Apr 3, 2009

Putting It into a Way Patients Can Understand



The dance performances that I look forward to every year are performances for the Harvard China Care kids at their weekly "Dumplings" activity Saturdays and their annual Children's Day Carnival. The kids are just too cute!

In an hour's time, I have to get the kids, ranging in age from 3-8 years old, excited about cultural dance and teach them a short routine. The excitement part is easy. Rhythmic music, extravagant costumes, flashy props, and the mere fact that I'm someone new is usually enough to generate excitement. Teaching is where I have to get creative.

Forget about formal dance terms. Plie, chasse, fifth position, and even the concept of beats often don't make sense to these kids. What do I do? I translate these dance terms into words and concepts they can understand. I tell them to not just stand on their toes to releve with their hands above their heads, but to reach for the stars. Instead of telling them to maintain a happy expression during the fast moving section, I tell the kids to remember to smile at their mommys and daddys who will be watching them.

I also constantly fish for feedback. I tell the kids to "Follow me!" or "Show me!" If there are any kids left standing still with a confused look on their face, I repeat the movements and try different analogies. For example, instead of smiling at their parents, I tell them to look for the funniest person in the audience. After the short lesson, we give a quick performance for the parents and China Care mentors. Performing, teaching, and then watching the kids dance is such a rewarding experience! It even beats dancing for audiences of over 1000 people!

Pauline Chen of The New York Times, recently wrote two pieces that I feel should be read together. The first piece is about connectedness as a measure of the strength of the doctor-patient relationship (click here to read!). In the piece, Chen refers to The Annals of Internal Medicine study led by researchers at Massachusetts General Hospital, which found that 60% of patients had a "connected" relationship with their doctor, 1 in 3 patients were "connected" to a practice of doctors, and 5% of patients were not "connected" at all. The study suggests that patients who are "connected" with their doctors receive better care.

The second piece is about health literacy and the large percentage of people who do not follow a doctor's advice simply because they do not understand it (click here to read!). Chen reports that nearly half of all Americans have difficulties obtaining, understanding, and acting upon information important to their health. The story Chen recounts of a former patient called Jack illustrates the great tragedy that a lack of understanding can lead to.

The messages of these two pieces intuitively make sense. As Chen says, for patients that she has known for a long time, she knows about their family and work and the patients know about her family and work. This allows for doctors to establish what Chen calls a clinical baseline. Providers then are quickly able to sense whenever the patients veer from that baseline.

It's quality interactions that help achieve this sense of connectedness between patients and their providers. In Chen's article, Dr. Steven Atlas talks about how care should be patient-centered. To illustrate this, Dr. Atlas suggests different models of care including patient interactions via e-mail, instant messaging, and phone calls all in addition to regular visits-- adapting the care model to the patient rather than trying to fit the patient to the provider.

While I believe exploring different models of care to adapt the care model to the patient is an important component of making care patient-centered, patient-centered care also puts a lot of the responsibility of care on the patients' shoulders. Shared decision making is what many call it. But, how do patients make good decisions if they lack understanding? How do patients and doctors achieve "connectedness" without understanding?



These questions become extremely important when treating underserved populations. How do you establish connectedness or impart the importance or urgency of medical advice if the patient doesn't speak English, works several jobs, does not have a reliable source of transportation, and only seeks medical attention when absolutely necessary? How are providers supposed to deliver the best possible care to these underserved populations? Simply waiting for these patients to come knocking or waiting for them to ask questions is not delivering patient-centered care and not delivering the best care possible to these populations. Providers need to mold care to the lifestyle of the patients and in a way these patients can understand.

As an Asian American, the difficulties minorities face in receiving the best care is a reality that I see often. Just a few months ago, a very close family friend was admitted to the hospital with an abdominal aortic aneurysm. My family friend, whom I'll call Auntie Ling, is an immigrant from Taiwan. She has been living in the United States for over twenty years. In that time, Auntie Ling has developed a strong support network of friends from the local Chinese school and local Chinese church. We are her extended family.

When we went to visit her in the hospital, Auntie Ling explained to us her various treatment options. She could either wait out the aneurysm and take blood pressure lowering medications or she could undergo surgery. Auntie Ling's husband then interjected that he did not want her to have surgery because there was only a 7% survival rate in the surgery. While we were visiting, the doctor came in for a short check-up and we were told to leave. We did not have the opportunity to discuss her condition with the doctor. Auntie Ling and her husband can both speak English more or less fluently, but did they both really understand what was going on?

Auntie Ling was discharged from the hospital on meds after a few days, but by the end of the week, she was back in the hospital because her pain and nausea had worsened. By the next week, she was transferred to another hospital for surgery. Her sudden decision to have surgery baffled me. My mom later explained to me that one of Auntie Ling’s friends from church had asked for clarification on the risks of surgery and found that Auntie Ling and her husband had misunderstood the survival rate. The surgery had not a 7% survival rate, but a 7% failure rate. That's a completely different message!

What kind of improvements could we have made to avoid this confusion? Auntie Ling and her husband demonstrated the ability to speak English, but this misunderstanding still occurred. Several national campaigns including Speak Up and Health People 2010 address health literacy and several reports including the 2007 National Healthcare Disparities Report and the National Quality Report recognize that significant gaps in care to underserved populations still exist.



On an individual level, all patients need to feel empowered to raise questions and providers should constantly check back for understanding. Recommendations and advice need to be framed in a way patients can understand. The National Healthcare Disparities Report and the National Quality Report recommend increased efforts of cultural competency training. Actions related to cultural competency are calling for language interpreters and using any means possible to communicate including pictures and diagrams while maintaining a respect for each patient's beliefs and culture. Families should also be involved in understanding when appropriate. Rather than "Do you understand?", perhaps "Can you please explain back to me what I have just said, so that I know you understand?" is more helpful.

What efforts can be made on a macro level to improve the connectedness between doctors and patients and improve the health literacy of all?

When it's health that is at stake, taking the extra time to ensure understanding by putting information into a way that patients can understand seems like a wise investment. When a patient returns with improved health because he/she was able to obtain, understand, and act upon good health advice, I'm sure that is just as, if not more rewarding, than teaching kids how to dance!

1 comment:

Eva said...

Sometimes I think Dr. Pauline Chen of The New York Times and I have connected stream of thought. In a piece about the underutilization of interpreter services, Dr. Chen writes...
“To a certain extent,” Dr. Fernandez said, “physician-patient communication is driven by the physician’s need for patient input rather than by the patient’s need to communicate. Communication is viewed as something that is supposed to change decisions that the doctor can foresee. So the use of interpreters may have more to do with how we think about communication with our patients and less to do with our views on interpreters, limited English proficiency patients or even time pressures.”Click here to read the entire article.