tag:theconversation.com,2011:/us/topics/doctor-patient-relationship-30258/articlesdoctor patient relationship – The Conversation2022-01-11T13:36:27Ztag:theconversation.com,2011:article/1738052022-01-11T13:36:27Z2022-01-11T13:36:27ZConfused by what your doctor tells you? A new study discovers how communication gaps between doctors and patients can be cured<figure><img src="https://images.theconversation.com/files/438464/original/file-20211220-13-ivqi91.jpg?ixlib=rb-1.1.0&rect=0%2C512%2C6872%2C4140&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new study identifies significant language barriers between doctors and their patients. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/just-relax-royalty-free-image/1320931826?adppopup=true">ljubaphoto/E+ via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>Most doctors use language that is too complex for their patients to understand, but some have the unique ability to tailor their language to meet their patients’ communication needs and overcome the confusion that is so common in health care. These are the key findings of <a href="https://doi.org/10.1126/sciadv.abj2836">our new study</a> recently published in Science Advances. </p>
<p>This language-matching strategy – what we call “precision communication” – appears to be especially helpful for the one in three Americans who have low health literacy. Prior studies have shown that individuals with low health literacy have <a href="https://doi.org/10.1016/S0738-3991(03)00107-1">worse comprehension</a> of medical information and instructions and <a href="https://doi.org/10.1001/jama.288.4.475">poorer health outcomes</a> compared with those with adequate health literacy. </p>
<p>To conduct our research, we analyzed hundreds of thousands of secure email messages between doctors and patients with diabetes. Using sophisticated computational linguistics techniques, our research team discovered that only about 40% of patients with low health literacy have a doctor who adapts the complexity of their language to match the language their patient uses. We also found that even fewer patients are cared for by doctors who are consistently attuned to the kind of language that their patients use – whether it be low or high health literacy – and then adapt their communication accordingly. </p>
<p>We found that patients fortunate enough to be under the care of doctors who practice this form of precision communication were better able to understand and act on their doctors’ advice and instructions. Patients whose doctors don’t match their language to their patients’ health literacy are more likely to be confused and may get sicker. The benefit of this approach was so strong as to eliminate the usual gaps in understanding between patients of low and high health literacy.</p>
<h2>Why it matters</h2>
<p>Perhaps no health care experience is more universal than being sick and not understanding one’s doctor. Not only is this a frustratingly common – and often dangerous – experience, it’s also a massive and costly <a href="https://doi.org/10.17226/10883">public health problem</a>. Despite the outsized impact of this problem, few clinical studies have examined the issue, and no study has used artificial intelligence methods or has been large enough to draw firm conclusions. </p>
<p>Doctors and patients are relying more on <a href="https://doi.org/10.1093/jamia/ocaa281">secure messaging</a>, a digital communication innovation that has expanded during the COVID-19 pandemic. Our findings suggest that most doctors can and should adjust how they listen and respond to patients to achieve more effective communication. </p>
<p>Patients who find themselves confused should ask their doctor to restate their explanations and advice in more approachable ways. And our study suggests that health systems should carefully consider the ways that they can best support doctors and patients to achieve shared meaning. This includes how they train clinicians and how they allocate and reimburse for the time, personnel and technologies that can promote communication.</p>
<h2>What still isn’t known</h2>
<p>While <a href="https://doi.org/10.1016/j.pec.2008.11.015">prior research</a> has shown that understanding one’s health condition and its treatment is key to getting healthier, we do not know how beneficial this form of precision communication is to achieving better health outcomes. We also can’t yet determine whether doctors’ written communications reflect how they communicate verbally – in person – although the results of the <a href="https://doi.org/10.1177/2374373518793143">patient survey</a> that we used in this study suggest overlaps between doctors’ written and spoken communication. </p>
<h2>What’s next</h2>
<p>We are designing studies to examine whether language-matching improves health outcomes such as blood sugar or blood pressure control. We have also developed and are testing whether an automated feedback system embedded in the electronic health record can enable precision communication in email exchanges. The system rapidly analyzes patients’ email messages and alerts the physician if the complexity of their email response is too high.</p><img src="https://counter.theconversation.com/content/173805/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dean Schillinger received funding from NIH/National Library of Medicine grant R01LM012355 and NIH/NIDDK grant 2P30-DK092924 </span></em></p><p class="fine-print"><em><span>Nicholas Duran receives funding from the National Science Foundation (NSF 1660894). The current work is funded by the National Institutes of Health (NIH R01 LM012355). </span></em></p>Communication breakdowns between doctors and their patients have real-life consequences and can result in poorer health outcomes and sicker patients.Dean Schillinger, Professor of General Internal Medicine, University of California, San FranciscoNicholas Duran, Associate Professor in Social and Behavioral Sciences, Arizona State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579582021-04-04T20:36:35Z2021-04-04T20:36:35ZHow your doctor describes your medical condition can encourage you to say ‘yes’ to surgery when there are other options<figure><img src="https://images.theconversation.com/files/392709/original/file-20210331-15-vdznal.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6240%2C4156&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There are many factors that influence whether you choose to have surgery for a health condition.</p>
<p>But one you might not have considered is the very name your doctor uses to describe your condition can make you more or less likely to go under the knife, according to a growing body of research.</p>
<p>This is concerning because there are often less invasive options than surgery that are equally effective and safer.</p>
<h2>What’s in a name?</h2>
<p>Let’s take shoulder pain as an example.</p>
<p>Three of us (Joshua, Mary and Giovanni) <a href="https://doi.org/10.2519/jospt.2021.10375">published new research</a> last week finding health professionals’ use of certain medical terms might be encouraging patients to say yes to unnecessary shoulder surgery.</p>
<p>Our world-first trial involved 1,308 people from five countries, some with and without shoulder pain, who were randomly allocated to read one of six hypothetical scenarios. The only difference between the scenarios was the medical term used by the health professional to describe the person’s shoulder pain.</p>
<p>In our study, we used the <a href="https://pubmed.ncbi.nlm.nih.gov/25560729">most common type of shoulder pain</a> where people feel pain at the front of one of their shoulders which is made worse by lifting the arm and lying on it.</p>
