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Langham: Communication and Activation

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Medical News Today (MNT) recently published "Did I understand you correctly, doc?", an expose of communication between patients and physicians. It is a worthy subject for the workers' compensation industry, because every injured worker becomes immersed to some depth in medicine. For many, it will be both their first and most significant foray into medicine.

Judge David Langham

Judge David Langham

The MNT article contends that patient understanding is a critical element of care, and particularly so when dealing with "chronic diseases." Patients need to be engaged in caring for their conditions, and particularly aware of "potential complications" that are involved with or associated with those conditions. If patients are not "actively engaged in their own care," then we might anticipate an "impact (on) both care and safety."

Effective communication is a two-way street. Over decades of working with a vast variety of people, I have concluded that both speaking and listening are critical skills. Unfortunately, I have often found that listening is a skill that is too often ignored.

Sometimes, that is through a personality trait; some people seem to just be inherently weak listeners. Other times, I have seen that to be a situational issue in which poor listening is associated with the stress or emotion of a particular setting, such as a hearing or a doctor's appointment.

MNT contends that patients must be engaged in their own care. Becoming engaged will enhance care effects and outcomes. The informational deficit is illustrated by the story's example of diabetes. Studies are cited supporting that less than half of diabetes patients understand the link between this disease, heart disease and mortality. Even fewer appreciate the diabetic risks of stroke, and a great number do not appreciate diabetic risks of kidney disease and amputations. 

These risks are all well documented, and the Internet is replete with information. Why do patients lack this knowledge?

The point of disease knowledge is directed at care. Patient appreciation for risks and complications "improves patient adherence to treatment," and will perhaps delay or even prevent the onset of various complications. The adherence to treatment may include effective and regular use of medications, engagement of healthy lifestyle choices in broad contexts such as diet and exercise, and avoidance of behavior or situations with a demonstrated deleterious probability, such as alcohol or smoking.

In the age of the internet, there is a great deal of information available. Unfortunately, the internet is so full of information, that finding appropriate and succinct information can sometimes be challenging.

Stanford University recently issued a report that concludes there is untrue information on the internet. No surprise (how do I get funding for my own study?). But even some of our best and brightest have trouble recognizing bias or are "duped by sponsored content." Seemingly, if people are duped when they are at their best, they might be more susceptible to being mislead when under emotional strain that accompanies physical injury or illness.

The primary source of information for patients, however, is the physician, particularly the "primary care" physician. Patients have reported frustration at the volume of information received from their physician. And their perceptions include complaints of (1) a lack of information provided, (2) a failure to understand or remember the information provided, or (3) a combination of the two.

Patients have been documented as perceiving their physician's communication skills as lacking. Patients are not faulting their own listening skills, but their physician's speaking skills.

The MNT suggests that communication skills training for physicians could be of benefit in changing this dynamic. It cites data supporting that doctors with such training have demonstrated a patient "adherence to treatment" rate that is "1.62 times higher than among patients of doctors without training."

Patients whose doctors are trained communicators follow instructions better. The focus of this communication skills training is predictably two-fold, focused on both effectively conveying information and, equally important, the critical task of listening actively to the patient and thus understanding their perceptions, concerns and overall comprehension of the situation.

What impacts patient understanding and compliance? Some suggest that when a patient is provided information is important. They encourage the physician to consider whether the patient is ready to understand and absorb the information. 

It is also likely important how often the patient is provided with information. Repetition can be important in retaining information. We all seem to have a natural tendency to remember things that are repeated often. Sometimes that may be positive, but unfortunately, repetitive disinformation may have a significant and similarly effective negative reinforcement.  

MNT suggests that the physician's engagement with, and empathy for, the patient affects how communication from the physician is received and processed by the patient. It cites multiple examples of positive patient reaction to information delivered with consideration and genuine concern, both in comprehension and retention.

So physicians will be more successful with well-timed, empathetic and repetitious communication, and communication training can enhance their communication delivery capabilities. But this affects only half of the equation. The patient must be ready to receive and process that communication. Patients must be active listeners also. While physicians can affect that with timing, empathy and repetition, the patient must still be able, willing and prepared to receive. The best radio broadcast process is of little value if people lack functional radio receivers.  

The receipt and processing of information is referred to as "activation." Patients with "low activation" may ask fewer questions in the clinical setting. It is estimated that a significant volume of patients suffer from "low activation," for whatever reason. They may be unready to receive and process — that is, the timing may be wrong. This may be because of focus on other life issues, focus on primary diagnosis, focus on treatment details or the simple fact that new and unpredictable situations (the aftermath of an accident) are inherently stressful and, therefore, probably confusing and frustrating for even the best listener/patient.

MNT suggests longer patient interaction — longer physician consultations. Some physicians are said to offer "double appointments," a more complex interaction with patients, in furtherance of this. There is the suggestion that physicians can enhance care by recommending "reliable sources" of information, thus facilitating patient access to information that is less likely to be "sponsored content" (websites paid for by a party with a financial interest in selling some good or service) or otherwise inaccurate.

A patient might be directed, for example, to the web resources of the American Diabetes Association instead of being left to the mercy of whatever internet sites a particular browser produces in response to a general query on diabetes.

As with many issues in life, professional and personal, the critical point in communication is perhaps fairly simple: recognizing that there is a problem. When patients and doctors understand that communication is a skill, that it must be appreciated, learned and practiced, then both can become better at it. With enhanced communication skills on both sides of the conversation, patient care can be enhanced.

Physicians can be trained, reminded and encouraged to both effectively deliver information and actively listen. Patients can perhaps less readily be trained (by the time they know they will be a patient it is too late to train, and until they are a patient, they have little motivation to be trained).

But perhaps there are other ways to overcome potential patient deficits. I have been involved with some very skilled nurses and case managers who accompanied accident victims to doctors' appointments. They were adept at retaining and reiterating information for injured workers.

I have seen instances in which spouses and other family members successfully fulfilled a similar role in care and treatment. They can perhaps be a less-stressed set of ears, a dispassionate note-taker, or possibly ask some pointed clarifying questions.

The point of medical care is recovery when possible, prevention of further decline or complications, and alleviation of symptoms. Those engaged in care must appreciate that patients may not be ready for information, may not understand information and may simply forget information. Patience, repetition and empathy may be the keys to overcoming those communication challenges and to the success of the medical care process. And, some may need help from a third person to assist and facilitate the communication process.

David Langham is deputy chief judge of the Florida Office of Judges of Compensation Claims. This column is reprinted, with his permission, from his Florida Workers' Comp Adjudication blog.

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