- Duc M. Chung [forum disccusion]

Introduction

Global-minded and culturally-sensitive communication skills are pertinent yet often overlooked components of our health care education system. Emphasis in health professional schools has been on mastery of scientific concepts via problem and system based learning, following didactical algorithms to make diagnoses. While these do provide necessary clinical skills to treat patients, of equal importance is that health care providers are aware of national health care issues and attain effective communication skills to promote healthcare prevention and continuity of care for all patients. Research from the World Health Organization indicates that although the US has the most costly healthcare system, it is the only developed nation aside from South Africa that do not provide healthcare to all of its citizens.ⁱ In fact, an estimated 42.6 million people are uninsured.ⁱⁱ These astounding statistics account for the US’s low ranks in health and well-being (it ranks 26th amongst industrialized nations in infant mortality rate) and healthcare satisfaction (only 40% of US citizens are satisfied with their healthcare system).ⁱⁱⁱ

A 2001 survey of 6,772 patients indicated that minorities are more likely to have trouble communicating with healthcare providers compared to non-minorities;^iv as many as twenty percent of Spanish-speaking patients do not seek medical attention due to language barriers.^v The healthcare student should be mindful of these growing disparities in our healthcare system and become an advocate for those who lack a voice.

At the community level, errors in communication have profound adverse effects. Within healthcare facilities, misinterpretation of prescriptions, poor interactions amongst health care providers, and inadequate patient education have estimated to harm approximately 1.5 million people annually, amounting to 400, 000 preventable drug-related injuries in hospitals, 800, 000 more in long-term care facilities and 530,000 in outpatient Medicare clinics.^vi

Increases in costs which resulted from these communication errors and inadequate clinical judgments prove to be most significant, as demonstrated in the table below:

Table 1. Increases in Cost due to Medical Errors.^vii

^{More emphasis should thus be placed on establishing stronger communication skills that would cultivate a more patient-centered approach to health care delivery to eliminate these costly errors. A proposed mechanism for this change would be to strengthen three specific tiers of communication in our medical training: provider-community, provider-provider, and provider-patient interactions.}

I. Provider-Community Communication: The Provider as a Community Leader

^{An essential aspect of patient care is understanding the needs of the community in which the patient belongs. Health professional students should be required to engage in a set number of community outreach events, such as volunteering at free clinics or organizing community health fairs to promote health prevention. Interwoven with these outreach activities would be mandated courses in public health and communication skills to strengthen the student’s leadership role in his or her community.}

The mode of health information dissemination is a crucial component of this interaction. Information that patients obtain at home has more recently shifted from media-based to internet-based and interactive software. Closer examination, however, reveals that there is a literary and “digital divide” amongst variant socioeconomic classes.^viii As health information is often written at the eighth grade level, low literacy members (those reading at grade two or below, often non-native members of the community) may have trouble understanding available information. Subsequently, studies have demonstrated these members have four times annual health care costs compared to those with higher literary skills.^ix Moreover, low literacy in elderly patients should not be disregarded. A recent study demonstrated that 81 percent of the elderly had difficulties comprehending basic healthcare information such as prescription labels.^x To better accommodate for these barriers, health professional students should be trained to communicate healthcare information in a manner that is accessible to everyone, be it using more visual stimuli such as on-line videos, skits, or showing health-related movies as part of community events. Furthermore, as immigrant communities emerge, it is imperative that health professional students be required to take additional foreign language courses to better understand the needs of those communities.

Yet a primary concern remains access to information in certain racial ethnic groups as well as low-income and rural communities. A study in 1998 reveals such growing disparities as shown below.

Table 2. Internet Access at Home by Race, Family Income, Geographical Location^xi

Compounded with low literacy and personal disabilities low-income, rural, and minority groups are at a clear disadvantage in terms of access to health information. More focus, then, should be placed on other mediums of disseminating health information. These could take the form of students traveling to remote areas to educate rural communities or journeying to schools in underprivileged neighborhoods to promote health prevention. Students could then articulate the needs of these communities to local leaders to enhance internet access for all.

In promoting more access to the community, the Health Promotion and Prevention Initiative recommends that students be made aware of the following:

Table 3. Presentation of Information to Promote Health & Prevention^xii

In addition to being a proponent for change in their communities, professional students could take additional technology courses and collaborate on designing websites and interactive programs that are easily accessed by all members of the community. Taken with community outreach opportunities and public health communications training, the technologically-conscious professional could better accommodate for the needs of his or her patient.

II.Provider-Provider Communication: Providers as a Collective Team

Working collaboratively and respecting the roles of other healthcare providers are an integral part of caring for the patient. However, research shows that communication barriers still exist between healthcare providers. For instance, amongst residents and attendings, varying age, disparate cultural backgrounds, and training often lead to tension when caring for patients. A few real life scenarios of these tensions along with ways to overcome them are outlined below.

