Category: Doctor-Patient Communication

Improving Patient-Provider Communication: Meet Crystal Bentley

Last week, Crystal Bentley, RN, second-year Master of Public Health student in the UNC Gillings School, joined our class to share with us her interests and work in health communication.

Crystal is currently a research assistant in the Community Engagement, AHEC, and Outreach Services department of the UNC Health Sciences Library where she is developing provider-facing health literacy training modules. The goal of her work is to improve patient-provider communication and patient knowledge.

This is not a recent interest of hers, however. Crystal spent the past six years working as a registered nurse in the areas of emergency medicine, public health, and collegiate campus health prior to beginning her graduate program. These experiences are what sparked her interest in patient-provider communication, patient advocacy, and shared decision making. In her daily interactions with patients, Crystal would often see a disconnect between the way patients and providers would communicate and interact with each other in the clinical setting. It was not long until she discovered her calling was to help bridge this gap within patient-provider sphere.

Some of the key takeaways from Crystal’s talk were that lack of health literacy can have both important health and financial implications. She also described the important of using plain language and being mindful of cultural sensitivity when developing health communication materials for different audiences.

Crystal Bentley is a second-year Master of Public Health student in the Department of Health Behavior at the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. She is also an Interdisciplinary Health Communication scholar, and will be completing her certificate next semester along with her degree program.

What are your thoughts on health literacy? What do you feel are important components of good patient-provider interaction and communication? Let us know in the comments below!

FDA Expands HPV Vaccine for People Ages 27 to 45

Earlier last month, the FDA announced it has approved Gardasil 9, a vaccine for Human Papillomavirus (HPV) for people between the ages of 27 and 45. Previously, the FDA approved the HPV vaccine for individuals aged 9 through 26 years.

Gardasil 9 protects against nine types of HPV, a virus that is transmitted sexually and through intimate skin-to-skin contact. HPV is a very common virus and many individuals will get it at some point in their lives. While most HPV infections go away on their own, some may stick around and cause genital warts and cancer. This may be cancer of the cervix, vulva, vagina, penis, or anus, as well as cancer of the back of the throat.

It is recommended that all children aged 11 or 12 receive the HPV vaccine series. The vaccine is most effective at this age, before children are exposed to HPV.

Still, however, individuals up to age 45 years can now get the HPV vaccine. Older individuals can protect themselves against nine types of HPV. And even if one has been exposed to a few types, the vaccine will protect against the other strains they have not been exposed to.

HPV vaccination is cancer prevention. Why not consider protecting yourself?

For more information, check out the following Centers for Disease Control and Prevention resources:

What is HPV? 

HPV and Cancer

HPV Cancer Screening

References

Centers for Disease Control and Prevention. (2018, August 23). Human Papillomavirus: Questions and Answers. Retrieved from https://www.cdc.gov/hpv/parents/questions-answers.html

Centers for Disease Control and Prevention. (2016, December13). What is HPV? https://www.cdc.gov/hpv/parents/whatishpv.html

U.S. Food & Drug Administration. (2018, October 9). FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old. Retrieved from

https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/UCM622715.htm?utm_campaign=10052018_PR_FDA%20approves%20expanded%20use%20of%20Gardasil%209%20to%20include%20individuals%2027%20through%2045%20years%20old

Grady, D & Hoffman, J. (2018, October 5). HPV Vaccine Expanded or People Ages 27 to 45. Retrieved from https://www.nytimes.com/2018/10/05/health/hpv-virus-vaccine-cancer.html

October is Health Literacy Month!

Founded in 1999 by Helen Osborne, Health Literacy Month is all about promoting understandable health information. This information is critical in order for individuals to make appropriate health decisions.

Health literacy is the ability to obtain, process, and understand basic health information and services. This includes reading, writing, and numeracy of health information. Sometimes, health information can be difficult to understand and communicate among different audiences. This can make navigating the healthcare system challenging.

According to the U.S. Department of Health and Human Services, 77 million U.S. adults have basic or below basic health literacy. Low health literacy can lead to poor health outcomes, such low uptake of preventive health services and/or greater use of treatment health services. This can lead to high healthcare costs.

There are many factors that can affect health literacy. Some of these factors include: education, age, language, and culture. Culture can play a key role in how one understands and responds to health information. Culture involves certain beliefs, values, communication styles that all can affect how one processes health information. Therefore, it is important that health information is communicated in a way that is culturally appropriate for the individual or audience.

One key setting for health literacy is that of patient and health care providers. Patients may have difficulty understanding complex medical information, while providers may have difficulty communicating complex medical information. It is important for providers and patients to work together in order to ensure that health information is understood and communicated effectively, so that the best health care decisions are made for the patient.

