suspected she had mono, based on a previous experience.

• A doctor at the student health clinic dismissed her concerns without a thorough examination, attributing her symptoms to burnout and suggesting rest and ibuprofen.

• Cheryl felt dismissed and unsupported by the doctor.

• Nathian suggested Cheryl take more communication classes, leading her to consider a double major in health communication.

Helen's Experience

• Helen's family worried about her declining health and convinced her to see her primary care provider.

• Sally accompanied Helen to the appointment, anticipating potential ageism from the doctor.

• The doctor repeatedly interrupted Helen and was patronizing.

• Sally intervened, advocating for Helen to finish her thoughts and pointing out the doctor's dismissive attitude.

• Joe praised Sally's advocacy and support for Helen.

Patient-Provider Communication

• Patient-provider communication involves the exchange of information and the creation of shared meaning and understanding between a healthcare provider and a patient.

• Communication is essential for good patient health outcomes.

• Rick Street and colleagues presented a model that identifies multiple paths along which verbal and nonverbal communication impact health.

• Six functions of communication in healthcare encounters:

  • Exchanging information

  • Responding to emotions

  • Managing uncertainty

  • Fostering relationships

  • Making decisions

  • Enabling self-management

• Communication affects health directly and indirectly through proximal (short-term) and intermediate outcomes.

• Proximal outcomes: patient understanding and satisfaction, patient-provider agreement, trust, and rapport.

• Intermediate outcomes: access to care, self-care skills, commitment to treatment, and social support.

• Health outcomes: physical (survival, cure/remission, pain control, functional ability) and socio-emotional (less suffering, emotional well-being, vitality).

• Example of communication healing high blood pressure:

  • Indirectly: diagnosis shared, patient understands seriousness, commits to treatment, blood pressure lowers.

  • Directly: touch lowers blood pressure, respiratory rate, improves sleep, and decreases pain (Papathanassoglou & Mpouzika, 2012).

• Research needs to be more systematic in approach and conceptualization (Street, 2013).

• Four steps for research (Street, 2013, p. 287, Table 1):

  • Step 1: Identify the health outcome and the mechanism for improved health

  • Step 2: Model the pathway through which communication leads to improved health

  • Step 3: Select appropriate measures for communication variables, proximal outcomes, and intermediate outcomes

  • Step 4: Develop interventions to target communication processes to activate that mechanism

• Research needs theory-driven explanations (Shen et al., 2018; Thompson & Schulz, 2021).

• Need multivariate, multilevel models that capture how patient-provider communication is influenced by contextual factors (Head & Bute, 2018).

• Need longitudinal studies to account for changes in health outcomes over time.

Patient-Centered Medicine

• Biomedical model: privileged physical manifestation of disease, snubbed psychological/sociological influences.

• George Engel (1977) proposed a biopsychosocial model: added psychological and sociological dimensions.

• This model promotes a systems approach, recognizing multiple levels of influence on health.

• Emphasizes how social and psychological characteristics interact with biological factors to influence health experiences and outcomes.

• Shift from physician-centered/paternalistic medicine to patient-centered medicine.

• In physician-centered medicine, the provider has all the knowledge, power, and decision-making authority. Patients are expected to do what they’re told.

• Moira Stewart and colleagues (2014) present the four components of patient-centered medicine:

  • Explore the concepts of health, disease, and illness with the patient

    • Health: what being healthy means to the patient

    • Disease: physical manifestation of the health condition

    • Illness: individual patient’s experience of the health condition

  • Understand the patient as a whole person

    • Learn about patients as unique individuals, exploring their life histories, and eliciting their health beliefs and values

  • Find common ground between the patient and provider

    • Agreement on health problems and priorities

  • Enhance the patient–provider relationship

    • Compassion, empathy, respect, and trust are essential qualities

Patient-Centered Communication

• Street (2019) presents an analysis of how various communication behaviors map onto conceptual components of patient-centered medicine.

• Providers need to:

  • Ask about patients’ health beliefs and concerns, elicit their perspectives on health, and clarify patients’ values as related to health

  • Work toward building a partnership with the patient and set an agenda for each visit that considers both patient and provider perspectives

  • Present information clearly and check for patient understanding

  • Be supportive, to listen, and to show respect for the patient

• Patients must do their part, as well, by:

  • Being a partner in the relationship (to the extent they feel comfortable).

  • Asking questions when they don’t understand

  • Listening and showing respect to the provider, and by sharing their beliefs, concerns, perspectives, and values.

• Finney Rutten et al. (2016): the more patients with chronic conditions experienced patient-centered communication, the higher their levels of self-efficacy.

• Zwingmann et al. (2017): an enhanced patient-centered communication style that emphasized empathy was associated with less self-reported patient anxiety and greater patient trust in the physician.

