Clarity is Not Dumbing it Down

Did you understand me?

The last time I was in the emergency room, I was a little taken aback by how one of the nurses spoke to me and I realized she was interpreting my self-advocacy combined with, what I considered to be a rational fear, as hysteria. The situation was this: I occasionally have dystonic storms. Most of the time I do okay and ride out the storm at home. Sometimes, as the article in the link describes, they get away from me. My rational fear is of medication reactions. I've had a number of times when medications have depressed my breathing and virtually paralyzed me, making it impossible to let someone know I'm in trouble. 

At this emergency visit, I was being pumped full of drugs. I made it clear they needed to monitor my breathing because of past reactions I've had. They assured me they would. A couple of hours later, in the room, I told the nurse again that my breathing needed to be monitored. She smiled and said, as though explaining to a 5 year old, "Don't worry, if you stop breathing, all sorts of bells and whistles go off at my desk." Her body language and tone of voice made me feel as though I was just being silly. I didn't know they really were monitoring me. As far as I could tell, I wasn't hooked up to any monitors and the monitors in the room were not on, but I was afraid to say anything more or ask any more questions. She made it very clear how they saw me as a patient. 

How could I have communicated my concerns in a better way? How could the doctors and nurses have communicated to me more effectively?

Patient engagement

I've been pondering this question for a long time, not just because of this one visit to the emergency department, but because of numerous experiences with medical professionals when I accompany my husband, my parents, or one of my kids to an appointment or the emergency room. One phrase I remember hearing (and using) any number of times is "Why should I go back? I know what they're going to say." How many people put off going to the doctor for this reason? 

Several years ago, I became involved with the wonderful organization called PCORI (Patient Centered Outcomes Research Institute). PCORI channels funding to various entities for clinical studies. The applications for funding for these studies go through a rigorous process, all of which include patient representatives in making the decision. I was one of those patient representatives during one funding cycle. It was a lot of work, especially as all four of the applications I read were chosen to be presented during the in-person review in Washington DC. It meant I had to attempt to speak about each one. It was exhausting and I don't know if I really have the stamina to do this, at least not often, but it was also amazing to be part of the process.

The Alan alda center for communicating science

I was also able to attend the first annual meeting of PCORI in 2015. This was truly an amazing experience. To hear first hand the direction we are going in the field of health care was awe inspiring. I wish I could go every year. I especially wished I could have gone this year because one of their keynote speakers was Alan Alda. Yes, the Alan Alda, aka Hawkeye Pierce from M.A.S.H. His presentation was titled, "Improving How We Talk to the Public about Science and Health". Fortunately, even though I couldn't attend in person, I was able to attend virtually through their webcast. Mr. Alda's talk was shown live and would not be archived, so this meant getting up at 6:00 am to be ready and somewhat awake when it started at 8:30 eastern time. It was worth the effort.

Few of us know about the work Mr. Alda has done in this area. Having had a life long interest in science, he hosted a PBS program called "Scientific American Frontiers". He discovered by asking questions of the scientists, he could help them to explain their work in such a way that he could understand it and become even more excited about it. This, of course, helped the audience to become engaged as well. Taking this idea even further, Mr. Alda, along with others at the Alan Alda Center for Communicating Science at Stony Brook University, have created training programs - workshops, online learning, and private coaching - all designed to help scientists and health professionals to communicate in such a way that others will understand and be engaged. 

I will let Mr. Alda explain it himself. This isn't his talk from this week, but a short video I found on youtube which contains a small nugget of the treasures he shared with us.

Good Communication 101 by Alan Alda

Real listening doesn't take place unless you're willing to let the other person change you ~Alan Alda

Considering what I learned from listening to Alan Alda speak, what could I have done to communicate my concerns better? What could the doctors and nurses have done? To be honest, I'm not sure I could have done anything more at that point. I was in pain. I was frightened. There's something about labeling someone with anxiety that irks me. It's the tone of voice that says "Oh, you're just anxious. Aren't you being silly!" Maybe I'm not anxious. I'm afraid. Fear is not an emotion you hear about a lot these days, but how do you go through an emergency health issue without having some fear? Had the nurse acknowledged my fear and addressed it, things might have been different. She could have explained how they were monitoring my breathing and heart rate. I would have understood. She could have asked if I would feel more comfortable if the monitors were on in the room as well so I could relax and know the monitors were working. 

On the other hand, I don't wonder why this is difficult for medical professionals. Caseloads are so high for all the doctors I see, I don't know how they can possibly get to know their patients. When they are rushing from one room to another, where's the space for any connection? Perhaps what I could do, if I'm in a situation like this again, is try to connect with the doctor or nurse. Ask them about their busy day. I could acknowledge their undoubted frustration with trying to effectively communicate with patients, often patients they only see once or twice a year, in the short time they are allowed for each appointment. How many hours do they work? How often do they have to miss things they'd like to do? How stressful must it be to work like this! 

