by Winnie Furnari, RDH, BS, MS, FAADH and Toni S. Adams, RDH, MA
RDH: “So, Bob, how's your home care?”
Bob: “Well, I got the hedges trimmed and the gutters cleaned out this past weekend.”
Patient (upon receiving full upper and lower dentures): “How do I take care of my dentures?”
DDS: “Treat them as if they were your own teeth.”
So the patient made an appointment to see the RDH.
Brand new RDH to a patient in a perio practice who had been diagnosed with decay three months earlier: “Did you go see your dentist like we told you on your last visit?”
Patient (indignant): “I don't need to be told to do anything. I'm an adult!”
It took one full year for the RDH to smooth out this misunderstanding.
The middle-aged immigrant's condition had not improved, as it should have after taking the medication prescribed for him two weeks earlier. The patient was adamant that he had taken the medicine as recommended, so the physician asked to see exactly how. After receiving a glass of water, the patient took out a packet of waxed paper and opened it carefully to reveal the original, though faded, blurry, and wrinkled prescription. He put the paper in the water, drank the water, then carefully refolded and rewrapped the prescription in the waxed paper. He had been doing exactly as instructed: “Take this with a glass of water twice a day” (Desmond & Copeland, 2000, p. 203).
Miscommunication happens. Words and language can be ambiguous and some words give offense. We have encountered this problem in practice, teaching, and speaking. It is one thing when this type of miscommunication is easily noticed, perhaps gives everyone a laugh, and then is quickly corrected. It is quite another when the damage takes a year or more to repair, cannot be repaired, or worst of all, when the patient's health is affected. The clinical aspects of modern patient care are difficult enough — we want to minimize misunderstandings so we don't need to “talk on eggshells.”
The true scenarios at the beginning of this article illustrate a common axiom of the communication studies field: The message sent is often not the message received. We can all think of experiences in practice and in our personal lives that confirm this. There are many filters between the thought in one person's brain and the interpretation ultimately produced by another person's brain. The speaker translates a thought into spoken words that may not exactly express his/her original idea. The words the listener hears may not hold the same meaning for him/her as they did for the speaker, so understanding of those words may be further altered. We may also incorrectly “read between the lines.” The process is complicated even more when emotions, assumptions, lack of judgment, inattention, and numerous environmental factors get in the way. There may be problems with the English language, differences in native language, and/or lack of understanding of medical terminology and procedures.
Some of the answers can be explained in the context of culture. We treat people from numerous cultures and want to be sensitive to them. This is different from being politically correct. It is about considering that what you say may actually hurt someone's feelings or cause confusion in regard to health care. How can we best provide messages that are compatible with our patients' values and beliefs? Even though we may all be speaking English, our value systems and comprehension come from different influences.
Words can mean one thing to you and something entirely different to someone else. To communicate well, we must be aware of three main issues: cultural competence, linguistic competence, and health literacy. In general, the first two relate to practitioners and the third relates to patients. In 2007, the American Dental Hygienists' Association accepted the definition of cultural competence as “awareness of cultural difference among all populations, respect of those differences, and application of that knowledge to professional practice.” Linguistic competence refers to “the ability to communicate effectively and respond appropriately to the health literacy needs of all populations.” Health literacy refers to the patient's ability to find, understand, and correctly use health information. (For an expanded explanation, see the excellent article by Jennie N. Fleming in the March 2007 issue of RDH.) According to the Ask Me 3™ Web site, a patient's literacy level is a stronger predictor of health status than age, income, employment, education, or racial or ethnic group.
The English language is complex. Among the roughly 200,000 most commonly used words, many have multiple meanings, many have the same meaning, and pairs of words sound the same but have different meanings. The medical and dental languages can also cause confusion.
Wolf and colleagues (2007) found that people who spoke English as their first language had trouble understanding certain words on prescription labels, including antibiotic, medication, prescription, dose, orally, or teaspoonful. Many confused the words teaspoon and tablespoon. The outcome could be tragic if a parent gave a child a tablespoon instead of a teaspoon of medication. These and other terms can be even more confusing for people trying to master English.
Katalanos (1994) found that some Southeast Asian refugees who were trying to learn English had a tendency to confuse the words test and taste. Imagine the uncertainty that could result when a person is told he/she needs a blood test and thinks the clinician said “blood taste.” Even when the word test is heard correctly, someone who is unfamiliar with our culture might envision a written or school test rather than a medical procedure.
Some words are puzzling, but others can be offensive. When delivering presentations, we have been admonished for using certain terms to refer to specific groups, even when we thought we were being respectful. Be aware that preferred terminology to describe particular groups can differ depending on location and can also change over time.
