Not all patients grasp current, evidence-based information
by Diane Paz, RDH, EF, MEd
Just like any other year, I was full of high expectations for 2005. It was a year for new students, a new semester, and a chance to fulfill my resolutions, the ones I again swore I’d stick to. To that end, I set up doctor appointments so that at least I could smile proudly and say indeed, I was keeping my word.
Things were going well until I scheduled my routine mammogram. It was at a facility I had visited many times, and although my doctor was preparing to retire, he and his staff had always behaved professionally and I had full trust in them. My omen should have been when I arrived; they said that the doctor was not in. Apparently he was having a surgical procedure and would not be available for a few days. I was disappointed. One benefit of this facility was that the doctor would read the mammogram and ultrasound at the time of the appointment, alleviating any anxiety or making a referral if necessary.
With the doctor out of the office, I was told that as usual, the technician would take my radiographs and ultrasound. The doctor would read them at a later date and let me know the results. Unfortunately, that moment came sooner rather than later. The technician said something appeared different than last time and that she would show it to the doctor, the one who wasn’t supposed to be there! She returned and sheepishly explained that although he was in, he was sedated and not himself. But he wanted to see me anyway.
I entered the exam room and he began his physical. What came next is what prompted me to write this article. After a brief exam, I nervously asked if this could possibly be a cyst, to which he replied, “No, this is a mass. Anything else I can do for you?” The callousness with which he spoke was shocking. I said, “Well, I guess that isn’t good news,” to which he responded, “Could have been worse.”
I thought, “You just told me I have a mass in my breast. Not much to be happy about there.” The good news is that I went for another exam and biopsy and they couldn’t find what my doctor felt, and five years later, there is still no sign of anything unusual. The bad news was that appointment set in motion something I have never experienced before — a full-blown panic attack. If you have ever experienced one, you know what I mean. The consequences of that panic attack resulted in numerous doctor appointments to make sure it was not cardiac related, and even some therapy. I’m happy to report that all is now well. The point here is that his words were powerful, powerful enough to cause my entire nervous system to react.
I had another experience more recently. Since high school, I have had a slight hearing loss in my right ear. Every few years I get it checked and keep records of the audiograms to see if there are any changes. This year, a new doctor and audiologist treated me. After they conducted the hearing test, we viewed my old tests, and luckily nothing had changed.
I was then led into the doctor’s office for an interpretation of my tests. The exam went something like this. I sat down, and the doctor had his back to me with his computer on the table. Without so much as looking at my previous hearing tests, he said that unilateral hearing loss was a red flag, and he was sending me for a CT scan to rule out multiple sclerosis or a brain tumor. Was he kidding? Before I had a chance to question him about why he hadn’t considered my previous audiograms, he was out the door, and panic set in.
A final ordeal occurred involving my mother. After being hospitalized for pneumonia, she was preparing to come home. My sister and I said something to her doctor along the lines of how tough we thought our mom was (she is 85 now). The doctor looked straight at us, with my mother standing right next to us, and said, “Yeah, but she’s 85 and could drop dead at any time.” Did he really just say that?
The 50% of what is heard
My point is this — what we say carries considerable meaning to our patients. Because many factors affect people’s ability for understanding and retaining health information, there is a wide range of results, but studies indicate that overall about 50% of the information provided by health-care providers is retained (Shapiro et al., 1992). Depending on conditions, 40% to 80% of the information may be forgotten immediately (Kessels, 2003). I would like to add my opinion that if the information is perceived as negative, patients are not going to forget; in fact, they will likely remember more, and conceivably embellish it as well. I know that for me, after he uttered the word “mass,” I didn’t hear or remember anything else.
I realize we have all been taught the proper terminology to use, but maybe we should revisit that and give it more consideration. I always felt that “operatory” sounded like patients were to have an operation, and that “soft tissue exam” sounded less innocuous than oral cancer exam (though I thoroughly believe patients should understand the importance of what we’re doing and what we’re looking for).
A suggestion for dialogue might sound something like this: “Mrs. Jones, have you noticed the red spot on your tongue? We would like to send you to a colleague of ours who is better equipped to determine what is causing this and if we need to treat it.” This is instead of, “Mrs. Jones, we are sending you to an oral surgeon for this suspicious red lesion to see whether or not it is oral cancer.” I guarantee that all she will hear and remember is “oral cancer,” and regardless of the outcome, you have likely induced a great deal of anxiety while the person awaits the pending results. If it is positive, there will be plenty of time for discussion and treatment planning, but why inflict undue stress when there is not yet a definitive diagnosis? Our words are so powerful!