Interested in learning more about health literacy? Check out the following resources from the Centers for Disease Control and Prevention:

Additional resources from the U.S. Department of Health and Human Services:

References:

Kindig, D. A., Panzer, A. M., & Nielsen-Bohlman, L. (Eds.). (2004). Health literacy: a prescription to end confusion. National Academies Press.

National Institutes of Health. (2017, May 31). Health Literacy. Retrieved from https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/health-literacy

U.S. Department of Health and Human Services. (2008). America’s Health Literacy: Why We Need Accessible Health Information. Retrieved from https://health.gov/communication/literacy/issuebrief/

U.S. Department of Health and Human Services.  (N.d.). Quick Guide to Health Literacy: Fact Sheet – Health Literacy Basics. Retrieved from https://health.gov/communication/literacy/quickguide/factsbasic.htm

U.S. Department of Health and Human Services.  (N.d.). Quick Guide to Health Literacy: Fact Sheet – Health Literacy and Health Outcomes. Retrieved from https://health.gov/communication/literacy/quickguide/factsbasic.htm
U.S. National Library of Medicine. (N.d.). Health Literacy: Definition. Retrieved from https://nnlm.gov/initiatives/topics/health-literacy

Revised Cervical Cancer Screening Guidelines Offer Women More Options

New recommendation guidelines for cervical cancer screening were published this month in the Journal of the American Medical Association (JAMA). These guidelines are an update to the U.S. Preventive Services Task Force (USPSTF) 2012 recommendations on cervical cancer screening. The new screening guidelines now offer women more options and longer screening intervals when it comes to their preventative care. One of the most notable guideline changes is that women aged 30-65 can now get an HPV test alone every 5 years instead of just a Pap smear alone every 3 years, or in combination with a Pap smear every 5 years.

According to the guidelines:

  • Women aged 21-29 years should get a Pap smear every 3 years
  • Women aged 30-65 years can get:
    • A Pap smear alone every 3 years
    • An HPV test alone every 5 years
    • A combination of a Pap smear and HPV test every 5 years

The USPSTF does not recommend screening for women younger than 21 years as well as women older than 65 years who have received adequate screening before and are not at high-risk for cervical cancer.

Cervical cancer was once a major cause of death among women. However, with the advent of screening tests, such as Pap smears, cervical cancer rates have fallen considerably over the years. Still, the American Cancer Society estimates 13,240 women will be diagnosed with cervical cancer in 2018.

Almost all cervical cancers are caused by the human papillomavirus (HPV), a common sexually transmitted infection. There are many types of HPV, some low-risk and some high-risk. Low-risk HPV types can cause warts that can be treated. High-risk types, however, can cause cancer. While the body can often fight off HPV infection, this is not always the case. Some HPV infections can become chronic, and chronic infections with high-risk HPV types can lead to cancer in both men and women if left untreated. However, there are vaccines that can prevent cancers, like cervical cancer in women, caused by HPV. The Centers for Disease Control (CDC) recommends that all children get vaccinated against HPV at age 11 or 12. For young women in particular, the CDC recommends they get vaccinated through age 26.

Because it can take years for cancer caused by HPV to develop and for symptoms to appear, the CDC encourages women to regularly screen for cervical cancer. This includes both women who have and have not vaccinated against HPV, as the HPV vaccine does not protect against all types of HPV that can cause cancer.

References

U.S. Preventive Services Task Force. (2018). Cervical Cancer Screening. Retrieved from  https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening2

Centers for Disease Control and Prevention. (2017, December 16). The Link Between HPV and Cancer. Retrieved from https://www.cdc.gov/hpv/parents/cancer.html

National Institutes of Health. (2018, June 30). Cervical Cancer. Retrieved from

https://report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=76

American Cancer Society. (2017, November 1). What Are the Risk Factors for Cervical Cancer? Retrieved from

https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html

U.S. Preventive Services Task Force. (2012). Archived: Cervical Cancer: Screening. Retrieved from

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening

Centers for Disease Control and Prevention. (2018, August 23). HPV Vaccines: Vaccinating Your Preteen or Teen. Retrieved from

https://www.cdc.gov/hpv/parents/vaccine.html

American Cancer Society. (2015, February 19). HPV and Cancer. Retrieved from https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-fact-sheet

American Cancer Society. (2017, October 9). HPV and Cancer. Retrieved from

https://www.cancer.org/cancer/cancer-causes/infectious-agents/hpv/hpv-and-cancer-info.html