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<img alt="Man holding is shoulder in pain at the gym" src="https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392710/original/file-20210331-15-1qglsfu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There’s an abundance of terms for common shoulder pain, and it’s often difficult to determine what the specific cause is.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>Health professionals use a <a href="https://pubmed.ncbi.nlm.nih.gov/27806952/">variety of terms</a> for this pain, including “subacromial impingement syndrome”, “rotator cuff tear”, “bursitis”, and “rotator cuff related shoulder pain”.</p>
<p>The terms doctors use vary so widely because it’s currently impossible to pinpoint the exact cause of most shoulder pain, even <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6099421">with the help</a> of <a href="https://pubmed.ncbi.nlm.nih.gov/28122541">sophisticated technology</a> such as magnetic resonance imaging (MRI).</p>
<p>We found people told they had a “rotator cuff tear” wanted shoulder surgery the most. Those told they had “bursitis” (inflammation of a fluid-filled sac in the shoulder) wanted surgery the least. People told they had a rotator cuff tear had 24% higher perceived need for surgery than those told they had bursitis.</p>
<h2>Unnecessary shoulder surgery is a growing problem</h2>
<p>The use of surgery for common types of shoulder pain <a href="https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-015-0639-6">is</a> <a href="https://pubmed.ncbi.nlm.nih.gov/24395314/">increasing</a> <a href="https://pubmed.ncbi.nlm.nih.gov/23375667/">worldwide</a>, including <a href="https://pubmed.ncbi.nlm.nih.gov/27490156">in Australia</a>.</p>
<p>Yet some shoulder surgery provides limited benefit to patients. <a href="https://pubmed.ncbi.nlm.nih.gov/29169668/">One such example</a> is a type of surgery called “subacromial decompression”, which involves reducing pressure on a tendon by removing surrounding tissue. This procedure is no better than placebo surgery (where patients were put to sleep and researchers only conducted a joint examination, rather than surgery). </p>
<p>Other surgeries to repair torn tendons <a href="https://pubmed.ncbi.nlm.nih.gov/31813166">provide</a> little or no benefit compared with non-surgical treatments such as exercise.</p>
<p>Also, there’s no reliable way to determine that a rotator cuff tear is the cause of a patient’s symptoms. <a href="https://www.sciencedirect.com/science/article/abs/pii/S1058274614004480">Up to 21%</a> of people aged 30-39 years who don’t have any shoulder symptoms have rotator cuff tears when they are scanned.</p>
<p><a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">More than 20,000</a> potentially unnecessary shoulder surgeries are performed in Australia each year, which we estimate to cost <a href="https://pubmed.ncbi.nlm.nih.gov/27490156/">over A$200 million</a> per year. </p>
<p>Use of surgery is also increasing across many other conditions. For example, <a href="https://www.mja.com.au/journal/2018/208/8/increasing-rates-anterior-cruciate-ligament-reconstruction-young-australians">knee reconstructions</a> for anterior cruciate ligament (ACL) ruptures, and spinal fusions for some <a href="https://pubmed.ncbi.nlm.nih.gov/28441309/">spinal conditions</a>. However, evidence suggests surgery is <a href="https://www.nejm.org/doi/full/10.1056/nejmoa0907797">not superior</a> <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/imj.14120?fbclid=IwAR3BjuVv-t8jNFL_KnfZz1AtkFX7ue0gZ_dNl4f2jHGyff8J_iE7bRmWwN4">to non-surgical management</a> for either of these surgeries.</p>
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Read more:
<a href="https://theconversation.com/australians-are-undergoing-unnecessary-surgery-heres-what-we-can-do-about-it-46089">Australians are undergoing unnecessary surgery – here's what we can do about it</a>
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<h2>What about other conditions?</h2>
<p>Our study adds to <a href="https://bmjopen.bmj.com/content/bmjopen/7/7/e014129.full.pdf">increasing evidence</a> showing the name your doctor uses to describe your condition can encourage you to consider unnecessary treatments.</p>
<p><strong>Low-risk “cancer”</strong></p>
<p>There’s a type of abnormal breast cells that can build up in the milk ducts called “ductal carcinoma in situ”. For many people, these cells are low-risk and won’t grow, or grow so slowly they’ll never cause harm.</p>
<p>Using the terms “cancer” or “carcinoma” to describe this condition <a href="https://pubmed.ncbi.nlm.nih.gov/26376460">elicits strong</a> <a href="https://bmjopen.bmj.com/content/5/11/e008094.short">negative reactions</a> from patients, and increases their desire for more aggressive treatments, <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1731962">including surgery</a>.</p>
<p>For patients with these low-risk cells, surgery, radiotherapy and/or hormonal treatments <a href="https://www.nytimes.com/2015/08/21/health/breast-cancer-ductal-carcinoma-in-situ-study.html">may not improve overall survival</a>. Instead, these interventions may cause harm through surgical complications such as persistent pain or skin burns, as well as financial costs and the psychological impact of being diagnosed with “cancer”.</p>
<p><strong>Acid reflux</strong></p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639462/">One study</a> asked parents to consider a hypothetical scenario in which their otherwise healthy infant cries a lot and “spits up excessively”.</p>
<p>It found parents who were told their child had gastroesophageal reflux disease (commonly known as “acid reflux”) were more interested in medication compared to parents who didn’t receive a diagnosis at all. This was true even when parents were told medication wasn’t beneficial. Medication in babies shows <a href="https://pubmed.ncbi.nlm.nih.gov/21464183/">no difference to placebo</a> in reducing these symptoms.</p>
<figure class="align-center ">
<img alt="Baby in bed crying" src="https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392711/original/file-20210331-17-ahi982.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hearing your baby might have a scary-sounding reflux disease can increase the likelihood you request medication.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p><strong>‘Pink-eye’</strong></p>
<p>A <a href="https://journals.sagepub.com/doi/abs/10.1177/0009922815601983">similar study</a> presented a hypothetical scenario to parents about viral conjunctivitis. One group of parents were told their kids had “pink-eye”, and another were told their kids had an “eye infection”. </p>
<p>Parents told their children had “pink-eye” remained interested in antibiotics despite being told the medications were ineffective. Conversely, parents told their children had an “eye infection” became significantly less interested in antibiotics when told they were ineffective.</p>
<p>Parents given the “pink-eye” label perceived the infection as more contagious than those given the “eye infection” label, even though both are simply other ways of saying conjunctivitis.</p>
<p><strong>Polycystic ovary syndrome</strong></p>
<p>This is a common hormonal condition affecting many women. But <a href="https://theconversation.com/4-myths-about-polycystic-ovary-syndrome-and-why-theyre-wrong-131908">symptoms</a> are on a spectrum of severity, with no clear line separating normal from abnormal.</p>
<p><a href="https://academic.oup.com/humrep/article/32/4/876/3003211">One study</a> found young women told their symptoms indicated “polycystic ovary syndrome” — in a hypothetical scenario of a doctor’s visit — were more likely to want further medical testing than those given the term “hormonal imbalance”. These women also perceived their condition to be more severe and had lower self-esteem.</p>
<h2>What should health professionals do?</h2>
<p>It’s vital health professionals consider whether the terms they use to describe a condition might be causing unnecessary fear and anxiety, and leading patients to consider unnecessary tests and treatments.</p>
