Map of life expectancy at birth from Global Education Project.

Thursday, November 05, 2009

Okay, people have been asking

Why don't you write more about your own research? So say the masses. Well, partly it's because of the weird rules about discussing stuff that hasn't been published yet. So, while this may not be the greatest thing since The Revolutions of the Heavenly Bodies, it has been published, and best of all, it's open access. (It's kind of hard to explain, but being listed last is a funny privilege I don't quite deserve in this case. The main thing you should know is that Doug and Tim started the project and I came in to deal with the Spanish language material and participate in the interpretation and writing.)

Most of the work I'm doing now is more wonky and quantitative than this, but I also do keep up with the qualitative work. The major takeaway from these focus groups, for me, is that there is a big difference in the way physicians and patients experience their shared interactions. Physicians, health care researchers, and the NIH that funds these studies mostly view communication as instrumental. They're worried about whether patients understand the facts, concepts, guidance and instructions they get from their doctors, and whether doctors are getting an accurate understanding of the history and symptoms patients relate to them. And indeed, studies have found that immediately after a medical visit, people do not remember or cannot accurately report half of what the doctor said to them.

But as patients, most people don't know what they don't know. (Donald Rumsfeld had a point there, although what he didn't know was everything, and he didn't know that.) If they hear doctors saying "Magamamagama anamanapuna" they'll just nod and say okay. They will tend to fill in the blanks of their understanding. They are much more likely to be annoyed by the way they are treated -- that they don't feel respected, listened to, cared about. They may well perceive that the doctor didn't bother to give them some important piece of information at all, or would not accept what they were saying. This may be true, or it may be that the doctor did say something that they just didn't absorb, or heard them but placed a different interpretation on the information that she or he did not clearly and respectfully negotiate with the patient. But as patients, people just don't disentangle instrumental aspects of communication from the total experience of health care.

People just aren't going to say, "I don't think I understood that," or "I hear you but I don't believe you," or "I'm not going to do what you advise for reasons that I'm not going to tell you because I don't think you want to hear them." They'll nod and say okay and then go home and get on with their lives, however they are going to do it. These interactions are much more likely to be successful instrumentally -- as effective exchange of information and motivation of health promoting behavior -- if they are successful as interpersonal relationships. For that to happen, we need to find ways of narrowing the gap of experience and culture between physicians and patients, and achieving a more symmetrical relationship that nevertheless honors professional boundaries and the differential expertise between the parties.

So that's what a lot of my work is about. I'll try to incorporate more of it here.

BTW: Unusual for me to miss yesterday. I often generate my Wednesday post by riffing on something in JAMA, but the entire issue was about %$^&* flu. Feh.


roger said...

"I'm not going to do what you advise for reasons that I'm not going to tell you because I don't think you want to hear them."

love that.

an interesting study.

kathy a. said...

it is very interesting. i also like the quote roger cited, because it is a great illustration of a communication breakdown.

breakdowns can run in both directions, too. the conclusion that [i'm paraphrasing here] the patient's perception of a doctor's manners is very important -- that matches my experiences and hunches. i'm not afraid to ask questions, but if a doctor won't take time with me, wont' listen, dodges questions, behaves as though i'm an idiot -- that's a doctor i cannot trust.