Medical Ethics & Patient-Provider Communication

There are four primary principles for ethical decision-making in health care; however, these four principles do not necessarily yield the most beneficial results for trans youth or bodies that exist in contradistinction to state controlled modes of life. In essence, these bodies are unruly (or unrule-able), but the state continues to control them within the biopolitical frame, where biopolitics refers to the state’s ability to control the way its subjects live. Susan Stryker expands on Foucauldian biopolitics, with a specific trans studies bent, to describe it as “the calculus of costs and benefits through which the biological capacities of a population are optimally managed for state or state-like ends.” The medical-industrial complex works within this frame to manage the modes of life for trans youth, relying on non-maleficence and a paternalistic notion of future expectations to continually withhold medical intervention. Through withholding medical intervention, the state continually retains the ability to name and define trans youth within the gender framework—which isn’t to mention the biopolitical control of scientific claims to a “biological sex” or the medical narratives required to achieve intervention even for adults.

The four primary principles of health care ethics, referenced previously, are (1) respect for autonomy, (2) justice, (3) beneficence, and (4) non-maleficence. The principle of respect for autonomy refers to an individual’s ability to make decisions about their own body without constraints and refers to the ability to act freely (Beauchamp, 2007). Within the biopolitical framework, there are clearly constraints placed on the individual by the state, limiting the various modes of life that should be available to the autonomous individual. Further, for any youth, autonomy is diminished because of parental control. Nonetheless, informed consent in the medical setting provides the illusion of autonomy, though informed consent also positions the question of adequate information. Within the doctor-patient power relation, doctors are able to establish what counts as truth and the state determines what counts as adequate information, allowing for continued constraints on various modes of living that are unruly. For example, misinformation provided before receiving an abortion.

Dr Lisa on the Streets: An approach to improve health literacy

Health literacy has become a buzzword not only in the public health world but in general. As the technologies, treatments and advancements are improving the quality of medicine, the way that these new discoveries are communicated are not. One physician and public health professional has made it her mission to increase the awareness of the health literacy crisis here in the United States by taking it to who it affects the most, Americans. She has launched a “Dr. Lisa on the Streets” campaign to increase awareness and gather support to improve the way health information is communicated. In her TedX talk “Are you confused about health information? You’re not alone” she discusses the economic consequences of low health literacy and how as a nation we can attempt to improve this. She refers to the “grapevine” (casual conversations, internet etc.) as one of the most powerful educators and needing to capitalize on this as a means of sharing health information.

Here are few strategies mentioned in the video about improving health literacy:

  • Manage the grapevine, it’s like ivy if it isn’t maintained it will get out of control
    • Need grapevine to counteract misinformation through verification before spreading information
  • Doctors need to embrace technology
    • Change is inspired by the masses
  • Health literacy is up to you!
    • Avoid gaps in care
    • Find your provider
    • Be persistent

To learn more about this movement and health literacy watch the full TedX talk: https://www.youtube.com/watch?v=-x6DLqtaK2g

STOP Act: Implementation and Effects Part II

Earlier today, The News & Observer reported that thousands of doctors in North Carolina were breaking the recently passed STOP Act, by over-prescribing prescription opioids. In a previous post I briefly explained provisions under the STOP Act, STOP Act: Implementation and Effects on the Opioid Epidemic in North Carolina.

Based on preliminary data from the North Carolina Department of Health and Human Services, and Blue Cross and Blue Shield, showed that many were over-prescribing. The STOP Act limits opioid prescriptions to five days to first time patients, or seven days if the patient had surgery. The state health department presented their findings to staff of the North Carolina Medical Board, who noted that they do not have the capacity to investigate every prescriber reported to determine if prescriptions were legitimate.

Blue Cross and Blue Shield had started to electronically block the filling of prescription opioids for more than seven days at the start of April, noting that this policy had blocked more than 1,100 prescriptions. While there were questions about the precision of the data and its accuracy, these preliminary reports showcase the difficulties of challenging the opioid epidemic by policies limiting prescribing.

 

Sources –

The News & Observer – Thousands of N.C. doctors are over-prescribing opioids, breaking a new state law – http://www.newsobserver.com/news/business/article209824434.html

Health Orientations for New Patients

Orientations for new patients are one technique for setting the stage for positive patient experiences with a new clinic, especially for those who are unfamiliar with the healthcare system. These orientations have been shown to be successful in reducing stress for cancer patients, preparing patients for beginning psychotherapy, and reducing no-show appointments in a primary care setting, which improves clinic efficiency.