<p>Health professionals may find it challenging to avoid terms they’ve been using for many years. But the potential cost of increasing patient’s fear and anxiety, and making people feel they need surgery when they don’t, cannot be ignored.</p>
<p>Changing how health professionals describe conditions to their patients is a simple strategy that could curb the rise of unnecessary health care.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1026460631724187648"}"></div></p>
<p>For patients with shoulder pain not caused by severe trauma, we suggest health professionals avoid telling patients they have rotator cuff tears as this may make some patients think shoulder surgery is needed (which it isn’t).</p>
<p>Health professionals could instead label people with this type of shoulder pain as having bursitis (inflammation), as this was the label that mostly made people think surgery was unnecessary.</p><img src="https://counter.theconversation.com/content/157958/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua Zadro receives fellowship funding from The National Health and Medical Research Council (NHMRC). </span></em></p><p class="fine-print"><em><span>Brooke Nickel receives fellowship funding from The National Health and Medical Research Council (NHMRC). </span></em></p><p class="fine-print"><em><span>Mary O'Keeffe has received funding from the European Commission. </span></em></p><p class="fine-print"><em><span>Tessa Copp receives funding from the NHMRC Centre for Research Excellence in Creating Sustainable Healthcare. </span></em></p><p class="fine-print"><em><span>Giovanni E Ferreira does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Health professionals should carefully consider the terms they use to avoid needless anxiety and unnecessary surgeries.Joshua Zadro, NHMRC Emerging Leader Research Fellow, University of SydneyBrooke Nickel, NHMRC Emerging Leader Research Fellow, University of SydneyGiovanni E Ferreira, Postdoctoral research fellow, University of SydneyMary O'Keeffe, Postdoctoral Research Fellow, University of SydneyTessa Copp, Postdoctoral research fellow, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/900612018-01-21T21:17:29Z2018-01-21T21:17:29ZIs your 10:30 medical appointment really for 11:15?<figure><img src="https://images.theconversation.com/files/202464/original/file-20180118-158546-14ky7qv.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5599%2C2925&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Good appointment schedules keep physicians busy and minimize patients' waiting. (Shutterstock)</span> </figcaption></figure><p>Patients often wait weeks or months for medical appointments. Canada’s Fraser Institute <a href="https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2017">recently reported</a> that Canadians typically wait 10 weeks to see specialists. Long wait times are one reason Canada ranks behind other developed countries in <a href="https://theconversation.com/how-healthy-is-the-canadian-health-care-system-82674">health-care quality</a>.</p>
<p>In the United States, waits are shorter but also increasing. <a href="https://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2017waittimesurveyPDF.pdf">Merritt Hawkins reported</a> an average wait of 24 days in their 2017 sample, up 30 per cent from 2014.</p>
<p>When they finally arrive at physicians’ offices, patients in both countries often face further delays. They may spend substantial periods in the waiting room, despite having specific appointment times. It’s something <a href="https://www.huffingtonpost.com/inga/doctors-office-wait_b_9045632.html">we love to complain about</a>.</p>
<p>This in-office waiting occurs for many reasons. Perhaps those patients arrived early. Perhaps earlier patients put the physicians behind schedule, or urgent calls interrupted them.</p>
<p>But sometimes clinics purposely schedule appointments before physicians expect to be ready. They do this to ensure physicians don’t run out of work.</p>
<p>So your appointment time might be the moment your physician really expects to start seeing you. Or it might merely be when they want you to begin standing by in the waiting room.</p>
<p>Appointment schedules aim to maximize physician productivity in order to avoid wasting valuable health care resources. But they should also try to minimize patients’ in-office waiting.</p>
<h2>Real and simulated waiting</h2>
<p>Research at our university aims to improve appointment scheduling by better balancing these competing goals under various conditions. <a href="http://www.emeraldinsight.com/doi/full/10.1108/01443571311307253">One study</a> examined the impact of emergencies interrupting the physicians. <a href="http://onlinelibrary.wiley.com/doi/10.1111/deci.12091/abstract">Another</a> involved patients arriving earlier or later than planned.</p>
<p>Each study began by recording patient arrival, waiting and treatment times at several clinics. The two studies together collected that data for 664 patients. As well, clinic staff completed surveys about their experiences.</p>
<p>In those samples, about half of appointments started later than scheduled. One third began early, and the rest were on time. </p>
<p>Most late starts occurred because physicians were not yet available. Few were due to patients arriving late.</p>
<p>The next step was to load the data into computer software that simulates patient flow through a clinic. The simulation estimates waiting by patients and physicians. It can compare different schedules to see what works best.</p>
<p>Of course, scheduling would be easy if no one ever ran late: Simply spread out the appointments evenly across the day. If treatments always take 10 minutes, then schedule one patient every 10 minutes. Patients would show up on time and walk right in.</p>
<h2>Late is bad, unpredictable is worse</h2>
<p>Alas, reality rarely runs so smoothly. Some patients or physicians run late, and waiting occurs. But the simulation confirmed that the type of lateness matters.</p>
<p>It’s easy to compensate for consistent lateness. If patients habitually arrive late, the clinic should schedule the appointments slightly earlier in the day. If physicians always start late, set the appointments a bit later.</p>
<p>But patient and physician timings often vary randomly. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/202299/original/file-20180117-53295-gu2nil.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/202299/original/file-20180117-53295-gu2nil.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=452&fit=crop&dpr=1 600w, https://images.theconversation.com/files/202299/original/file-20180117-53295-gu2nil.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=452&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/202299/original/file-20180117-53295-gu2nil.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=452&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/202299/original/file-20180117-53295-gu2nil.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=568&fit=crop&dpr=1 754w, https://images.theconversation.com/files/202299/original/file-20180117-53295-gu2nil.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=568&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/202299/original/file-20180117-53295-gu2nil.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=568&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are ways for physicians’ offices to minimize wait times, but for the time being, patients may need to show patience.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>If half of patients arrive early and half are late, it’s harder to compensate. (“No-show” patients who don’t arrive at all had relatively little effect on scheduling in these particular clinics.) In these less predictable situations, evenly spaced appointments don’t work well. The physicians periodically run out of patients.</p>
<p>Instead, physicians do better by putting appointments earlier and closer together. Ideally, they’d have all patients arrive the instant the clinic opens, to ensure always having some ready.</p>
