Health Communication

Chapter 10

September 7, 2011 Sarah Gehlert, PhDThe Brown School

Washington University in St. Louis

Objectives of Session

1. Define the clinical encounter in medicine 2. Distinguish illness from disease 3. Understand what contributes to health beliefs 4. Distinguish immigrants from refugees 5. Understand social work roles on health care teams 6. Understand the role of medical interpreters 7. Understand medical terminology

Clinical Encounter in Health Care

A negotiation between two cultural constructions of reality that yields clinical reality

Patient Reality + Provider Reality = Clinical Reality

Cultural BeliefsLife Experiences

Negotiating Clinical Reality

Provider Reality

Medical specialty

Cultural background

Life experiences

Personal health experiences

Medical training

ClinicalReality

Patient Reality

Past experiences with disease Health literacy

Culturalbackground

Gender/age/race biases

Gender/age/race biases

Lifeexperiences

Education

Potential Outcomes of Clinical Encounters

The interactions between patients and providers that occur during healthcare encounters shape:

The development of treatment plansAdherence to those plans

Health consequencesSocial consequences

Clinical Reality

• Can be negotiated

• Outcomes (e.g., adherence to plans) rely on how these negotiations between patients and providers go

• The less similar realities are, the more challenging the negotiations will be

Illness Versus Disease

Disease = malfunctioning or maladaption of biological and psychophysiological processes

Illness = personal, interpersonal, and cultural reactions to disease or discomfort

Source: Kleinman et al., 2006

Disease Versus Illness

Disease Illness Objective Subjective Patterned by social, psychological, & cultural factors

Patients experience illness, while physicians treat disease

Negotiations Between Providers and Patients

Challenged by:

• Time constraints on clinical encounters• Lack of training in how to interview• Limited appreciation of non-somatic aspects of

health

Effect of Challenges

Beckman & Frankel study (1984) - in 69% of visits, physicians interrupted patients within 18 seconds of their beginning to talk and redirected interviews

Frankel (1991) patients rarely list their most troubling complaint first, but instead submerge it in a list of less troubling complaints (3rd complaint usually most troubling)

Unequal Treatment

“ There are by now literally hundreds of competent studies and the overwhelming majority have found that, overall, African-Americans, Hispanic Americans, and Native Americans receive less care, and less intensive care, than comparable white patients.”

Source: Institute of Medicine, 2003

The Role of Clinical Discretion in Racial and Ethnic Disparities

Patient External Factors History (Financial incentives, legal environment, etc.)

DIAGNOSIS TREATMENT

Exam& Tests

Stereotypes Prejudice Internal factors

Adapted from Unequal Treatment, 2003, Institute of Medicine

RaciallyDisparateClinical

Decisions

Origins in Health Belief Differences

1. Cultural differences (geography, ancestry, etc.)2. Level of understanding of biology & health (health literacy, education)3. Religious & philosophical differences4. Bias & discrimination

Eliciting Patients’ Health Beliefs

Kleinman suggests asking seven questions:

1. What do you think caused your problem?2. How severe do you think it is?3. Will its course be short or long?4. What difficulties is it causing you?5. What are you most concerned about?6. What treatment do you think is warranted?7. What benefits do you expect from the treatment?

Source: Kleinman, 1980

New Immigrants and Refugees

As with immigrants in the early 20th century:

Wide range of health beliefs Many or most do not speak English The vast majority live in poverty

Acculturation not valued the same way by everyone

Diversity City of St. Louis (population = 319,284). Source US Census 2010

Category Percent City of SL Percent MO

Foreign born persons, 2005-2009 6.3 3.5

Language other than English spoken at home, 2005-2009 8.8 5.7

White persons 42.2 81.0

Black persons 49.2 11.6

Hispanic/Latino persons 3.5 3.5

Asian persons 2.9 1.6

NH/OPIa & AA/ANb persons 0.3 0.6

Persons reporting 2 or more races 2.4 2.1

aNative Hawaiian/Other Pacific Islander; bNative American/Alaska Native

Refugees Resettling in City of St. Louis

Country Number Country NumberBosnia 920 Iraq 194

Afghanistan 134 Bhutan 165

Congo 44 Myanmar 84

Somalia 26 Somalia 49

Vietnam 14 Cuba 41

Iraq 14 Ethiopia 34

Serbia 12 Burundi 12

Ethiopia 12

Iran 10

2000 2009

Origin of Persons Obtaining Legal Resident Status in St. Louis, 2007

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

N = 3,816

Immigrant Versus Refugee

Immigrant Refugee

Resettlement In new place or can return to own country

From refugee camp to a third country. Usually cannot return to own country

Legal status Proper documentation is required

Defined by United Nations

Reason for relocation Relocate for promise of better conditions

Forced due to fear of persecution or after disaster (i.e., no home)