As the Patient Navigator at a Federally-Qualified Health Center (FQHC) from 2016 to 2017, I was tasked with creating this type of program for immigrant and refugee patients, whose cultural differences and unfamiliarity with the American healthcare system often serve as a barrier to successful clinic interactions. From speaking to clinic providers on various levels, as well as patients from refugee communities, I established the following priorities for the orientation curriculum:

  1. Prescription refill process
  2. Calls to our clinic – what to expect, how to request an interpreter, how to speak to a nurse
  3. Difference between preventative and acute care, and emergencies, and benefits of seeing your provider at least once a year
  4. How to make and cancel appointments, and why no-shows reduce our efficiency
  5. Different occupations that clinic staff hold, and how staff can connect patients to other resources they may need
  6. General information about the American healthcare system that may be confusing, such as insurance coverage and social services application processes
  7. Patient rights and responsibilities
  8. Interactions with providers – letting patients know that they can and should ask questions when confused, or when misunderstood by an interpreter or provider

I quickly found that creating a curriculum like this presents several challenges. For example, “refugees and immigrants” is a broad group of people, representing those from wildly different education levels and familiarity with Western healthcare systems. Many times, it was impossible to know patients’ backgrounds before meeting with them to discuss our clinic. I had to be careful to be informational without seeming patronizing, while basing communication strategy on the perceived level of understanding of the patient, which can also be influenced by cultural norms.

Patient orientations have a great potential to reduce patient stress, improve understanding of clinic operations, and give the power back to the patient when it comes to their own health. However, cultural differences must be given weight when developing this type of program. Using community leaders or liaisons for curriculum development and delivery may be a way to bridge that gap.

Sources:

https://onlinelibrary.wiley.com/doi/abs/10.1002/(SICI)1099-1611(199805/06)7:3%3C207::AID-PON304%3E3.0.CO;2-T

https://onlinelibrary.wiley.com/doi/abs/10.1002/1097-4679(198311)39:6%3C872::AID-JCLP2270390610%3E3.0.CO;2-X

https://onlinelibrary.wiley.com/doi/full/10.1046/j.1525-1497.2000.00201.x

https://www.sciencedirect.com/science/article/pii/S0277953610003199

Discrimination and Health Part II: People of Color

Last week, I talked about how discrimination faced in healthcare settings can impact LGBTQ+ individuals’ attitudes towards healthcare, and how facing discrimination in everyday life can negatively impact their health outcomes. People of color (PoC) in the U.S., including immigrants, refugees, and Indigenous Peoples, face this double-barreled oppression as well.

Of course, one way racism affects health is through the broad structures that have placed many PoC groups at disadvantaged positions, intersecting with poverty – one study found that almost 100,000 black people die prematurely each year who would not die were there no racial disparities in health.

But discrimination itself, even on an individual level, can impact the health and healthcare experiences of PoC. Microaggressions, or everyday interactions rooted in racism, are a daily stressor for PoC, and these stressors can lead to premature illness and mortality.

Of course, this discrimination doesn’t just happen in daily interactions, but also in medical settings, which rightfully leads to mistrust and under-use of healthcare for PoC. Language and cultural barriers faced by immigrants can have similar effects.

Because race, socioeconomic status, and health are so intertwined, it may never be possible to know what levels of discrimination have the greatest ultimate effects on health outcomes. But we know they all have at least some, which should be enough to demand action.

Sources: https://www.ncbi.nlm.nih.gov/pubmed/12042611

https://www.hindawi.com/journals/tswj/2013/512313/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821669/#!po=2.38095

https://health.usnews.com/health-news/patient-advice/articles/2016-02-11/racial-bias-in-medicine-leads-to-worse-care-for-minorities

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696665/

https://www.ncbi.nlm.nih.gov/pubmed/17001262

Doctors are humans too

In binge watching the newest medical show “The Resident” this past weekend, the show made me consider the role of medical error and transparency. The show portrays an arrogant surgeon with a secret tremor unwilling to give up his career despite his inability to perform successful surgeries. While the story plot line is dramatized and designed to pull viewers in for higher ratings, it highlights the importance of medical error and transparency. According to The BMJ, medical error is the third leading cause of death in the United States. Examples of medical error include medication errors (wrong dose, wrong drug) and hospital infections. Medical errors are challenging to comprehend since healthcare providers are only human and they are bound to make mistake just like the rest of us. The amount of stress and pressure these providers face all while working at all hours undoubtedly will result in mistakes. However, their mistakes have much more severe consequences. The show discusses transparency as a way to address the stigma surrounding medical error and by having more transparency could result in lower rates of medical error. An interesting fact to note is that these are errors are not recognized as cause of death on death certificates. To me, this further stigmatizes the errors and places blame on the healthcare provider and doesn’t change the narrative that providers are human and errors will happen. We treat these healthcare providers as superhuman but we need to remember that they are just like us and as a humans we make mistakes and hopefully we learn from them.

References:

https://health.usnews.com/health-news/patient-advice/slideshows/5-common-preventable-medical-errors?slide=4

https://www.bmj.com/content/353/bmj.i2139.full