<p>But that “ideal” would mean very long patient wait times. They’d arrive at 8 a.m. and possibly wait for hours.</p>
<h2>Smarter schedules</h2>
<p>Instead of such simplistic extremes, the research tested more creative scheduling approaches. It found two that handled variation well.</p>
<p>The first method puts appointments closer together near the start and end of the work session. This helps keep physicians busy. But it spreads appointments farther apart in between. That reduces patient waiting.</p>
<p>Suppose a physician works from 8 a.m. until the noon lunch break. Their appointments in early morning and just before noon might be eight or nine minutes apart. Mid-morning appointments instead could be every 11 or 12 minutes. The average would remain 10.</p>
<p>The second approach puts appointments closer together in clusters of two or three, while spreading the clusters farther apart. The closeness within clusters and distances between clusters both increase as the day unfolds. The clusters keep physicians busy. The spaces between clusters reduce patient waiting.</p>
<p>With this method, early morning appointments might alternate being five and 15 minutes apart. Later bookings could alternate between zero and 20 minutes apart. (Zero means two patients are scheduled simultaneously.)</p>
<p>The simulation indicated the clustering method best balances physician productivity and patient waiting. But the other approach works almost as well. Some clinics might prefer its simpler pattern.</p>
<h2>Small detail helps big picture</h2>
<p>Patients often wait weeks for their appointments. They may find it frustrating to wait even a few minutes more at physicians’ offices.</p>
<p>But ironically, the latter wait can help reduce the former one. By keeping physicians busy, effective appointment scheduling helps them see more patients per day. That increased capacity reduces the number of days patients must wait for their appointments.</p>
<p>Improved scheduling systems are therefore one small way of increasing <a href="https://theconversation.com/why-do-we-wait-so-long-in-hospital-emergency-departments-and-for-elective-surgery-54384">health- care system efficiency</a> as the population ages and physicians face greater demands on their time.</p>
<p>That’s better for us than cutting the <a href="https://www.reuters.com/article/us-doctor-checkup-duration/the-doctor-will-see-you-now-but-often-not-for-long-idUSKBN1DS2Z2">time physicians spend with each patient</a>. And cheaper than paying to add more physicians or <a href="http://www.cbc.ca/news/canada/toronto/hospital-beds-crisis-flu-season-1.4367079">more hospital beds</a>.</p>
<p>So, for the foreseeable future, we patients need patience.</p><img src="https://counter.theconversation.com/content/90061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kenneth J Klassen received funding from NSERC (2004-2012)</span></em></p><p class="fine-print"><em><span>Michael J. Armstrong and Reena Yoogalingam do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Creative appointment scheduling minimizes in-office waiting for physicians and patients.Michael J. Armstrong, Associate professor of operations research, Brock UniversityKenneth J Klassen, Professor of Operations Management, Brock UniversityReena Yoogalingam, Associate Professor of Operations Management, Brock UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/867162017-12-06T11:30:40Z2017-12-06T11:30:40ZHow to talk to your doctor about information you find online<figure><img src="https://images.theconversation.com/files/197182/original/file-20171130-30937-18e459u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Digital health.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-attractive-woman-modern-office-desk-529004896?src=XZC1AooheSphsP0RY7C5OA-2-14">fizkes/Shutterstock</a></span></figcaption></figure><p>More and more people are <a href="http://www.telegraph.co.uk/news/health/news/11760658/One-in-four-self-diagnose-on-the-internet-instead-of-visiting-the-doctor.html">going online to search for information</a> about their health. Though it can be a minefield, where unverified sources abound, searching the internet can help people to understand different health problems, and give them access to emotional and social support. </p>
<p>For many in the UK, getting to actually see a GP remains difficult, and <a href="https://www.theguardian.com/society/2016/aug/28/doctor-appointments-15-minutes-bma-overweight-population">constraints around appointment times</a> mean that some discussions are often cut short. But by using the internet, patients can prepare for appointments, or follow up on issues that were raised in the consulting room but left them with unanswered questions. </p>
<p>But not everyone is so keen on patients using the internet in this way. Some GPs and other heath professionals <a href="https://inews.co.uk/essentials/news/uk/doctors-gps-dr-google-patient-list/">have doubts</a> about the quality and usefulness of the information available. There are also suggestions that “<a href="https://theconversation.com/dear-worried-well-the-internet-is-not-your-friend-83762">cyberchrondria</a>” may be fuelling a surge in unnecessary tests and appointments.</p>
<p>Similarly, though so many people are using online resources to fill in gaps in their knowledge, or to help them ask the right questions, they may not be comfortable bringing it up in the consulting room.</p>
<p>For <a href="https://dl.acm.org/citation.cfm?id=3079495&CFID=829758834&CFTOKEN=84113975">our latest research project</a>, we wanted to find out just why it can be so difficult to discuss online information with doctors. We found that in addition to people being embarrassed in case they have misunderstood the information, or can’t remember it accurately, they also fear a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319073/">negative reaction from the GP</a> who may think they are difficult or challenging.</p>
<h2>How to make it work</h2>
<p>So how can you as a patient bring up online information with your doctor? First, it sounds obvious but you need a good, open relationship with your GP. Tell them you have been looking online, but ask for their feedback on the information, and for any useful sites they know of. We found that patients with a good doctor relationship felt able to discuss information and ideas from websites and online forums in a considered and critical manner. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/197185/original/file-20171130-30937-dz82ol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/197185/original/file-20171130-30937-dz82ol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/197185/original/file-20171130-30937-dz82ol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/197185/original/file-20171130-30937-dz82ol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/197185/original/file-20171130-30937-dz82ol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/197185/original/file-20171130-30937-dz82ol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/197185/original/file-20171130-30937-dz82ol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There’s no shame in searching for health information online.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-tablet-pc-woman-hospital-371110727?src=88zlMsalxsJ_Md0BiZP0Og-3-20">Syda Productions/Shutterstock</a></span>
</figcaption>
</figure>
<p>Importantly, it is not about the patient trying to be the doctor. Ideally, patients should bring along their information, use it to help explain their key concerns, or detail the options they’ve explored, but also make clear that they still want and value their GP’s input on their findings. </p>
<p>Some of the patients we spoke to told us that they are acutely aware of their doctor’s negative feelings towards the internet. In these situations, people are sometimes tempted to disguise the source of their information. Rather than openly discussing their findings from the internet, they may pretend they got the information elsewhere when mentioning it to their doctor or be very careful not to reveal its origin at all. </p>