Moving on, keep in mind that not all patients understand what you mean even when you’re doing your best to present current, evidenced-based information. Lack of health literacy is a huge issue in this country and worldwide. There are a few signs that your patients may not completely understand what is happening. It is not specific to any ethnicity, gender, age, or even how affluent they look. Just as you or I may not understand the jargon used in engineering, otherwise well-educated people may not understand the jargon used in health care and dentistry.
In addition, we have patients with limited English proficiency (LEP). This can pose a whole new set of challenges. Some signs that your patients might be having trouble comprehending the information you’re presenting include an incomplete health history, saying they forgot their glasses, or looking disinterested. To help break down those barriers, use simple terminology. Say gum disease or a gum infection rather than gingivitis, bad breath rather than halitosis, high blood pressure instead of hypertension. These are general examples.
The goal is not to “dumb down” the appointment, but to keep this information in mind:
- 42 million American adults can’t read at all; 50 million are unable to read at a higher level than is expected of a fourth or fifth grader.
- The number of adults that are classified as functionally illiterate increases by about 2.25 million each year.
- 20% of high school seniors can be classified as functionally illiterate at the time they graduate.
With these statistics, it is imperative that we find other ways to communicate with our patients other than the written or spoken word. Flip charts, brochures written at an appropriate level, and demonstrations are all beneficial as adjuncts to the traditional oral hygiene education presentation we typically give.
Equally important is that you need to be culturally sensitive at all times. Did you know that it is common for some cultures not to have direct eye contact with you because you are perceived as a person of authority? Did you know that in some cultures, touching children on the top of the head is offensive? Did you know that in some cultures, an individual is not permitted to make a major decision without consulting family members, and therefore the family must agree to treatment? Did you also know that in some cultures, you can only treat patients the same sex as yourself? The world is a wonderfully diverse place and we need to be sensitive to all the uniqueness we encounter.
This leads me to my final point. We have all heard of the Golden Rule, which states that we should treat others as we would like to be treated. But I prefer the Platinum Rule, which states that we should treat others as they would like to be treated. The difference here is that the Golden Rule assumes that what I prefer, you should prefer; whereas the Platinum Rule suggests that we consider the feelings of others. This changes the relationship from what I want, to what you want or need.
This was introduced to me at a recent Arizona Public Health meeting, where I was privileged to hear John Molina, MD, JD, CEO of Phoenix Indian Medical Center, speak on the correlation between health status and access. My takeaway message from him was simple. We need to spend more time listening to our patients. If they present with caries, we need to ask them why they feel they have caries or how they believe it developed.
Many people have misconceptions of how and why illness occurs, and even more theories about how to best treat themselves. It is not our duty to discredit or demean them, but rather to use simple statements such as, “I see that you tried placing an aspirin between your painful tooth and your gums. Perhaps we can try an antibiotic that you swallow and a gel that you can place on your gums.” Bottom line — their treatment may not have been what you know to be effective, but you still need to treat them as they would like to be treated.
It is my belief that patients will trust and respect you if you trust and respect them. This is not an easy relationship to establish and takes a lot of nurturing and understanding. The first step is to watch what and how you say things. Your words ARE powerful and have a lasting effect, especially if you offend someone or their culture.
Health-care workers are not the only ones guilty of, “You said what?” comments. This type of communication has implications in your everyday life. Think of how important your words are to your significant other, your coworkers, and especially your children.
It is often said that we can’t “un-ring a bell.” As dental professionals, we’re in a unique setting where we’re expected to establish rapport with patients in one-hour increments. Use that time wisely. Educate in a manner they can understand, “listen” to them both verbally and nonverbally, and most importantly, don’t give them the opportunity to return home and say, “Did they really just say that?”
Diane Paz earned her CDA and RDH from Phoenix College, and her BSDH, Expanded Functions, and master’s degree in education from Northern Arizona University. She is currently an assistant professor at Northern Arizona University instructing in the Bachelor of Science Degree Completion Program. She can be reached at [email protected].
- Grim Illiteracy Statistics Indicate Americans Have a Reading Problem (Sep 20, 2007) retrieved from, http://educationportal.com/articles/Grim _ Illiteracy statistics_Indicate_Americans_Have_a_Reading_Problem.html
- Kessels RPC. (2003). Patients’ memory for medical information. J Roy Soc Med 96:219-222.
- Shapiro DE, Boggs SR, Melamed BG, Graham-Pole J. (1992) The effect of varied physician effect on recall, anxiety, and perceptions in women at risk for breast cancer: an analogue study. Health Psychol 11:61-66.