Laurence A Goldberg
HPE Editorial Consultant
The first time you see someone, about 15,000 connections are made in the brain. Although most remain at the subconscious level, they shape our perceptions and can have profound effects on the way we behave, Jenny Simanowitz (Independent Consultant in Communications, Vienna) told the audience in the opening session. Successful communications depend on perceived acceptance or rejection, and some 60% of our perceptions are influenced by body language rather than what is actually said. We experience the world through our senses, and the sense of touch can be particularly important. When we shake someone’s hand we receive immediate subconscious messages about them. Communications can also be blocked, and it is important to understand how this is done, and more importantly, how to unblock them. Commonly used blocking techniques include intimidation, taking all the space in the conversation or being stubborn. Both genders also make use of “blocking looks”, but whereas men tend to use aggressive looks, women are more likely to use depressive looks. One way to unblock communication is to use encouraging language and gestures to make the respondent look good. This is a way of working with people that you do not always think about, added Ms Simanowitz.
A WHO report in 2003 estimated that 30-50% of patients did not take their medicines for chronic illnesses as directed, and yet effective interventions to improve adherence remain elusive, said Robert Horne (Professor of Behavioural Medicine, School of Pharmacy, University of London). Professor Horne’s studies have shown that nonadherence that is, failure to follow an agreed treatment plan is usually the result of a logical decision based on specific beliefs about prescribed medication held by the patient. Such beliefs fall into two categories, “necessity beliefs” (how necessary the treatment is) and “concern beliefs” (how likely it is that the treatment will cause harm). Patients’ views of a disease and its treatment are often based on their own experiences and commonsense perceptions of the disease. For example, many patients did not share the medical model of asthma as a chronic condition with potentially severe consequences. Instead, their model reflected their episodic experiences of symptoms, believing they were ill when they had an asthma attack but otherwise normal.
These patients had significantly stronger doubts about their need for daily, inhaled corticosteroids and were significantly less adherent, said Professor Horne. Typically, more than 30% of patients will have strong concerns about medicines. Core concerns are that medicines are likely to accumulate in the body, they will give rise to addiction and they are likely to disrupt self-image. When a patient doubts the need for a medicine, the concerns become more salient, added Professor Horne. Patients’ beliefs are not set in stone and can be changed by appropriate education and negotiation. This involves providing a “commonsense” rationale for necessity that fits with the patient’s “commonsense” model of the illness, eliciting and addressing individual concerns and working out a convenient regimen. It could also involve tackling practical barriers such as correct inhaler technique. Most of all, we need to hear the patient’s voice- listen first, then speak, concluded Professor Horne.
Discussion with the doctor is rated as “very important” by 93% of patients and yet only 30% of physicians satisfy patients’ expectations in this regard, explained Florian Menz (Professor of Applied Linguistics, University of Vienna, Austria). Bad communication has negative influence on the course of disease whilst patient-oriented communication improves clinical outcomes and reduces hospital stay, he continued.
At present, relatively little time is spent in teaching pharmacy undergraduates to communicate effectively. In order for genuine shared decision-making about healthcare issues to happen, interviews with clients need to contain four critical elements. In addition to basic openings and endings and asking for information using both open and closed questions, the pharmacist needs to provide some “global orientation”, for example by explaining how long a treatment can be expected to take to work. The other key element is “active listening”. In this process, “back channels signalling” plays an important part. This can be actions or gestures, including paying attention and nods and signs to indicate “now I understand you” and comments such as “makes sense so far …”. It can also involve asking the patient to repeat things to clarify points. In the next stage the healthcare professional needs to provide detailed information about medicines and respond to the client’s concerns. Specialised vocabulary must always be explained. Try to adopt the client’s point of view, he recommended.
A critical approach
A critical approach to patient information is important, according to Giulio Formoso (Epidemiologist, Centre for Evaluation of the Effectiveness of Health Care, Modena, Italy).
Citizens need to get comprehensive and balanced information. A recent study in Israel has shown that information and shared decision-making were patients’ top priorities. In the UK, six out of 10 readers of the Sunday Times said they read it for health news. The real problem is that people often cannot understand information about drugs. Often when people hear about new drugs they miss the context, said Dr Formoso. Doctors can also have misunderstandings about drugs; they may not understand the benefits and risks of a new drug, and they may not find it easy to communicate with patients or deal with their expectations.
