Chapter 7: Improving Doctor-Patient Communication: Bridging the Gap
Many view interpreters as neutral individuals who transmit information back and forth - the "interpreter as a conduit" model. In real life, however, interpreters are often active agents, negotiating between two cultures, and assisting in promoting culturally competent communication. The translation may not be literal and may involve the use of metaphors and ideas that have no direct equivalent in the second language. This role is closer to that of a co-diagnostician, as interpreters decide which medical information is valuable, seek illness-related information independently, and participate in the diagnostic process.
When people talk about the need for health literacy, they often think first about what learners need to do for themselves. However, there is also a pressing need to teach doctors, nurses and medical students how to communicate more effectively with low-literacy patients. It is important for health care providers to speak the language of the patient - after all, theres little point in making a brilliant diagnosis if the patient ends up not following the doctors advice because he did not understand what the doctor said!
Literacy results from an interaction between the reader and the writer and it is not fair to criticise a patients reading skills without considering the skills of the author. The mismatch between what people need and what the healthcare system offers is unhealthy and can be deadly. Too often, there exists a chasm of knowledge between what doctors know and what patients understand. Both parties are equally responsible, and to understand why, we need to look at two concepts - the Curse of Knowledge and the ASK Problem.
"The Curse of Knowledge". The curse of knowledge, otherwise known as the paradox of expertise, is one of the reasons experts have trouble using plain language to communicate their ideas to others who do not share the same level of expertise. Doctors spend a great deal of time with other doctors, but not enough with patients with limited literacy skills, which means while they speak fluent "medicalese", they find it hard to talk to patients in plain language.
The "ASK" Problem stands for the Anomalous State of Knowledge. This occurs when the patient does not have the knowledge needed to ask the right questions to make a sound decision. In order to ask good questions, we must have fundamental understanding of the problem at hand. The more complex the nature of the information to be processed, the more difficult it is to ask the right questions.
To solve these issues, both patients and doctors need training in how to better communicate with each other. For low literate patients, remember that the spoken word is far more important than written communication. Here are some tips for clear verbal communication. None of this is rocket science - its simple common sense. Just pretend you were explaining diabetes to your 75-year old grandmother who is hard of hearing and you will know what to do.
Organise your information.
Use common words, not technical jargon.
Give your patients a chance to express how they feel and to tell the story of their illness.
Make direct eye contact.
Use written information as a backup.
Plan with your patients what they can do.
Let your patient know what you are thinking.
Explain procedures and take permission for every examination.
Focus on your patient, not on your notes, X-rays or the computer screen.
Check that your patients have understood what you have said.
Translation and Interpretation
It is difficult to achieve seamless communication between patients and doctors, even when they speak the same language. When there are language and cultural barriers, the difficulties get multiplied manifold. It may seem an easy solution to simply translate your pamphlets and materials into local languages. However, because of cultural differences, they will not be as useful because values and beliefs wouldnt match. This makes translating patient educational materials a challenging task.
Before you embark on translating yourself, check to see if there are appropriate materials already available in the languages you need - there is no need to reinvent the wheel. A few excellent websites to check include: Health Information Translations (@http://www.healthinfotranslations.org/); Ethnomed (@ http://www.ethnomed.org); Spiral (@http://www.library.tufts.edu/hsl/spiral/ index.php) and Healthy Roads Media (@http://www.healthyroadsmedia.org). It is high time that the Indian government creates a free library of patient educational materials in regional Indian languages.
If you decide to translate the material yourself, be sure to enlist the help of your patients! Foods, customs, traditions and rituals are widely different between cultures and they must be relevant to the reader in order to ensure comprehension. Once translated, materials should be translated back into English to ensure that no changes in meaning or content have been introduced. Interpreters can assist in improving health literacy. Many view interpreters as neutral individuals who transmit information back and forth - the "interpreter as a conduit" model. In real life, however, interpreters are often active agents, negotiating between two cultures, and assisting in promoting culturally competent communication. The translation may not be literal and may involve the use of metaphors and ideas that have no direct equivalent in the second language. This role is closer to that of a co-diagnostician, as interpreters decide which medical information is valuable, seek illness-related information independently, and participate in the diagnostic process.