Table 4. Tensions between Residents and Attendings & Mechanisms for Change^xiii

Miscommunications between nurses, pharmacists, and physicians are not uncommon in the hospital setting. A National Academy of Science’s Institute of Medicine report revealed that an excess of 7,000 people are killed each year as a result of poor handwriting by doctors misinterpreted by other providers and patients; less than 10% of American doctors also do not have access to the internet in their surgery.^xiv To mitigate these drastic statistics, all health professional students should be required to learn how to use electronic medical records as part of their medical training and schedule regular meetings with other providers to debrief about patients under their care. Fortunately, an e-prescription program is currently being implemented to help physicians and students become more aware of drug-drug reactions.^xv

More importantly, providers must mutually respect each other in the care of patients. For instance, in Nursing Against the Odds, Susan Gordon explores how nurses’ roles as empathetic health care providers are often strained by long work hours, insensible duties, and lack of acknowledgement from superiors. To promote better care, Gordon calls for a broad agenda that includes safer staffing, improved scheduling, and other policy changes that would give nurses and nursing students a greater voice at work. She proposes that the main stimulus for doctors and nurses to collaborate more effectively is respect-respect for each other’s presence, and respect for each other’s opinions in the care of patients.^xvi

Our health-care training should thus encompass a well-rounded knowledge of the potential impact that other healthcare providers may have on patients’ well-being be it dentists, doctors of eastern medicine, chiropractors, and perhaps most importantly, the role that interpreters may have on immigrant populations. Providers should be trained to interact with paraprofessionals in a respectable manner through attending one another’s annual conferences or community meetings where mutual intellectual exchange could take place. Students should also learn to work with medical interpreters at an early stage as often the biggest mistake that providers make is allowing interpreters to talk for the patients as opposed to letting patients talk for themselves. Below are key points implemented by the International Institute at Buffalo for effective usage of interpreters:

Table 5. Strategies to Communicate Effectively with Interpreters^xvii

^{Effective communication with interpreters, in turn, helps patients better understand their physicians and improve compliance. Taken collectively, a group healthcare providers who are cognizant and respectful of each other’s roles and who are willing to collaborate with one another could translate into more effective care for patients.}

III. Provider-Patient Communication: Global-Minded Providers and Well-Informed Patients.

The most essential component of caring for the patient is communicating effectively with the patient and understanding his or her individual needs. Because of the tremendous diversity around us, effective communication should encompass not only awareness, sensitivity, and knowledge of the patient’s condition but also transcultural and cross-cultural awareness. For instance, a culturally sensitive and aware student would realize that promoting the use of condoms by members of some African-American communities may be interpreted as a strategy to promote black genocide by limiting reproduction. The same mindful student would also not interpret a Native American patient’s lack of response or periods of silence as signs of resistance but as a common cultural means of communication amongst native members.^xviii

Yet gaining such valuable insights requires that health care students have a breadth of diverse cultural experiences. As statistics show that minorities compose only three percent of medical school faculty and sixteen percent of public health school faculty, professional schools should strive to increase these numbers to ensure that students gain multiple health perspectives in their training.^xix In addition to the required science coursework, professional schools should place more emphasis on a candidate’s depth and breadth of non-science coursework. Once in professional schools, students should be required to take a set number of electives in international health or medical humanities to gain an appreciation for other cultures. Moreover, students should also be given more clinical exposure to rural or underserved communities via precepting under physicians who care for these communities. Under such mentorships, students can take on research projects working to improve conditions for minority patients and their families. The table below outlines specific points to embrace in communicating with patients from diverse backgrounds.

Table 6. Strategies to Help Students Communicate More Effectively with Patients from other Cultures^xx

^{The common theme underlying these recommendations is an awareness and appreciation for patients’ personal beliefs and practices. These skills could only be cultivated through direct exposure, hence, students should begin their training with an conscious and receptive mind for these differences.}

Another imperative factor in establishing patient-centered care is involving the patient in health care decisions. The first step in this process is helping providers and students communicate more effectively through the elimination of medical jargon. Students can attain such skills through weekly classes with standardized patients and receiving feedback or role-playing with one another and engaging in community outreach projects. Patients would be empowered to collaborate with health-care providers to manage their illness without subsuming a more inferior role in the interaction.

The American Academy on Communication and Healthcare recommends the following three pronged approach toward healthy provider-patient interaction, which should be taught to all health professional students:

Table 7. Strategies toward Healthy Provider-Patient Interaction^xxii

Additionally, in the clinical setting, students could learn to focus more on the following key areas:

Table 8. Areas of Focus in Provider-Patient Interaction^xxii

^{The strategies and skills provided above simply could not be attained overnight, hence, professional schools should expose students to the clinical setting in the first semester of medical education and have students practice to reinforce these pertinent skills throughout their training. Effective provider-patient interaction translates into a more informed patient, better compliance, and an overall improvement in patient-centered care.}

Conclusion

Unifying the Three Tiers of Communication.

