Abstract
Health literacy has been identified as key to improving patient outcomes and is particularly important for patients facing chronic illnesses such as multiple sclerosis (MS). Low health literacy rates can negatively impact communication between healthcare providers and patients and is associated with poor health outcomes. It is critical to raise awareness of conversational techniques to healthcare providers that can support more effective communication with patients. In this podcast article, nurse practitioners discuss multimodal strategies that enable appropriate conversations to meet patients’ needs through the following four techniques: patient-centric language, teach-back, open-ended questions, and active listening and paraphrasing. These techniques are incorporated into example patient–provider conversations to demonstrate their effectiveness in clinical practice. Comprehensive patient conversations and optimizing patient interactions builds a trustworthy foundation for shared decision-making to improve health literacy and outcomes in patients with MS.
Podcast Discussion (mp4 37425 KB)
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Low health literacy rates can negatively impact communication between healthcare providers and patients with multiple sclerosis (MS) and contribute to poor health outcomes in these patients. | |
Shared decision-making can help patients with MS at varying health literacy levels work together with their providers to develop treatment plans for managing both symptoms and disease progression. | |
This podcast article introduces multimodal strategies that enable appropriate conversations to meet patients’ needs through the following four techniques: patient-centric language, teach-back, open-ended questions, and active listening and paraphrasing | |
Implementation of these techniques by healthcare providers may enable more effective communication with patients with MS. |
Digital Features
This article is published with digital features, including podcast audio and an infographic to facilitate understanding of the article. To view digital features for this article go to https://doi.org/10.6084/m9.figshare.21953120.
Introduction
Cortnee Roman (CR): Hello and welcome to today’s discussion about the art of patient conversation. In this podcast, we will share multimodal strategies that enable appropriate conversations to meet patients’ needs through four techniques: patient-centric language, teach-back, open-ended questions, and active listening and paraphrasing. Our examples will focus on patients living with multiple sclerosis, or MS. However, the same techniques can also be applied to other disease and/or conditions. My name is Cortnee Roman. I’m a nurse practitioner at Rocky Mountain MS Clinic in Salt Lake City, Utah, and I am delighted to be joined by Denise Bruen.
Denise Bruen (DB): Thank you. My name is Denise Bruen. I’m also a nurse practitioner that specializes in multiple sclerosis, and I am located in Charlottesville, Virginia.
Patient Scenario and Importance of Health Literacy
DB: The first thing we are going to do is give a patient example with different techniques that should help make the patient conversation flow better. So, we’re going to look at a hypothetical patient. This is 22-year-old Emily. She was experiencing episodes of unpredictable symptoms that impacted her daily activity and quality of life. She presented to her general physician and expressed her apprehension about experiencing significant fatigue while taking a shower and simultaneously having numbness sensations around and below her neck area [1]. After receiving a diagnosis of MS from her neurologist, Emily is in absolute shock and worried that she will no longer be able to do her favorite activities. When asked what she knows about MS, she recalls reading online forums and watching videos of patients with MS that had grim prognosis, with inevitably becoming disabled. These stories left her feeling hopeless and depressed. Emily grew up in a low-income family in rural Nebraska.
DB: She dropped out of college and runs her own business and does not have any friends or family that work in the medical field, aside from one cousin who is currently in PA school. Before we consider the best way to converse with Emily, it is important to consider health literacy. Emily has just admitted her fears that stem from what she read or has seen online, which is a common barrier to health literacy.
CR: There are definitely some common themes that can create barriers to communication and health literacy or understanding of health information. Some of these themes can include unreliable sources of information, such as misleading information online and/or on social media [2], sensational or overpromising language [2], or geographical location health literacy disparities across urban and rural areas [3].
DB: There was recently a large cross-sectional study looking at over 9000 MS patients, which revealed that low health literacy was associated with more visits to the hospital, more visits to the emergency room, even after adjusting or taking into account the patient’s income, disability, and cognitive impairment. Patients were given the following self-administered health literacy test, which was the Medical Term Recognition Test, and the Newest Vital Sign [2].
CR: I recently read about a different study that included patients with relapsing–remitting multiple sclerosis. Less knowledge of MS was associated with lower willingness to try a disease-modifying therapy. Increased medication willingness was observed following five talk therapy sessions that had an educational component [4]. Sometimes just focusing the conversation on what the patient’s concerns are or providing clear explanations to patients about the topic of discussion from start to finish, pausing if there’s any body language that looks like the patient may be confused and readdressing, and then first addressing the patient concerns that could be barriers to their understanding. For example, many patients will come into clinic newly diagnosed with multiple sclerosis and they’ll tell me that they’ve done a significant amount of internet research and they’re afraid because they found disability data or something that may have been old or sensational in language saying they have a cure or things like that [2, 5]. And so really, addressing what the patient might have experienced prior to the clinic visit can help with understanding and establishing that trust relationship.
