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'Patient-Centered Communication Listens More Than it Talks'

Op-Med is a collection of original articles contributed by Doximity members.

Growing up in the suburbs of Los Angeles, Spanish was in the schoolyard, on the TV, and on the street, though never in my home. While I got some Spanish language instruction in academic settings, knowing Spanish always felt more like a helpful way to get around town than something I needed to master. Then, I enrolled in nursing school. I quickly found out that saying, “I know a little Spanish,” was a fast way to get in way over my head. “Tienes dolor? Aqui? Aqui?” is not an HPI; it’s barely a sentence. It became clear, quickly, that if I was serious about making a career committed to care for all, one of the most impactful and, frankly, easiest ways, would be to get serious about learning Spanish.   

In the beginning, that meant taking Spanish lessons and a trip to Central America, in addition to my classwork. Many patients showed me, their student nurse, endless compassion as I bungled my way through phrases and new skills alike. Slowly, I got better.

People deserve to be cared for in the language of their choosing, just as they deserve to be called by their pronouns. This isn't exceptionalism — it’s humanity. But it’s only the tip of a very big iceberg. Working to make medicine less white and Eurocentric will take both systemic and personal work (3). Becoming a bilingual clinician took me years. And becoming an anti-racist clinician is the ongoing and perpetually expanding work of our lifetimes. 

There is moderate evidence that, as patients, many of us gravitate towards clinicians who look like us, who speak like us, who know the same home remedies from their grandmas as us, who have the same fight with their uncles about politics as us. These similarities can be shorthand to say, “I understand,” and the positive health outcomes associated with that sameness are statistically significant (1).

So how do I show up honestly, vulnerably, fully, when my appearance, my idioms, and my family secrets and grievances may not be the same? How can I find the longhand that conveys an authentic compassion and closes the outcome gap (6)? As a white woman serving Latinx clients, there are a few things I am keeping at the front of my mind these days. 

- The west side of Chicago is often called out for its deficits, but I know the communities my patients live in are vibrant and have lots of ideas about health and wellness. Patient-centered communication listens more than it talks. It asks questions like, “what have you tried?” and, “what do you think this might be?” before launching into any assessment or plan. I didn’t grow up applying chamomile tea bags to my conjunctivitis, but once I learned about it, it made sense. Nursing school taught me that a good HPI gets you very close to a diagnosis, and striving for cultural context creates trust, satisfaction, and intent to adhere in the diagnosis and plan. 

- My job is to see individual patients, but often the best solutions look at structural inequity. There is an epidemic of diabetes amongst those living in poverty but that’s not based on biology. Food access and insecurity shape the landscape of our community (2). We know that excellent newer drugs make it easier to control hyperglycemia, but many of these remain financially out of reach for many uninsured and underinsured patients. Yes, we each have a role in our own health outcomes, but collective action can create a stable, fertile ground for individuals to commit to healthy choices. My patients with diabetes can get to goal with medications like sodium glucose co-transporter 2 inhibitors, they just have to find a way to afford them, first. I don’t need another mid-conference sponsored lunch to find out how well these drugs work; I need them on the Medicaid drug formulary. I don’t want the chicken or the vegetarian option; can we put that toward a lobbyist instead? 

- I have a responsibility to call out the history of medicine and acknowledge its racist roots (2). In the past few months, I’ve started to share with my patients the history that exclusively white bodies were used to develop the BMI (4). Whose “ideal” is behind ideal body weight?  

- My patients work to rearrange their lives for appointments in the middle of the work day, to remember to take medicines two, three, four times a day, and to figure out who the heck is in their “network.” So yes, I can send that prescription over to a second pharmacy if they can offer it to them at a better price, and yes, we can see them on a Saturday, and yes, if they can send me a message on the portal with their blood pressure cuff readings, we can keep them safely home in the middle of a pandemic. We are all modifying our lives and plans to find solutions that fit — this is a two-way street. 

The work to make health care equitable and to eradicate systems of unexamined and unearned advantage will take head work and heart work. It will take all of us; it will take all of me. Each day, I aim to fail up, fail better, and fail smarter. I am working to stop dreaming of perfection and be more comfortable with discomfort. I aim to hear the next generation tell me that my ideas are too small for the expansive world they have built on the shoulders of our efforts today.

References

  1. Greenwood, B.N., Hardeman, R.R., Huang, L. Sojourner, A. (2020). Physician-patient racial concordance and disparities in birthing mortality for newborns. Proceedings of the National Academy of Sciences of the United States of America. https://doi.org/10.1073/pnas.1913405117 
  2. Hardeman, R. R., Medina, E. M., & Kozhimannil, K. B. (2016). Structural Racism and Supporting Black Lives - The Role of Health Professionals. The New England journal of medicine, 375(22), 2113–2115. https://doi.org/10.1056/NEJMp1609535
  3. Oluo, I. (2019). So you want to talk about race. New York: Seal Press.  
  4. Rahman, M., & Berenson, A. B. (2010). Accuracy of current body mass index obesity classification for white, black, and Hispanic reproductive-age women. Obstetrics and gynecology, 115(5), 982–988. https://doi.org/10.1097/AOG.0b013e3181da9423 
  5. Spencer Bonilla, G., Rodriguez-Gutierrez, R., Montori, V.M. What We Don’t Talk About When We Talk About Preventing Type 2 Diabetes—Addressing Socioeconomic Disadvantage. JAMA Intern Med. 2016;176(8):1053–1054. doi:10.1001/jamainternmed.2016.2952 
  6. Street, R.L., O’Malley, K. J., Cooper, L.A., Haidet, P. (2008). Understanding Concordance in Patient-Physician  Relationships: personal and Ethnic Dimensions of Shared Identity. The Annals of Family Medicine. 6(3). https://doi.org/10.1370/afm.821  

Dana Kroop is a family NP based in Chicago, Illinois. Originally trained in the history and philosophy of science at University of Chicago and Cambridge University, she spent her first professional years working in education at The Field Museum of Natural History. Driven to use science communication to best empower individuals, she then decided to become a family NP, training at the University of Illinois under a HRSA funded ANEE Traineeship, and then completing her post-graduate residency at Community Health Center, Inc. Dana is a bilingual Spanish speaker and currently works at a Federally Qualified Health Center on Chicago's West Side. She is a 2020–2021 Doximity Op-Med Fellow.

Illustration by Jennifer Bogartz

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