Time and again the same old questions are not clarified, said Dr Formoso. They are:
- In what circumstances should the drug be used?
- What and by how much does it improve?
- Which side-effects can occur, and how frequently?
- Are there any alternatives and, if so, how do they compare?
- What does any new information add to existing knowledge?
Much of the information that is available through the mass media is misleading. One example was a headline that said: “Painkillers double heart attack risk.” Although this was true, as the baseline risk was 0.1% the effect was only to increase the absolute risk to 0.2%. Distortions are also common because distorted news is often more appealing.
Health journalists have a responsibility to report on relevant topics and help people to understand the ways in which scientists and policymakers reach conclusions. If they fail to do this then they become the unwitting mouthpieces for incomplete, biased and unbalanced information. Drug manufacturers are also sometimes guilty of disease-mongering. This is best exemplified by so-called disease awareness campaigns that are often designed to sell drugs rather than to inform or educate about the prevention of illness or maintenance of health.
There are numerous examples of this, such as the way in which we have been given the impression that erectile dysfunction is a significant concern for most men, or at least for most of those over the age of 40.
Direct-to-consumer (DTC) advertising is less subtle than disease-mongering. Those in favour generally argue that it improves the amount of information available to patients whilst those against point out that the information is not impartial and tends to medicalise normal life.
What is needed is a change in paradigm from paternalism, sensationalism and drug promotion to a critical approach that gives patients the basic information to enable them to share decision-making about drugs, argued Dr Formoso. Pharmacists can help here because they have expertise relating to medicines. They need to be aware of methodological and policy issues and should contribute to the development of policy on drug information. They should also work with communication experts to develop appropriate information about medicines and should take part in the evaluation and promotion of existing drug information.
Patient-focused care requires an appreciation of patients’ expectations, beliefs and concerns, motivation to provide information and the ability to find common ground on what the problem is as well as knowledge of the best medical evidence, said Veerle Foulon (Assistant Professor, Research Centre for Pharmaceutical Care and Pharmaco-economics, Catholic University, Leuven, Belgium). Positive outcomes are linked to friendly and nondominant interpersonal behaviour, the provision of information and active patient participation. However, it is important to understand that the desire for information varies between patients and varies over time and that, sometimes, offering a choice may cause emotional distress. True patient-focused care involves respecting patients’ autonomy even if they do not want information, said Dr Foulon.
Patient counselling and adherence
In order for patients to adhere to treatment regimens, they need to have sufficient information about their diseases, therapy and medicines and have a good understanding of the handling of medicines, according to Roland Radziwill (Director, Department of Hospital Pharmacy and Patient Counselling, Fulda Hospital, and Professor of Clinical Pharmacy, University of Marburg, Germany). Patient counselling is something that is undertaken by the whole team, but each member has specific tasks. For example, the doctor explains the diagnosis and the overall therapy, the pharmacist explains the medication and handling of medicines, a technician explains the use of medical devices and the nurse reinforces information about medical devices and deals with IV medicines. The important thing is that all members of the team should give the same information about medicines so that the right messages are reinforced and patients are not confused by conflicting advice, said Professor Radziwill. One consequence of the team approach to patient management is that it is difficult to identify the impact of each professional’s contribution. Many studies of pharmaceutical care show that patients are better informed and satisfied with the service, but few deal with hard outcomes such as hospitalisation, complications or mortality, added Professor Radziwill.
A clinical pharmacy programme in a 90-bed specialised transplant hospital has been associated with a steady fall in medication errors between 2000 and 2006. Piera Polidori (Clinical Pharmacy Director, Medical Institute for Transplant and Advanced Specialised Therapies [ISMETT], Palermo, Italy) told the audience. A range of measures have been introduced to improve the safe use of medicines. These include audits of medication orders to identify missing information, steps to eliminate the risks of look-alike and sound-alike products, and measures to reduce the risks of medication errors in paediatric patients. A reporting system for medication errors has been developed, and critical risks are identified and publicised to ensure that they do not reoccur. Electronic prescribing with decision support and unit dose dispensing also contribute to safety. ISMETT ranks first in Italy for the survival of transplant patients one year after transplantation.
Information technology, communication and education are fundamental in improving quality, safety and efficiency, concluded Dr Polidori.