There is no universal solution to this problem, but we can minimize it through prevention — and dental hygienists are prevention specialists. Let's begin with self-assessment. Many cultural experts agree that the first step to becoming culturally competent is to become more aware of our own cultures (Goldman, Monroe, and Dubé, 1996; Thiederman, 2005). There is a tendency in North America to think that culture is the exclusive territory of certain racial, ethnic, religious, and national groups. This is not true. All people, including Americans and Canadians, have their own distinct cultures and subcultures. When we are steeped in a culture, we are less likely to notice it. It is necessary to understand our own cultures in order to begin to understand other cultures; such self-exploration is enlightening and just plain fascinating. Begin self-discovery by asking yourself some key questions and discussing your findings with others. For suggestions about how to get started, check out Thiederman's article online (see reference list).
How aware are we of cultural differences in our patients, and how do these differences become barriers to effective communication? We need to learn about other cultures. Attend a course. Read an article or a book. Research online. Talk to people from the cultures that interest you and those whom you serve in your practice. In light of your personal cultural exploration and new knowledge of other cultures, evaluate your personal beliefs and attitudes and determine which health beliefs are similar and which are different.
Now you're ready to mentor others. Incorporate increased awareness in the office with co-workers. Support and/or perform research on effective cross-cultural communication and then share your new knowledge.
Steer away from assumptions and stereotyping. Everyone is biased in some way; it is just human nature to be ethnocentric. The important thing is to be aware of our assumptions. And remember that there is as much diversity within cultures as there is among them. Learning some generalities about certain groups gives us some helpful starting points of understanding, but every individual is, well, an individual, so never assume that a person has particular beliefs or values just because he or she appears to belong to a certain group.
To further decrease the possibility of miscommunication, follow the advice of Ask Me 3™. Ask Me 3™ is a program co-sponsored by the National Patient Safety Foundation and the Partnership for Clear Health Communication to decrease medical errors by reminding patients to ask three key questions at every health-care encounter. It is mainly aimed at patients with low health literacy, but can be applied to all patients. In our case, it can be turned around for providers and become Tell 3. The three questions that patients should remember to ask are: “What is my main problem?” “What do I need to do?” and “Why do I need to do it?” It is amazing how often patients walk away without answers to these fundamental questions. If we make sure that all patients receive this information in an understandable format, then we will have gone a long way toward minimizing miscommunication.
Certainly we should use the correct scientific words but they can be explained using common words. The Ask Me 3™ Web site lists examples of problem words that can cause misunderstandings and offers suggestions for alternatives. Instead of saying “progressive,” say “gets better” or “gets worse”; and instead of saying “generic,” say “product sold without a brand name.” Also say “problem” instead of “dysfunction,” “wound” instead of “lesion,” and “checkup” instead of “test.” Many more examples are available on the Web site. One common problem word in the dental field could be “prosthesis.” Consider saying a “replacement for a tooth” or “teeth that are man-made.” Take the extra moment to use both the technical term and the more understandable explanation.
Besides educating yourself about cultural and health literacy issues, also try to create an open, nonjudgmental atmosphere to make it more comfortable for patients to ask questions. Use plain language; sit down when talking with the patient so that you are both at the same level; use various types of visual aids and models; and, probably more importantly, ask patients to “teach back” the information. George Bernard Shaw wrote, “The greatest problem in communication is the illusion that it has been accomplished.” The “teach back” step will help confirm that the message sent is the message received.
We are suggesting that you take a number of challenging steps that will take some time, both at work and outside of work. But that time will have been well spent. We should never stop learning about others or about ourselves so that we can diminish the need to talk on eggshells.
American Dental Hygienists' Association, Minutes of the Second Meeting of the House of Delegates, 84th Annual Session June 25, 2007. Available at www.adha.org.
Desmond J, Copeland LR. (2000). Communicating with today's patient: Essentials to save time, decrease risk, and increase patient compliance. San Francisco: Jossey-Bass.
Goldman RE, Monroe AD, Dubé CE. (1996). Cultural self-awareness: A component of culturally responsive patient care. Annals of Behavioral Science and Medical Education, 3(1), 37-46.
Katalanos NL. (1994). When yes means no: Verbal and nonverbal communication of Southeast Asian refugees in the New Mexico health-care system. Unpublished master's thesis, University of New Mexico, Albuquerque.
Thiederman S. (2005). American culture: Knowing yourself in order to understand others. Retrieved Nov. 7, 2005 from: http://www.thiederman.com/articles_detail.php?id=37.
Wolf MS, Davis TC, Shrank W, Rapp DN, Bass PF, Connor UM, et al. (2007). To err is human: patient misinterpretations of prescription drug label instructions. Patient Education and Counseling, 67(3), 292-300.
The authors wish to thank Shirley Gutkowski, Suzy Burzynski, and other special friends for generously sharing their personal stories and encouragement.
Brief parts of this article have been excerpted from Toni Adams' forthcoming communication handbook for dental hygienists.