A good interpreter serves as more than just a translator. He provides a cultural bridge between the patient and provider. "As interpreter, my heart is with the patient. I interpret what the patient feels and where he is coming from. But my mind is with the provider - where their knowledge, their wisdoms and their scientific values are. "(Navajo Interpreter)
The use of family and friends as interpreters is not always in the best interests of the patient. Unless the situation presents an emergency, there may be issues relating to confidentiality, conflicts of interest, and a lack of familiarity with medical terms. Untrained interpreters may miss, add, or substitute information, and they often do not understand the importance of interpreting everything the patient says.
They are likely to include their own thoughts and opinions and impose their own judgments as they speak. For example, if a family member knows someone that was cured of a similar condition using a certain medication; he may be convinced that the same medication will work on everyone else. That family member may not understand that differences between patients can mean significant differences in treatment needs. In addition, it is very difficult to be objective when you are talking about a loved one. Last but not the least, patients themselves may be less likely to be open about confidential or personal information with certain family members and friends. Where possible, a trained health interpreter is best. If one is not easily available, you can use online interpreters using Skype, and there are also commercial organisations that offer these services over the telephone.
The health issues encountered by immigrants reveal the need for interactive, two-way health literacy efforts. True dialogue can only be achieved if health literacy is erceived as a goal for both the patient and the provider. In the centre column are suggestions for both sides to improve the likelihood of a successful health outcome.
Patient navigation and patient advocacy
In your practice, you may wish to consider using patient navigators or patient advocates, who help low-literate patients with the complex process of managing their health. In 1990, Dr. Freeman established the first Patient Navigation programme at a hospital in Harlem, New York, USA when he noticed that many poor or low-literate patients were either avoiding cancer screening altogether, or not following through on their abnormal test results. The purpose of the programme was to help improve access to cancer screening and ensure proper follow-up among poor patients. A five-year review showed that the survival rate for cancer patients had increased from 39% to 70%!
Poor patients face many barriers in receiving cancer screening and appropriate follow-up. These include: financial constraints; transportation hassles; and bias amongst healthcare staff. Patient navigators can guide patients interpret test results (e.g. possible cancer), take them through complex procedures in cancer care and help ensure they get the right tests and follow-up done at the right time. They can also ensure adequate respect and compassion for the patients.
Patient Advocates (@http://www.patientadvocate.org) are similar to patient navigators, but their role is expanded to include help with filling out complex forms, accessing healthcare and disability services, and negotiating financial issues such as medical debt. They help patients navigate the maze of health insurance throughout their care.
Patient advocates come from healthcare professions including nursing, medicine, and social work. They use their skills to help patients make the right decisions for themselves.
The most effective patient advocates are trained in low literacy and cultural communication issues.
Many hospitals run a separate Department of Medical Social Work and medical social workers are specially trained professionals who help patients access affordable care.
Most doctors tell patients to improve their lifestyle in order to remain healthy. However, no matter how well intentioned your patient maybe, we all know that its hard to lose weight, stop smoking, and start exercising. Even if your patients know what they need to do, actually incorporating these changes in their daily behaviour can be very difficult. This is where health coaches come in. A health coach is trained to help people break their health goals into manageable steps, nudge them in the right direction, track their progress, and identify and overcome personal roadblocks.
Like traditional coaching, health coaches utilise goal setting, obstacle identification, and use of personal support systems, thus setting up an accountability partnership that is focused on helping people reach their health goals. Doctors just dont have enough time to spend with their patients going over nutrition, lifestyle and stress reduction. Health coaches can fill that gap, thus preventing their problems from becoming worse.
Learning from patients
Communication is a two-way street, and your task is not only to teach your patients, but to learn from them as well. If you keep your eyes, ears and mind open, you will find that patients have expertise that can be used and shared, if they are involved in their own treatment plan. You owe it to your patients that they feel respected and treated as people who bring practical experience to the table.
Make use of the expertise that your patients bring as learners.
Respect, involve and appreciate them.
Recognise that patients can teach health professionals.
Support organised learners groups and activities.