by Brian Taylor
“Signal & Noise” is a bimonthly column by Brian Taylor, AuD.
Last fall, JAMA published a thought-provoking commentary on the unnecessary harm caused by the words used by physicians. Known as iatrogenesis, the inadvertent occurrence of a disease or illness caused by a physician or by medical treatment or diagnostic procedure can have serious unintended consequences. Because several healthcare professionals are involved in delivering care, prescriptive medication and surgical procedures are two common areas rife with potential iatrogenic mishaps. Bad physician handwriting that results in a pharmacist providing the wrong medication to a patient, which leads to a visit to the emergency room because of a serious reaction is one such example of an iatrogenic condition.
The JAMA article, authored by Arthur Barsky of Boston’s Brigham & Women’s Hospital, discussed how providing patients with certain information can contribute to stress, misunderstandings, and poor decision-making. Barsky points out that several common clinical scenarios represent the iatrogenic potential of a physician’s words, including presenting ambiguous laboratory information and preparing patients for painful procedures: The words used and the tone of voice used to describe things to the patient have a real impact on the patient’s reaction and outcome.
Barsky cites several examples from the published literature where the mere mention of a potential side-effect related to a medication or procedure resulted in a greater likelihood that the patient experienced the exact side-effect mentioned by the physician. Fascinatingly, there is an extensive body of research indicating that professionals can make a problem worse simply by the way they talk about it with patients.
How Language Affects Patients
Given the evolution of modern diagnostic imaging, and the early identification of conditions through genetic testing, iatrogenic potential could be on the rise, as conveying equivocal test results or subtle anatomical abnormalities of unknown clinical significance are likely to increase the stress levels and anxieties of patients.
In one randomized study of women receiving an epidural anesthesia during childbirth, cited by Barsky, those told the injection would “feel like a bee sting, this is the worse part of the procedure” reported significantly more pain than those told “the local anesthetic will numb the area and you will be comfortable during the procedure.”
Viscerosomatic amplification is the term used to describe the underlying mechanism in which information can affect the perception of symptoms.
Although conveyance of information by the physician does not cause the somatic symptoms, the way the information is conveyed by the physician to the patient can amplify or intensify the symptoms.
At the heart of viscerosomatic amplification is a mismatch in knowledge between clinicians and patients. Even in the age of Google and Wi-Fi, where everyone has access to an abundance of high quality medical information, physicians and other medical professionals remain the experts and possess substantially more knowledge and expertise about any condition compared to patients.
The evolution of modern medical testing and the amplifying effects of iatrogenesis also intersects with way healthcare professionals talk about risk with their patients. Although machine learning and precision medicine are thought to reduce uncertainty, some believe their advent will generate more of it, not less. In an April 17 New York Times, reporter and medical doctor, Dhruv Khuller discussed the importance of language and why healthcare professionals need to be more aware of how they talk about test results and treatment options. The article discussed the use of decision aids and risk pictographs to help healthcare professionals discuss uncertainty in a manner that’s in alignment with the goals and values of the individual.
Words Spoken by Audiologists Have Consequences
Clearly, the way we discuss test results and treatment options in the audiology clinic does make a difference. Amyn Amlani, in a December, 2017 HHTM post, offered a glimpse into the impact the communication style and substance might influence the perception of patients. In a study comprised of more than 1200 older adults with self-perceived hearing loss, survey respondents were asked their opinion about the profession of audiology both before and after their appointment with a local hearing care provider of choice. The respondents were asked to classify the profession of audiology into one of three categories: medical, rehabilitation or consumer electronics. More than 60% of the respondents classified audiology as a rehabilitation professional prior to their appointment.
Following their appointment with a local audiologist, there was a dramatic shift in respondents’ perception, as more than 60% classified audiology as a consumer electronics profession. This dramatic shift in perception also appeared to facilitate a shift in respondents’ interest in receiving hearing aids.
Prior to the appointment 67% of respondents expressed interest in amplification; that number dropped to an astounding 22% who remained interested in hearing aids following their appointment. Amlani’s data could be an indication of the iatrogenic effects of poor communication among audiologists and their patients.
Amlani’s data speaks to the fixation many audiologists have on hearing aid technology during the initial consultation with hearing aid candidates, and the unintended consequences associated with it. This finding, however, is not novel; it has been explored by several audiologists at the University of Queensland (UQ) in Australia. There is a vein of research, led by Caitlin Barr, Carly Meyer, Louise Hickson and others at UQ suggesting audiologists tend to be perceived as emotionally distant and overly focused on technological solutions.
Their work reflects a growing movement within audiology to become more patient-centered. Although the term “patient centered” is a little ambiguous, it essentially means focusing more attention on the psychosocial aspects of hearing loss and the impact hearing loss has on daily activities, while spending less time talking about the patient’s test results and technology options.
Communication Methods and Words Matter
The paper by Barsky and the research of Amlani tell us that we need to pay close attention to our communication methods and the words we say to patients during any appointment. When we fixate too much on technology or provide a fuzzy explanation of test results, we can lose the trust of the patient and create unnecessary anxiety.
Based on their insightful work, there are at least three simple things audiologists can do in the clinic to reduce iatrogenesis from words.
- Although audiologists don’t typically inflict too much physical pain, they can create undue emotional anxiety when discussing audiological assessment results. Thus, the use of neutral language with an emphasis on positive outcomes associated with treatment could be helpful. Moreover, if you want to discuss the negative consequences associated with untreated hearing loss, focus on the percentage of the population with hearing loss that may not suffer the undo effects linked to it.
- Explore the motivations, confidence and attitude of the patient. Enable patients to set the agenda for the appointments in which hearing aids might be discussed. The use of visual aids that shown all potential treatment options, including non-device options can be a good starting point. See https://health.ebsco.com/products/option-grid/clinical-decision-support for examples of patient decision aids.
- Throughout the appointment, remind patients that the use of hearing aids is a choice. When individuals are given a range of treatment choices (and informed that they have choices) they are more likely to actively participate in the rehabilitation process.
Further Reading on Shared Decision Making and Decision Aids:
Meyer, C. et al (2016) What is the International Classification of Functioning, Disability and Health and Why is it Relevant to Audiology? Seminars in Hearing 37, 163-186.
Grenness, C. et al (2015) The Nature of Communication Throughout Diagnosis and Management Planning in Initial Audiologic Rehabilitation Consultations. JAAA. 26, 1, 36-50.
Ekberg, K., Barr, C. & Hickson, L. (2017) Difficult conversations: talking about price in audiology consultations with older adults. International Journal of Audiology. 56, 854-863.
Brian Taylor, AuD, is the director of clinical audiology for the Fuel Medical Group. He also serves as the editor of Audiology Practices, the quarterly journal of the Academy of Doctors of Audiology, and editor-in-chief of Hearing News Watch for HHTM. Brian has held a variety of positions within the industry, including stints with Amplifon (1999-2008) and Unitron (2008-2015). Dr. Taylor has more than 25 years of clinical, teaching and practice management experience. He has written and edited six textbooks, including the third edition of Audiology Practice Management, recently published by Thieme Press. He lives in Minneapolis, MN and can be reached at email@example.com
*feature image courtesy of Cambridge in Color