QUITE a few of my friends exercise regularly and eat a balanced diet. One of these gym-going friends recently went to have a COVID-19 test and during the pre-test screening was asked whether she was fit and healthy, to which she answered “yes”. The next question was whether she was on any medication, to which she responded with information about her intravenous immunosuppressant infusion schedule. This response prompted the nurse to cross out my friend’s initial “yes” response to being fit and healthy.
By crossing out the “yes”, the nurse demonstrated her understanding of the phrase “fit and healthy” – that it referred to other diseases and illnesses. My friend, on the other hand, who exercises regularly, eats well, looks after her mental and physical health proactively, and has multiple sclerosis understood the question in reference to how she perceives herself.
While we could spend time discussing the conceptualisations of “health”, we can also look at what this means for communication in practice. When we teach doctors, we often say to avoid jargon, which is important given the low availability of understandable health information in Australia.
However, miscommunication is not just about medical terminology; commonly used medical terms as well as lay terms, like “fit and healthy”, can also be understood differently by patients compared with clinicians.
Take the attempt to simplify cardiovascular risk into the term “heart age”. On the surface, this seems like a clear solution; however, it reduces credibility of the information provided and does not improve engagement in behavioural change. The word “cancer” is another example, when used to refer to low risk conditions it can result in an increased desire for unnecessary invasive treatments.
The ambiguity of lay terms in clinical settings can also cause problems between clinicians, with varying understandings of the same words. While words, such as “fit and healthy”, can provide insight into a patient’s life outside the disease for which they are receiving treatment, the differences in understanding of what these words refer to and, in the medical setting, their general ambiguity, mean that information is not explored further.
Research methods that focus on how communication works in real life give insight into health literacy in practice. In conversation, we can identify whether someone has understood us by how they respond to what we have said. And when someone has shown they did not understand in the way we intended, we can adjust what we have said. This, in conversation analysis, is called “repair” and is necessary for mutual understanding.
This is an important concept when we look at health literacy in practice. We are constantly making decisions about how much the people we speak to know when we’re talking to them, such as when we ask them questions. Clinicians make choices about what level of health literacy the patient might have, which helps design an explanation. Listening to the patient response can give information about whether they pitched it accurately.
When providing one-to-one feedback to a doctor a few years ago, we noticed that the doctor often used medical jargon, even commenting to one patient that what they were explaining was “kind of technical”. In the recordings following training, which included advice on using less technical language and providing explanations when medical terminology was used, we observed that patients responded with more indications that they were following along with what the doctor was explaining.
More explicit approaches to assessing patient understanding come with their own challenges. Teach-back, usually a question formulated to elicit the patient’s explanation of what has been explained to them, is often advised as an approach to assess patient understanding; however, there is recent evidence that in practice explicit teach-back requests are met with more minimal responses in comparison with other approaches. By using a conversation analytic approach, the authors identified more effective ways of determining patient understanding. This included implicit teach-back questions, where doctors asked for information from third parties, and “experience questions”, which were questions that enquired after the patient’s experience so far.
It is impossible, and ill-advised, to suggest there is one right way to formulate a question or an explanation. You will continue to make choices for the patient in front of you and attentively listening to their responses will help you assess whether you need to make adjustments for your next turn at talk.
When we look at written information, considering the audience as well as the purpose is essential to assist patient understanding. In the context of survey questions, considering how their formulation affects the response is important. If the information required by the question about being “fit and healthy” is necessary for clinical decision making, then the question needs to be redesigned so that it is clearly understood in the same way by those asking and those responding. If it is not, then maybe it does not need to be asked.
Dr Sarah J White is a Senior Lecturer in the Faculty of Medicine, Health and Human Sciences at Macquarie University. Dr White is the current Australian National Representative for the International Association for Communication in Healthcare.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.