<p>For some people we spoke to, the process of trying to integrate the results of their web searches into their communications with the GP was frustrating to say the least. They felt uncomfortable, embarrassed, and sometimes held back key information. This made for unproductive meetings which were felt to be a waste of time.</p>
<p>This process can definitely be improved. As more appointments are going to be <a href="http://www.bbc.co.uk/news/health-41884142">conducted over smartphone</a> rather than face to face, and some GPs have admitted <a href="http://www.dailymail.co.uk/news/article-2933982/Wikipedia-GPs-Half-doctors-online-help-diagnose-patients-quarter-want-health-apps-help-treat-sick.html">using Wikipedia to diagnose patients</a>, the rest of the process needs to catch up with technology.</p>
<p>There needs to be a new and more productive way to integrate online information into doctor-patient discussions. First of all, there should be better ways for patients to collect and organise accurate information online so that they can organise their thoughts and prepare for a visit. </p>
<p>In the consulting room itself, GPs should use the research as an opportunity to have more productive discussions, and use it as a way to teach patients more about their own health issues. They need to question the information source, message and credibility, but GPs could also use it as an opportunity to nudge patients to think about their health options and consider what’s important to them. </p>
<p>Just as a GP is not solely responsible for the health of a patient, neither is the patient themselves. Internet research can no longer be dismissed. Even if inaccurate, it can help build a better relationship between patient and doctor, and give them both a better understanding of managing health in the modern world.</p><img src="https://counter.theconversation.com/content/86716/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p><p class="fine-print"><em><span>Lauren Georgia Bussey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The internet can help answer patients’ lingering questions.Elizabeth Sillence, Senior Lecturer Psychology, Northumbria University, NewcastleLauren Georgia Bussey, PhD Researcher and Demonstrator, Northumbria University, NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/761542017-04-20T05:17:12Z2017-04-20T05:17:12ZA doctor’s sexual advances towards a patient are never ok, even if ‘consensual’<figure><img src="https://images.theconversation.com/files/166017/original/file-20170420-2423-1ub7602.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's important patients know what is appropriate and what isn't.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>In a recent <a href="https://nhpopc.gov.au/wp-content/uploads/Chaperone-review-report-WEB.pdf">independent review</a>, I recommended chaperones no longer be used as an interim protective measure to keep patients safe while allegations of sexual misconduct by a doctor are investigated. </p>
<p>The review was commissioned by the Medical Board of Australia and the Australian Health Practitioner Regulation Agency (AHPRA), <a href="http://www.smh.com.au/national/health/sex-abuse-doctor-andrew-churchyard-allowed-to-keep-working-by-cabrini-hospital-20160729-gqgl4k.html">following media reports</a> that a Melbourne neurologist was facing criminal charges for sexually assaulting a patient. </p>
<p>Dr Andrew Churchyard was allowed to keep practising after the alleged sex abuse. But this was subject to a condition on his registration that an approved chaperone be present for all consultations with male patients.</p>
<p>The Medical Board of Australia and AHPRA have accepted my recommendations that the current system of using chaperones is outdated and paternalistic. In future cases where a doctor is accused of sexual misconduct, and interim protection is considered necessary, restrictions may be imposed after an assessment of the allegations by a specialist board committee. </p>
<p>They will include prohibitions on contact with patients of a specified gender, prohibitions on any patient contact, or suspension from practice. </p>
<p>Sadly, cases of sexual misconduct are likely to continue. It’s important patients know the warning signs and where to seek help if they suspect their doctor is behaving inappropriately.</p>
<h2>Ethical boundaries</h2>
<p>The <a href="https://books.google.com.au/books?id=cZC-W0JlNBMC&pg=PA64&lpg=PA64&dq=abstain+from+all+intentional+wrong-doing+and+harm,+especially+from+abusing+the+bodies+of+man+or+woman+hippocratic+oath&source=bl&ots=_yzf2K3Gvq&sig=5L69JwrqQOXLO6eoJOAvVBj7yYI&hl=en&sa=X&ved=0ahUKEwi4-Nau77HTAhVBo5QKHbrhC2QQ6AEIOzAF#v=onepage&q=abstain%20from%20all%20intentional%20wrong-doing%20and%20harm%2C%20especially%20from%20abusing%20the%20bodies%20of%20man%20or%20woman%20hippocratic%20oath&f=false">Hippocratic Oath states</a> that in their professional lives, doctors will:</p>
<blockquote>
<p>abstain from all intentional wrongdoing and harm, especially from abusing the bodies of man or woman. </p>
</blockquote>
<p>The oath frames sexual contact with patients as a type of intentional harm that is forbidden. Much has changed in medical practice since the days of the ancient Greeks, but Hippocrates’ clear-eyed prohibition on sexual contact with patients, and categorisation of such conduct as a form of abuse, remains apt. </p>
<p>It seems likely that the disciplinary findings and criminal convictions that come to media attention are only the tip of the iceberg of doctor-patient sexual contact. </p>
<p>International <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/228872/7015.pdf">studies indicate</a> that the prevalence of sexual boundary violations by health practitioners may be as high as 6 to 7%. A <a href="http://www.worldcat.org/title/crossing-the-boundaries-the-report-of-the-committee-on-physician-sexual-misconduct-prepared-for-the-college-of-physicians-and-surgeons-of-british-columbia/oclc/839388109?referer=di&ht=edition">Canadian survey</a> of 8,000 members of the public in 1992 found that 4.1% of respondents (4.7% of women, 1.3% of men) reported touching of a private body part by their doctor “for what seemed to be sexual reasons”. </p>
<p>During my review, I heard first-hand accounts of the harm sexual contact from their doctor causes patients. The harrowing stories from abused patients and their families confirm what the literature says. </p>
<p>Patients who are sexually exploited by their doctor <a href="http://www.professionalstandards.org.uk/docs/default-source/publications/policy-advice/clear-sexual-boundaries-guidance-for-fitness-to-practise-panels-2008.pdf?sfvrsn=6">suffer from major depressive disorders</a>, suicidal and self-destructive behaviour, and relationship problems. They <a href="https://books.google.com.au/books/about/Sexual_Exploitation_in_Professional_Rela.html?id=hAzAZ2V57D4C&redir_esc=y">experience feelings of shame</a>, guilt, isolation, poor self-esteem and denial. They may also delay seeking medical help.</p>
<p>Their trust in their doctor, and in the consultation room as a safe place to share problems and seek advice, is shattered.</p>
<h2>Consensual relationships?</h2>
<p>The impact on patients who have been indecently assaulted – by being subjected to unnecessary and inappropriate clinical examinations – has much in common with the effects of sexual abuse on victims in other, non-clinical contexts. </p>
<p>But patients who engage in “consensual” sexual relations with their doctor also suffer harm. Issues of vulnerability, transference and breach of trust are <a href="http://www.rcpsych.ac.uk/usefulresources/publications/books/rcpp/9781904671374.aspx">well recognised</a> for current patients. Yet even former patients may be harmed by entering a sexual relationship with their former doctor. </p>