• Jiang (2019): patient-centered communication significantly improved patient satisfaction and patient trust, which in turn improved perceived emotional and physical health.

• Freytag and Street (2022) argue that there is mutual persuasion between the patient and the provider

• Shared decision making: happens when the patient and provider work together to make a high-quality decision that is based on the best current clinical evidence, the patient’s values and preferences, and is feasible

• Patients need to recognize and be mindful of their persuasive power in clinical encounters.

Patient-Centered Communication and Individual Differences

• Shen et al. (2018): Black patients experienced significantly lower quality of communication, less participatory decision-making, and less patient information giving and participation than white patients.

  • Black patients tended to have better experiences when their physicians were Black, and white patients tended to have better experiences when their physicians were white.

• Roter et al. (2002): female physicians engaged in more psychosocial information giving and information seeking, more partnership building, and more positive talk than male physicians

  • Visits with female physicians were about two minutes longer than visits with male physicians.

  • Better communication outcomes for female concordant visits than any other combination.

• Bertakis and Azari (2012): female physicians provided greater patient-centered care than male physicians and that female concordant visits had the greatest amount of patient-centered communication.

• Mitchell and Perry (2020): white patients reported receiving more patient-centered communication than Black and Latino patients, and Black patients reported receiving more patient-centered communication than Latino patients.

  • Black men experiencing discrimination and not having health insurance received less patient-centered communication

  • Latino men not having a usual healthcare provider received less patient-centered communication.

• Miller et al. (2019): patient-centered communication to be significantly related to patient likelihood of disclosing their sexual orientation to their provider in LGBTQ-identifying deaf adults.

Patient-Centered Communication and Technology

• Street et al. (2014): providers spent nearly 40% of the visit looking at the computer screen, and a little more than 30% was spent in silence

  • The more time providers spent looking at the computer screen and the more silence there was, the lower the ratings of patient-centeredness.

• Rathert et al.’s (2017) review found that every study had implications for at least one, if not more, of the communication functions:

  • 31 studies had implications for fostering relationships,

  • 29 for exchanging information,

  • 9 for making decisions,

  • 6 for enabling self-management,

  • 5 for managing uncertainty,

  • 4 for responding to emotions.

• In terms of fostering relationships, Rathert et al.’s (2017) review found that studies showed the vital importance of eye contact and how it can be undermined if a provider spends too much time focusing their attention on the computer screen and too little time engaging the patient.

• For information exchange, although the exchange of biomedical information may be facilitated by having access to the EHR, there was concern that the exchange of psychosocial information may be hampered.

• Too great a focus on the EHR may compromise a healthcare provider’s ability to recognize and respond to patient emotions

• Alpert et al. (2017) worked with a large healthcare system that had recently instituted the EpicCare system, which includes MyChart, a portal that allows patients to access their records, make appointments, and communicate with their providers.

  • When you consider both categories combined, provider responses to patient messages contained patient-centered responses about half the time.

    • Partnership building was evident in 36.2% of responses, and supportive talk was evident in 22.4% of responses.

• Duke et al. (2013) offer tips to help healthcare providers “optimize use of the EHR in the examination room while maintaining rapport with the patient and building the patient-provider relationship” (p. 359).

Communication Skills Training

• PACE program: teaching patients how to present information about their health concern, ask questions about the diagnosis and treatment, check their understanding of information the provider gives, and express any concerns they might have about the treatment.

  • Cegala, McClure, et al. (2000): trained patients were better at seeking and obtaining information from their doctors, better at giving their doctors more information about their health condition, and more likely to summarize and verify the information their doctors gave them than the informed or untrained patients.

• Harrington et al. (2007) developed PACE for Parents and PACE for Physicians to help improve parent-pediatrician communication about prescribing antibiotics for children.

• Accrediting bodies for nursing and medicine include communication skills as an essential competency

• Teach-back Training: is based on the principle that patient understanding is essential to achieving optimal healthcare outcomes.

  • After healthcare providers explain to the patient what their condition is and how to treat or manage it, they ask them to describe in their own words what has been explained.

Difficult Conversations in Healthcare

• Every conversation involves three goals: task, identity, and relational

• John Caughlin (2010) has argued that people who craft their messages to address task, identity, and relational goals have higher quality communication than those who do not.

• Allison M. Scott has identified four types of difficult patient–provider conversations: sensitive disclosures, challenging health contexts, high-stakes decisions, and charged topics (Scott, 2022).