DB: Yes, this is a great segue to learning the technique of shared decision-making with patients. So, this is a process that can help patients at varying health literacy work together with their provider to make treatment plans. So, following a diagnosis of MS, it is important that patients understand that treatment can involve two different components. So, it’s managing the disease, trying to prevent progression or relapses, but it’s also managing the symptoms of the disease. Using shared decision-making, it can help facilitate the conversation to consider clinical evidence, patient preference, and expected outcomes [6,7,8]. Research has suggested that people living with MS who take an active role in their medical choice may be more likely to adhere to treatment and have a better understanding of their treatment risks and/or benefits [4]. Patients with chronic pain who have used the shared decision-making tools said it really helped them think about treatment goals, it helped them understand their chronic pain, and also to make the most of their healthcare visits [8], which at the end really makes our job as healthcare providers a little easier. For patients like Emily, it’s key to frame the conversations about MS, symptom management, and disease progression as those of advocacy and partnership through the communication techniques that we’ll discuss next.
DB: These techniques can definitely help build a trustworthy foundation for shared decision-making.
Communication Techniques
Technique 1: Patient-Centric Language [5]
CR: Let’s dive right in and talk about the first technique, which is patient-centric language, defined as a strategy for making written and oral information easier to understand [5, 9]. This technique is useful in preventing the patient from feeling intimidated or excluded. It allows them to actively participate in the discussion and removes confusion or misunderstanding [9]. Some key elements of this technique include organizing the information so that the most important points come first. Breaking complex information into understandable and digestible formats. Thinking about patients’ understanding of health information and then using active voice, such as “the nurse will draw your blood” instead of “your blood will be drawn.” For example, acute, which means sudden, short-term, or quick. In MS, we use acute to describe potentially a relapse, also called an exacerbation or a flare-up. This is a sudden increase in neurologic dysfunction that’s either new or worse than before. This could indicate new MS disease activity or new lesions forming in the brain or spinal cord, which could indicate suboptimal treatment with the current DMT [disease-modifying therapy] [10].
CR: Another term that’s commonly used is chronic, which means repeating over a long time. In multiple sclerosis, chronic lesions are old plaques or scars from previous relapses. Another example is chronic neurological symptoms that are the, quote, “new normal” for daily function. These are symptoms that patients experience regularly because of chronic scars in the brain and spinal cord [10].
DB: Autoimmune, when we talk about this with patients, telling them that they have an autoimmune disease can be very confusing for patients because it’s a neurologic condition, but it really stems from an autoimmune issue, meaning that their immune system is confused or misprogrammed, and instead of protecting, it’s attacking ourselves. In the case of MS, the immune system thinks the myelin, the coating on the nerves, is a pathogen, and it mounts an attack. Although it’s, again, a neurologic disease, the damage occurs to the central nervous system, but the treatments focus on the immune system [10]. Oftentimes patients will ask for medication to help with symptoms or to help with a relapse. Often, they’ll just say steroids or corticosteroids is what we think of. Or patients will joke that if they take too much steroids, they’re going to be big and muscular, although those are very different steroids than what we use for inflammation. So, prednisone, methylprednisone, those types of steroids, these are the types of medicines that we use to reduce inflammation. They’re temporary treatments to decrease that active cells that are causing the new lesions or MS attacks or progression. It doesn’t actually slow down progression of the disease, but it can help people recover from relapses to a new baseline function a little bit faster [7, 10].
DB: Some pitfalls to avoid with this technique is going too far. We want to target the conversation and use language appropriate to the individual patient’s level of health literacy and cultural background. We want to take care not to accidentally slip back into technical jargon. And it’s critical that we keep the patient at the center of decisions, and we want to engage directly with the patient.
Technique 2: Teach-Back [5]
DB: The second technique we’re going to talk about is teach-back. Teach-back is a technique when we ask patients to repeat in their own words what they need to know or do, and in a non-shaming way. It really tests how well the healthcare provider has explained a concept or taught the patient. It provides an opportunity to re-teach the information if needed.
CR: Some examples of teach-back may be, “So, we talked about a few different causes for multiple sclerosis today. I want to make sure I explained to them clearly. Would you please tell me how you would explain the possible causes of MS to a family member?” Or an additional example might be, “I want to check how well I explained the signs and symptoms of multiple sclerosis. Can you tell me in your own words how you would recognize an episode and what symptoms to look out for?”