<p>Critics of a “zero tolerance” approach to doctor-patient contact suggest notions of vulnerable patients being exploited by their doctor are old-fashioned. They argue that a mature, consenting adult <a href="http://www.hdc.org.nz/decisions--case-notes/commissioner's-decisions/2004/03hdc11070">should be free</a> to enter a consensual sexual relationship with their doctor, once the doctor-patient relationship has ended. Such views are misguided.</p>
<p>It is one thing to accept that a doctor may later become romantically involved with a patient after fleeting professional contact. But if the doctor-patient relationship has endured for some time, and has involved confidential disclosures and advice, any subsequent sexual relationship risks harm to the patient, and damaging professional consequences for the doctor.</p>
<h2>Warning signs</h2>
<p>It may be very difficult to discern whether an examination of the genitalia is warranted. For all the rhetoric about empowered patients, when we are unwell and consulting a doctor (especially someone new) for diagnosis and treatment, it can feel awkward to ask whether it is really necessary to disrobe for a full examination. </p>
<p>During my review, <a href="https://nhpopc.gov.au/wp-content/uploads/Chaperone-review-report-WEB.pdf">one patient recalled</a> seeing a specialist about his severe migraines. He thought a full body examination was unusual, but said: “How was I meant to know what was normal?” </p>
<p>Ideally, patients will know that it’s always ok to ask why an examination or procedure is necessary, to request to have a support person present, and to raise any concerns with a practice manager after a consultation. </p>
<p>Patients concerned that their doctor may have acted improperly can contact support services such as <a href="http://www.casahouse.com.au/">CASA House in Victoria</a>, which provides information and counselling to victims of sexual assault.</p>
<p>Patients should be alert to signs that their doctor’s interest is more than professional. Scheduling appointments for the end of the day, asking personal questions unrelated to the presenting problem, and providing their mobile number may all be warning signs. </p>
<p>Doctors should always be willing to question their own motives and, if in doubt, to seek advice from a professional mentor.</p>
<p>Sexual advances or sexual assault by doctors causes significant harm. A strict “zero tolerance” approach protects patients and doctors.</p><img src="https://counter.theconversation.com/content/76154/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ron Paterson received funding from AHPRA (the Australian Health Practitioner Regulation Agency) for researching and writing a report entitled 'Independent review of the use of chaperones to protect patients in Australia' (2017). He is employed as a Professor of Law at the University of Auckland.</span></em></p>It seems likely that the disciplinary findings and criminal convictions that come to media attention are only the tip of the iceberg of doctor-patient sexual contact.Ron Paterson, Professor of Health Law and Policy, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/682282017-01-12T19:28:12Z2017-01-12T19:28:12ZAre our busy doctors and nurses losing empathy for patients?<figure><img src="https://images.theconversation.com/files/149794/original/image-20161213-1625-kg08zw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health professionals needs to be skilled in understanding what the other person is going through, so they can respond appropriately.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>This is the last article in our series on <a href="https://theconversation.com/au/topics/understanding-others-feelings-33600">understanding others’ feelings</a>, in which we examine empathy, including what it is, whether our doctors need more of it, and when too much may not be a good thing.</em></p>
<hr>
<p>Every day, doctors, nurses and other health professionals are presented with situations that demand empathy and compassion. </p>
<p>Whether telling a 40-year-old man with cancer he doesn’t have long to live, or comforting an elderly woman who is feeling anxious, the health professional needs to be skilled in understanding what the other person is going through, and respond appropriately.</p>
<p>With more demand on doctors and nurses and a push for quicker consultations, clinical empathy is being dwarfed by the need for efficiency. But this doesn’t mean patients have stopped wanting to be treated in a caring and empathetic manner. And there is a growing body of evidence that this need is often not being met.</p>
<h2>Empathy is key to good communication</h2>
<p>In the novel To Kill a Mockingbird, Atticus Finch tells his daughter Scout that “you never really understand a person until you consider things from his point of view … until you climb into his skin and walk around in it”. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/149781/original/image-20161213-25498-i0iwa0.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/149781/original/image-20161213-25498-i0iwa0.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149781/original/image-20161213-25498-i0iwa0.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=297&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149781/original/image-20161213-25498-i0iwa0.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=297&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149781/original/image-20161213-25498-i0iwa0.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=297&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149781/original/image-20161213-25498-i0iwa0.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=374&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149781/original/image-20161213-25498-i0iwa0.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=374&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149781/original/image-20161213-25498-i0iwa0.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=374&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Atticus Finch taught his daughter the meaning of empathy.</span>
<span class="attribution"><a class="source" href="https://www.youtube.com/watch?v=iZkZ36iU4B0">Screenshot/YouTube</a></span>
</figcaption>
</figure>
<p>This is empathy – where one identifies with another’s feelings. It involves compassion and the ability to understand and respond to the feelings of others. Often, an empathetic response leads to a caring response.</p>
<p><a href="https://www.youtube.com/watch?v=Y9VW7wGO4vY">Empathy is different to sympathy</a> which is described as feeling sorry for another person. This does not require us to understand the other person’s point of view, but is an automatic, emotional response. In health care, feeling sympathy for another person can overwhelm us with sorrow and often preclude us from helping.</p>
<p>In recent times, poor communication, including lack of empathetic and caring behaviours, has resulted in an increasing number of <a href="http://www.hccc.nsw.gov.au/ArticleDocuments/75/HCCC_Annual%20Report_2014-15.pdf.aspx">complaints</a> against health professionals in Australia.</p>
<p>Shocking cases of maltreatment at a <a href="http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspublicinquiry.com/">United Kingdom public hospital</a> between 2005 and 2009 reveal the extreme consequences of negligence, poor communication and lack of empathy in health care. Incidents ranged from patients being forced to drink from flower vases to lying in their own excrement. More than 300 deaths were directly linked to this neglect. </p>
<p>At the crux of the recommendations made in a report of the inquiry into the incidents was the need for improved communication between health care workers and patients.</p>
<p>Empathy is fundamental to effective communication. For doctors and nurses, this means placing the patient at the centre of care. This skill leads to increased levels of satisfaction not only in patients but also the doctors and nurses. Importantly, it is <a href="http://www.sciedu.ca/journal/index.php/jnep/article/view/9328">also associated with</a> improved patient outcomes.</p>