It's very important for us to see that science is done by people, not just brains but whole human beings, and sometimes at great cost.

Alan Alda
 

The PCORI Experience - The Key

I arrived home this morning from attending the first Annual Meeting of PCORI - Patient Centered Outcomes Research Institute. Over the next week or so, I'll be posting some short articles about this experience. They will probably be sort of random, working like my mind and memory work as I try and process all the information I received. 

Here is the first:

THE KEY

It hangs from my coin purse because I don't take my keys with me when I travel. The plain silver key has not been cut and doesn't fit any lock. It's a reminder of all the people who do not have keys. It's a reminder of my obligation to speak for those who do not have keys.

We were listening to a panel on the topic of Engagement of Patients and Other Stakeholders in Research. There were three groups represented,but Loretta Jones will be the one I don't forget. She and Dr. Clete Kushida spoke about their work with Healthy African American Families. I encourage you to look at their website. Loretta recently received the Honorable Diane E. Watson Community Service Award from the United Nations for her work addressing disparities in health care.

Which brings us back to the key. While Dr. Kushida and Loretta were speaking, we were handed keys. Loretta asked us about our own keys. What do they open? House, car, safety deposit box, bicycle lock, a gym locker; these were a few of the answers given. Keys represent access and assets. A house key means we have a place to live, an anchor. A car key or bicycle lock key means we have the ability to easily move out of our area and see more of the world.

There are other keys which are not visible, but are important: access to health care, access to transportation, access to education. This list is just a beginning. Who are the people without keys? The homeless, the uninsured and underinsured, those who don't have transportation to a doctor's visit, those who don't have access to healthy food, those who do not have an advocate.

At the PCORI Annual Meeting, there were scientists, clinicians, nurses, social workers, health insurance representatives, lawyers, patients, patient caregivers, patient advocates, and more. Who, among all these groups, is going to speak up for those who don't have keys?

It's the responsibility of each one of us. As a patient advocate and patient reviewer for PCORI, what can I do to bring attention to the needs of people who do not have a voice, those who are marginalized by being part of a minority group or stigmatized by a health condition? Can I look at clinical studies and try to sort out whether and how the studies will help those who have no voice - no keys? 

The Patient's Voice - A PCORI Experience

I wish I could say I did this for purely noble purposes, but I have to admit, part of the draw was being able to travel to Washington D.C. for the in person panel reviews. Now that I'm home, I'm still very glad I went, but for different reasons. To attend and be the voice, the advocate of patients in the decision making process for funding clinical studies is an amazing and humbling experience. 

I found out about PCORI from my niece, Anne Schuster, who received her Master's degree in Health Economics at Johns Hopkins University. She knew I had been on patient panels at the University of Colorado Medical School and School of Pharmacy and she knew I valued the chance to speak on behalf of patients. She suggested I apply.

I was assigned 4 applications to review under 3 different criteria. I did not have to grade the appications on technical merit. There were plenty of scientists to do that bit. The criteria we looked at as patients were: whether the study identified a critical gap in knowledge, whether the study was patient centered, and whether there was adequate patient/stakeholder engagement in every stage of the study proposal.

If it was a challenge for me to read and determine the strengths and weaknesses in each of these areas, I know it was even more of a challenge to write up the proposals. PCORI is unique in insisting upon patient and stakeholder engagement and many scientists are struggling to figure out just what this means. So far, I'm truly impressed with the work the organizations have done in this area. For our part as reviewers, it was helpful to have a mentor to guide us and answer our questions. My mentor, Kayte, was very patient.

After writing up my critiques of each application and submitting them, it was soon time to go to Washington DC for the in person panel review. We started early on Thursday with breakfast and a short training. Then we were welcomed by Dr. Joe Selby, the Executive Director of PCORI, and others. Then came the actual panel reviews. We presented and discussed each application before giving them our individual scores. Everyone had a chance to speak and everyone's voice was respected equally. The discussions were quite lively. 

Dinner was lively the first night, too, as Kayte and company cheerfully welcomed me to sit at their table. I found out what PCORI mentors and staff do when they're not working. Before long, someone mentioned the new tequila diet, which certainly must be a great idea for another study proposal. The conversation went round and round and I laughed till I hurt. At some point, the originator of the tequila idea looked at us seriously, "But no salt and no lemon. This is a clinical study." And we all collapsed laughing again.

After dinner, I went for a walk with a very nice young doctor. Most of the doctors seem young and I felt a bit like a grandma. Oh, right. I am a grandma. We walked around a few blocks and then back to the hotel, where a nice staff person saw me and came over to give me directions to my room... again. Time to rest up for another day of reviews.

If invited, I would do it again. I believe in what they are trying to do.

Interested? There are many ways to get involved. Start here! Let me know. Maybe one day we'll be on a panel together.