Definition Move of own volition (because want to relocate)

Move out of fear or necessity (e.g., to flee persecution, or because homes have been destroyed in a natural disaster)

Ways of Negotiating Clinical Reality

1. Determine the health belief system of patient and family

2. Communicate with a team of healthcare professionals to help bridge the gap between disease and illness

3. Develop a treatment plan that takes both into account

Eliciting Patients’ Health Beliefs

Kleinman suggests asking seven questions:

1. What do you think caused your problem?2. How severe do you think it is?3. Will its course be short or long?4. What difficulties is it causing you?5. What are you most concerned about?6. What treatment do you think is warranted?7. What benefits do you expect from the treatment?

Source: Kleinman, 1980

St. Louis Health Services Organizations

Source: Tranel, 2008

Mainstream Specific

Immigrant BJH*; Catholic Charities Family Services; Catholic Immigration Law Project; Christian Friends of New Americans; Community Alternatives; Family Health Centers; Grace Hill Neighborhood Centers; People’ s Health Centers; Legal Services of Eastern Missouri; Preferred Family Healthcare; Queen of Peace Center; Salvation Army; YMCA of Greater SL

African Mutual Assistance Association of MO; Amigos Group; Bi-Lingual International Assistance Services; Chinese Culture & Education Foundation; Interfaith Legal Services for Immigrants; Casa de Salud; La Linea de Ayuda; Language Access Metro Project; Lao Mutual Aid Association; Organization of Chinese Americans; Puerto Rican Society; SL Christian Chinese Community Service Center; Vietnamese Health Center

Refugee Catholic Charities Relief Services Bridging Refugee Youth & Children’s Services; Center for Survivors of Torture & War Trauma; International Crisis Aid; Oasis International

Inclusive Acción Social Communitaria; African Refugee & Immigrant Service; Immigrant & Refugee Woman’s Project; International Institute; Refugee & Immigrant Consortium of American

*Barnes Jewish Hospital

Social Workers on Healthcare Teams

Work in a variety of settings (primary care, specialty care, inpatient, outpatient, advocacy organizations, federally qualified & other community health & free clinics, health departments, government, industry, hospice, etc.)

Work in clinical, management, and policy roles

Take on a variety of roles: advocate, broker, manager, enabler, mediator, educator, integrator/coordinator, analyst/evaluator

Social Workers on Healthcare Teams

Less likely than other disciplines to haveroles identified as uniquely their own:

•Overlap with nursing, psychology, etc.•Overlap more likely when less technology (e.g., long-term care vs. ICU or ED)•Overlap less when working with individuals and families living in poverty

Social Workers on Healthcare Teams

Empirical evidence that interprofessional collaborations with social workers are more effective than those without:

hospital admissions, readmissions, office visits, ED visits self-rated physical, mental, & social functioning

Source: Sommers et al., 2000)

Monodisciplinarity

Only one discipline is involved in addressing a health problem

Not successful in capturing the multi-faceted and complex nature of illness & disease Ineffective in informing effective interventions

Multidisciplinary Practice

Professionals from a variety of disciplines work together

Each approaches the issue through her own disciplinary lens, or on the other extreme, forgets her discipline and blends with the team

Fails to create new ways of knowing

Interdisciplinarity

Goal is to transfer knowledge from one discipline to another

Allows professionals to inform one another’s work and compare their individual findings

Complex interactions between biological, behavioral, and social phenomena are difficult to capture

Transdisciplinarity

Professionals work entirely outside their disciplines

Goal to understand the world in its complexity, rather than a part of it

Allows them to transcend and operate outside their own disciplines to inform one another’s work and capture complexity

Monodisciplinarity Limits Our View

“It’s a snake”

“It’s a brick wall” “It’s a whip”

Interdisciplinary Broadens it a Little

“It’s a snake on a brick wall!”

Transdisciplinarity Allows a Full View

“Its an elephant!”

Medical Terminology

Knowing medical terminology levels the playing field among disciplines

Deconstructing medical terms

1. Identify the suffix and determine its meaning2. Identify any prefix and determine its meaning3. Identify the first root and combining vowel and determine their

meanings4. Identify any additional combining forms and determine their meanings5. Read the word from its suffix to its prefix to its combining forms and

roots