<h2>Why are nurses and doctors losing empathy?</h2>
<p>Technology has greatly contributed to health professionals’ diminishing levels of empathy. </p>
<p>It has come at the cost of changing the way doctors and nurses interact with their patients. Because there are fewer opportunities for direct patient contact, it hinders the ability to develop a rapport with patients, monitor their non-verbal communication and elicit feedback on the interaction.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/149784/original/image-20161213-25492-1yb4g09.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/149784/original/image-20161213-25492-1yb4g09.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/149784/original/image-20161213-25492-1yb4g09.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149784/original/image-20161213-25492-1yb4g09.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149784/original/image-20161213-25492-1yb4g09.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149784/original/image-20161213-25492-1yb4g09.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149784/original/image-20161213-25492-1yb4g09.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149784/original/image-20161213-25492-1yb4g09.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Historically, touch was a big part of a nurse’s work.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>For instance, <a href="http://onlinelibrary.wiley.com/doi/10.1111/jocn.13470/full">touch has historically been</a> a large part of the work of a nurse. When nurses hold a patient’s hand or arm to take their pulse, for instance, it contributes to the kind of connection that <a href="http://search.proquest.com/openview/654ac7021e23cc992d51e12362cab92c/1?pq-origsite=gscholar">has been shown to release</a> the feel-good hormone oxytocin.</p>
<p>But taking a patient’s pulse manually is now more often than not replaced by a probe attached to a patient’s finger. </p>
<p>Computers on wheels create a physical barrier for nurses when they use them to administer medications and access documents; and smart phones that support patient interviews have replaced the opportunity for a nurse to physically be present and develop a rapport with a patient. </p>
<p>Meanwhile, virtual reality games and experiences are often used to distract patients undergoing painful procedures, when in the past a nurse may have held the patient’s hand. </p>
<p>Learning often takes place using simulation technology, where students interact not with actual human beings but with computerised mannequins. </p>
<p>It is understandably difficult to respond to a mannequin as a patient with emotional needs. Students subsequently find it difficult, in a real clinical setting, to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765783/">integrate desired communication skills</a> – in particular, <a href="http://www.tandfonline.com/doi/full/10.1080/10376178.2016.1163231">empathy.</a></p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/149796/original/image-20161213-1610-1au0r68.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/149796/original/image-20161213-1610-1au0r68.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/149796/original/image-20161213-1610-1au0r68.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/149796/original/image-20161213-1610-1au0r68.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/149796/original/image-20161213-1610-1au0r68.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/149796/original/image-20161213-1610-1au0r68.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=483&fit=crop&dpr=1 754w, https://images.theconversation.com/files/149796/original/image-20161213-1610-1au0r68.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=483&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/149796/original/image-20161213-1610-1au0r68.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=483&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Taking a patient’s pulse is now done with a probe attached to a patient’s finger.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>University programs are often content-heavy, with graduates required to meet many competencies before they can be registered with professional bodies. </p>
<p>The result can sometimes be that students in health professional courses tend to <a href="http://onlinelibrary.wiley.com/doi/10.1111/jan.12891/abstract">focus on clinical and technical skills</a> at the expense of good communication. </p>
<p>The disruptiveness of technology may also be a factor affecting the ability of nurses and doctors to be empathetic and compassionate. Technology encourages multitasking, which is good for efficiency, but can distract health care professionals from important interpersonal interaction with patients. </p>
<p>Funding constraints in the university sector, decreasing clinical placement opportunities, the increasing complexity of patients, and a heightened awareness of ensuring patient safety and the associated legal responsibilities, all contribute to the increasing use of the controlled learning environment laboratories offer. </p>
<p>Learning in laboratories using technology is being developed to maximise experiences that develop empathy. Good communication needs to be role-modelled, taught and assessed in university programs and throughout clinical practice. </p>
<p>We need a better understanding of empathy development in health professions and more research on how to improve the situation with changing technologies. Most importantly, though, we need always to listen to our patients.</p>
<hr>
<p><em>Read the rest of our articles on empathy <a href="https://theconversation.com/au/topics/understanding-others-feelings-33600">here</a>.</em></p><img src="https://counter.theconversation.com/content/68228/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sue Dean does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With more demand on doctors and nurses and a push for quicker consultations, clinical empathy is being dwarfed by the need for efficiency.Sue Dean, Lecturer, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/639392016-08-16T20:12:32Z2016-08-16T20:12:32ZDoctors need to be taught how to discuss their patients’ excess weight<figure><img src="https://images.theconversation.com/files/134064/original/image-20160815-15264-13be4qx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors need to be able to discuss their patients' weight, but they need to be taught how to do so delicately, for the best outcomes. </span> <span class="attribution"><span class="source">www.shutterstock.com</span></span></figcaption></figure><p>With <a href="http://www.aihw.gov.au/overweight-and-obesity/">80% of adults and close to one-third of children</a> expected to be overweight or obese by 2025, doctors are increasingly likely to be working with people who are overweight or obese.</p>
<p>An individual’s weight is a complex and sensitive issue, which may be related to many factors that are not only medical but social, environmental and emotional. The skills to address the issue in a way that communicates the health risks of being overweight without judgement and without inciting negative responses are not easy to acquire or universally taught. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/22450855">Health professionals repeatedly report</a> a lack of confidence in knowing how to address obesity in their patients. They report minimal, if any, training on obesity as well as limited resources for effective conversations and insufficient clinical time to be able to do this well. </p>