  • Sensitive disclosures: bad news delivery, medical errors

  • Challenging health contexts: end-of-life planning, pregnancy

  • High-stakes decisions: genetic testing, complicated treatment decisions, participation in clinical trials

  • Charged topics: obesity and weight management, sexuality and sexual behavior, religiosity or spirituality, substance use, disability, mental health

The Montgomery Family

• Following Helen getting a breast cancer diagnosis, the Montgomery family was filled with medical uncertainty and pending decisions.

• Samuel was showing signs of teenage mood swings, snapping at his parents and not wanting to participate in school activities. Everyone looked stressed and worried.

The Patient Experience

• Heidi Ferrer had long Covid, but ultimately, committed suicide

• There are many people who suffer with profound uncertainty about their health.

Uncertainty:

• Inherent part of human existence, permeating all aspects of a person’s life

• Dale Brashers (2001), an expert on uncertainty in health, stated that “Uncertainty exists when details of situations are ambiguous, complex, or probabilistic; when information is unavailable or inconsistent; and when people feel insecure in their own state of knowledge in general” (p. 487).

Types of Uncertainty:

• Medical: some can be quite straightforward, whereas others are incredibly complex, information characteristics such as clarity, accuracy, completeness, amount, and ambiguity can all influence the patient’s uncertainty experience. A classic example is how it’s compromised when providers use medical jargon that patients simply do not understand.
  *Personal: involves whether the illness will affect patient identity (e.g., active, independent) and roles (e.g., parent, breadwinner). It also involves unpredictable financial consequences faced by the patient because of their illness (e.g., potentially outrageous medical bills).
  *Social: relates to unpredictable interpersonal reactions, such as encountering stigma, dealing with meddlesome or intrusive questions, and facing uncertain relationship implications.

Theorizing About Uncertainty:

*Charles Berger and Richard Calabrese (1975) developed uncertainty reduction theory to explain how strangers communicate during initial interactions. Their premise was that uncertainty was undesirable and that people would strive to reduce it so that their interactions with others would be more predictable.
*Merle Mishel’s (1988, 1990) uncertainty in illness theory and Dale Brashers’ (2001) uncertainty management theory are among those challenging these assumptions.
*Uncertainty in illness theory suggests that uncertainty results from the “ambiguous, complex, and unpredictable” nature of illness, which makes it impossible for patients to “determine the meaning of illness-related events” (Clayton et al., 2018, p. 49).
*Uncertainty management theory focuses even more on the evaluative aspect of uncertainty and recognizes that in some situations, maintaining or even increasing uncertainty may be what is desired.

Decision Making:

Four Components of Shared Decision Making:

*Using the best clinical evidence
*Considering the patient’s values and preferences
*Respecting the patient’s desire to be involved in the decision-making process
*Assessing the feasibility of the decision

*There are also research-based tools available to help patients and physicians make informed decisions, these tools are called decision aids, and they “prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty” (Stacey et al., 2012, p. 2)

Theorizing about Decision Making In addition to making decisions about their illness, patients must also make decisions about the communicative work of disclosing their diagnoses to other people. Sandra Petronio’s (2002) communication privacy management (CPM) theory and Kathryn Greene’s (2009) health disclosure decision-making model (DD-MM) lay groundwork for understanding this process.

Coping:

*Coping is defined as “ongoing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (Lazarus, 1993, p. 237).

Five Styles for Coping:

*A problem-focused coping style involves taking action to manage the illness as much as possible.
*An emotion-focused coping style involves dealing with emotions in some capacity.
*A seeking-understanding coping style involves trying to find meaning in the illness experience.
*A seeking-help coping style involves turning to others for social support (see Chapter 7). For example,
*An avoiding-the-problem coping style involves attempting to ignore the illness.

*Renee Lyons and colleagues (1998) wrote, “Communal coping is a process in which a stressful event is substantively appraised and acted upon in the context of close relationships” (p. 583).
*“Basinger’s results showed that the data supported three coping styles, not four as predicted by the model. The three styles were individual coping, communal coping, and ambivalent coping.

Health Literacy:

*The term health literacy was coined by Scott Simonds (1974), a professor of health education who argued that “Minimum standards for ‘health literacy’ should be established for all grade levels K through 12” (p. 9)

Definitions and Types of Health Literacy:

*Health literacy was originally defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and ser- vices needed to make appropriate health decisions.

*The 2030 Healthy People report however, distinguishes between personal and organizational health literacy. This dis- tinction recognizes that health literacy is not the responsibility of the patient alone.
*Four core components of health literacy are print literacy, oral literacy, numeracy, and cultural and conceptual knowledge.
*Additional components include media literacy, eHealth literacy, and scientific literacy
*You are not a horse. You are not a cow. Seriously, you’all’t'Tweet'

The Patient Experience:

• A lot going on for the patient ,often are in pain, afraid, and sometimes ashamed.