Patient-centered care really beings at the community level, where professional students learn to be mindful of the needs of their communities through direct work with those communities. Such an active role could only take form if students are trained on how to communicate effectively with patients and execute those skills in a variety of clinical settings, be it journeying to local free clinics or schools to promote health prevention. Having learned the needs of their communities, providers could work together in an environment of mutual respect and intellectual exchange to provide more cohesive care for patients. These could take the form of more frequent seminars and conferences or simply learning to the respect the important role that each provider may have on the well-being of patients. Any tension or miscommunication should be addressed in an open-manner and through peer feedbacks to improve upon disparate modes of health-care delivery.

Patient-provider communication could be strengthened through repeated exposure to patients from diverse backgrounds. Such interactions begin with a receptive and culturally conscious mind. It is imperative that providers also learn to communicate without medical jargon or cultural biases. Most importantly, providers should listen carefully to patients and engage patients and their families in the decision-making process. Providers should empathize and have open communications with patients to ensure that individual needs are met. Although some of these skills can be taught, the vast majority can only be cultivated through many years of clinical experiences. As Dr. Francis Peabody eloquently states in his final talk, “The Care of the Patient” in 1927:

“Medicine is not a trade to be learned but a profession to be entered. The treatment of a disease may be entirely impersonal, the care of a patient must be completely personal…the secret of the care of the patient is in caring for the patient.”^xxiii

If we embrace this philosophy, certainly we would realize that there is an intricate science and art to patient care. It’s not just about pinpointing a chief complaint and fixing it, it’s about understanding the human condition and recognizing the humanity behind every patient. If we are attuned to the needs of a patient, we would realize that although medicine can cure, only an attentive ear can heal.

ⁱ World Health Organization. (2009). Facts about Healthcare Inequaties. www.who.int.
ⁱⁱ “Health Insurance Coverage,” Current Population Reports, US Census Bureau, September 2000.
ⁱⁱⁱ Ibid,WHO.
^iv Collins, K. et al (2002). Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. The Common-wealth Fund 2001 Health Care Quality Survey. The Common Wealth Fund.
^v Institute of Medicine, Committee on Understanding & Eliminating Racial & Ethnic Disparities in Healthcare (2002). Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care, B.D. Smedley, A.Y. Stith & A.R. Nelson, eds. Washington, DC, National Academies Press.
^vi Ibid, Institute of Medicine, National Academy of Sciences.
^vii Encinosa, W. and Hellinger, F. Impact of Medical Errors on 90-Day Costs and Outcomes: An Examination of Surgical Patients.Health Services Research Journal. July 2008.
^viii Street, RL, Gold WR; and Manning T, eds. Health Promotion and Interactive Technology: Theoretical Applications and Future Directions. Mahwah, NJ: Lawrence Erlbaum Associates, 1997.
^ix Eng, T.R; Maxfield, A; Patrick, K; et al. Access to health information and support: A public highway or a private road? Journal of the American Medical Association 280 (15): 1371-1375, 1998.
^x Ibid, Eng et al.
^xi “Computer and Internet Use Supplement to the Current Population Survey,” Current Population Reports, US Census Bureau, 1998.
^xii Adapted from US Department of Health and Human Services. Healthy People 2010. 2nd Edition With Understanding and Improving Health Objectives for Improving Health. 2 vols. Washington, DC: US Government Printing Office, November 2000. http://www.healthypeople.gov/document/HTML/Volume1/11HealthCom.htm.
^xiii Scenarios adapted from: McCue, JD; Beach, KJ. Communication Barriers between Attending Physicians. Journal of General Internal Medicine, March 1994, Volume 9 Number 3. Springer New York. P.151-161.
^xiv Ibid, Institute of Medicine, National Academy of Sciences.
^xv Ibid.
^xvi Gordon, Susan, Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Medical Hubris Undermine Nurses and Patient Care, Cornell University Press, New York, April 2006.
^xvii International Institute of Buffalo. http://www.iibuff.org/ 2009.
^xviii Kavanagh, K; Kennedy, P, Promoting Cultural Diversity: Strategies for Health Care Professionals, Sage Publications, Newbury Park, CA. 1992. p.39-40.
^xix Betancourt, JR et al (2002) Cultural Competence in Health Care: Emerging Frameworks & Practical Approaches. The Commonwealth Fund.
^xx Ibid, Kavanagh et al. p.46.
^xxi American Academy of Communication and Healthcare. http://www.aachonline.org/
^xxii Frankel, RM; Stein, Getting the Most out of the Clinical Encounter: The Four Habits Model, The Permanente Journal, 1999;3(3) http://xnet.kp.org/permanentejournal/fall99pj/frhabits.htm.
^xxiii Oglesby, Paul, The Caring Physician: The Life of Dr. Francis W. Peabody, Harvard University Press, Cambridge, MA 1991. p. 220.