<p>Starting a conversation about weight requires not only empathy but awareness of strategies people can use to manage weight issues and an understanding of the range of local services available to assist. It <a href="http://onlinelibrary.wiley.com/doi/10.1038/oby.2008.636/abstract">has been shown</a> that although behavioural and medical strategies can be effective, uninformed discussion in the clinic can disengage, stigmatise or shame patients, which then has negative impacts on the outcomes.</p>
<p>Many patients do expect weight-loss guidance from health professionals and the discussion can influence outcomes. In fact, having the conversation and formally diagnosing and documenting excess weight or obesity is <a href="http://www.ncbi.nlm.nih.gov/pubmed/17673060">the strongest predictor</a> of having a treatment plan and weight-loss success.</p>
<h2>Choice of language is crucial</h2>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/23369374">Research has identified</a> the terms “fat” and “fatness” are the least preferred terms. The words “obese” and “obesity” have also been found to arouse negative responses. The <a href="https://www.nice.org.uk/guidance/ng7">National Institute of Clinical Excellence</a> in the UK suggests patients may be more receptive if the conversation is about achieving or maintaining a “healthy weight”.</p>
<p>The <a href="http://www.ncbi.nlm.nih.gov/pubmed/22777543">STOP Obesity Alliance in the US suggests</a> using “people first” language such that a person “has” obesity rather than “is” obese, similar to “having” cancer or diabetes. </p>
<p>This is part of a debate about whether obesity should be labelled as a disease rather than a risk factor. </p>
<p>Regardless of how this issue is classified, doctors and patients both require the knowledge to understand effective therapies do exist and obesity treatment is not futile. Losing 5-10% of body weight can have a significant impact on risk factors such as blood pressure and can lower the risks of later health problems such as heart disease or type 2 diabetes. </p>
<p>This sort of weight loss also often improves other factors more immediately beneficial to the patient, such as energy levels, mood and mobility.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/134065/original/image-20160815-15238-1ylxkb1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/134065/original/image-20160815-15238-1ylxkb1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/134065/original/image-20160815-15238-1ylxkb1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134065/original/image-20160815-15238-1ylxkb1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134065/original/image-20160815-15238-1ylxkb1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134065/original/image-20160815-15238-1ylxkb1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134065/original/image-20160815-15238-1ylxkb1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134065/original/image-20160815-15238-1ylxkb1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">How a doctor discusses excess weight with the patient makes a big difference to the outcome.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>A communication style that encourages shared decision-making and helps people change their behaviour is key. The objective is not to solve the problem but to help the patient begin to believe change is possible and develop a plan about health goals. </p>
<p>Let’s take the case of a woman who presents with urinary incontinence. The woman may describe the problem of needing to wear sanitary pads because of daily leaking of urine. Factors such as obesity will worsen the problem, but the woman may not be aware of this. </p>
<p>The doctor might say:</p>
<blockquote>
<p>I hear you’re concerned about your loss of urine, is that correct? Let’s talk about that; and would it be OK to discuss your weight too, as that may be related?</p>
</blockquote>
<p>The practitioner might listen for a willingness to have further discussion and then pose a goal-orientated question: </p>
<blockquote>
<p>If, as part of our plan to help your urinary symptoms, you decide to work on getting to a healthier weight, what might be a first step?</p>
</blockquote>
<h2>Repercussions for our kids</h2>
<p>For men and women of reproductive age the conversation is potentially not just about their own health but also about that of their children. Women who have higher pre-conception weight and pregnancy weight gain are <a href="http://www.ncbi.nlm.nih.gov/pubmed/18611299">at increased risk</a> of developing diabetes and heart disease in later life and are <a href="http://www.ncbi.nlm.nih.gov/pubmed/23731445">less likely to lose weight</a> after they give birth.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/134073/original/image-20160815-15253-y6vr1c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/134073/original/image-20160815-15253-y6vr1c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/134073/original/image-20160815-15253-y6vr1c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134073/original/image-20160815-15253-y6vr1c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134073/original/image-20160815-15253-y6vr1c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134073/original/image-20160815-15253-y6vr1c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=591&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134073/original/image-20160815-15253-y6vr1c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=591&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134073/original/image-20160815-15253-y6vr1c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=591&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Being a healthy weight is important for people planning to have kids.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>This vicious cycle results in larger babies that are predisposed to short-term risks as newborns, longer-term risks of increased childhood obesity and an <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3984422/http://www.ncbi.nlm.nih.gov/pubmed/20562299">increased lifetime risk</a> of obesity, diabetes and heart disease. </p>
<p>Between 1985 and 1995 the rate of excess weight and obesity in childhood <a href="http://www.obesityaustralia.org/LiteratureRetrieve.aspx?ID=168776&A=SearchResult&SearchID=9345738&ObjectID=168776&ObjectType=6">increased by 50%</a> and obesity tripled in Australia. <a href="http://www.ncbi.nlm.nih.gov/pubmed/26974008">Animal studies also suggest</a> obesity in the male parent can increase the chance of their offspring developing obesity or diabetes.</p>
<p>The intergenerational nature of obesity therefore means until we address overweight and obesity in adults who are planning a pregnancy, it may be impossible to lower rates of childhood obesity. </p>
<p>The framing of the issue as a problem for patients’ own health as well as for the health of their children is even more complex. However, unless there is a greater understanding of this risk and more training of doctors in talking to patients about obesity this will be difficult to tackle.</p>
<p>Currently, many health professionals remain uncomfortable and unsure in this area of practice. Ensuring the workforce is skilled will also mean there is the ability to discuss weight when it is not the primary issue a patient presents with, but where an important conversation at a critical life stage may actually have lasting effects on patients’ health and that of their children.</p>
<hr>
<p><em>Adrienne Gordon will be online for an Author Q&A between 4 and 5pm AEST on Wednesday, 17 August, 2016. Post any questions you have in the comments below.</em></p><img src="https://counter.theconversation.com/content/63939/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An individual’s weight is a complex and sensitive issue, which may be related to many factors that are not only medical but social, environmental and emotional.Adrienne Gordon, Neonatal Staff Specialist, NHMRC Early Career Research Fellow, University of SydneyKirsten Black, Associate Professor & Joint Head of Discipline Obstetrics, Gynaecology and Neonatology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.