DB: That’s great. Some pitfalls to avoid with this is to use careful wording. Don’t make the patient feel like they’re being tested on their knowledge. Don’t let the patient feel as if it’s their fault if they don’t understand, because it’s really the healthcare provider’s responsibility to give the information at the right level for that patient.
One thing I was going to say about teach-back that if there’s a big culture or language barrier, to make sure that none of that has kind of gotten lost in literal translation. If English is not their first language, having the interpreter ask them to tell me, “What is the risk of this medication?” And then documenting that. So, I think that’s a really good time to think about using teach-back in those situations.
Technique 3: Open-Ended Questions [5]
CR: The third technique that we’d like to talk about is open-ended questions. So, this technique indicates that these may elicit a thoughtful response that are more likely to bring more details about the patient or their understanding to light. You want to ask an open-ended question and then follow up with more focused questions to gather specific details. Here are some examples. “Tell me what medications you take for multiple sclerosis.” “What infections have you had in the last 3 months?” or whatever time frame you’d like to add. “What types of antibiotics did you receive to treat those infections?” I’ll oftentimes just ask a question about what antibiotic they’ve been prescribed in the last 6 months, because patients don’t always recognize what infections we’re talking about. Additional examples of open-ended questions are, “What symptoms continue from previous infections?” “What neurologic symptoms do you experience on a regular basis?”
“What concerns do you have about your treatment plan as we’ve discussed?” “How were you told to take the medication or how many doses have you missed?” This is an important one. This is a friendly way to phrase whether or not the patient has been taking their medication as prescribed. Normalizing the humanity that sometimes life gets crazy and sometimes they may miss a dose. But we just want to make sure that we’re staying on top of their treatment regimen and understanding if they’re missing too many doses for that medication to be fully therapeutic. And an additional follow-up question could be, “What issues have you had with access to your medication?” That could be cost, mailing from the special pharmacy, et cetera.
DB: So, pitfalls here for this technique is we don’t want to pressure or interrupt the patient. In fact, we want to leave a pause to encourage the patient to speak more freely. We want to avoid asking any leading questions that might make patients feel they have to have a particular answer. Avoid questions that can be just a simple yes or no because that really closes down the conversation, and kind of being able to dig in a little deeper with patients. Avoid any assumptions or preconceived follow-up questions. We have to listen really carefully [to] the initial answer and then tailor the follow-up questions accordingly.
Technique 4: Active Listening and Paraphrasing [5]
DB: Technique four is active listening and paraphrasing. So, this technique is when we’re listening to the patient or their caregiver, to understand the speaker’s message. We state what has been heard and show understanding without implying agreement and/or evaluating. This approach offers an opportunity for the patient to be sure that the healthcare provider correctly understood them. And this also gives patients confidence that their message has been heard and that they’re being listened to.
CR: Some examples of this include “I’m hearing that one of the most bothersome symptoms for you is currently nerve pain that you have in your legs. Is that correct?” Or another example might be, “I’m hearing that you’re concerned about side effects of the medication that we discussed. Would it help if we discuss some strategies to lessen side effects or even prevent them?”
DB: Some pitfalls to avoid here is any condescending or technical language. Avoid shaping your response at an inappropriate health literacy level for the individual patient, and do not dismiss the patient’s message as being trivial or unworthy of comments. Because again, then the patient’s not going to ask other questions that could be even more important than the one they just asked.
Patient Conversation: Poor Example
CR: Okay, so let’s transition into the role-play. This conversation does not follow the four techniques and/or includes commonly made errors or pitfalls, such as a yes or no question, technical jargon, and/or poor listening skills. We will stop at key points in the conversation to explain where each technique would have been useful and to highlight the errors made. And this conversation reinforces the value of the four techniques in a comprehensive patient conversation. So, I’ll play the provider first, and I’m entering the room to discuss Emily’s care with her.
“Hello, Emily. I’m here to get your medical history and assess your treatment plan for multiple sclerosis. Have you had any infections in the past month?”
So, just as commentary for this first opening question to Emily is this provider does not center the conversation around the patient’s needs. He does not speak with an empathetic tone and asks a yes or no question right out of the gate.
DB: I’m going to play Emily.
“No, I don’t think so, but the back of my neck really hurts, and I’m worried it’s going to get worse.”
As a result of the yes or no question, the conversation about infections doesn’t go any farther. That’s just kind of dead in the water. The patient doesn’t want to talk about that. They have other things on their agenda.
CR: So, then the provider responds.
“Okay, it says here in your chart that you’re experiencing chronic fatigue. Have you taken any corticosteroids recently?”
Some comments on this question. The provider uses medical terminology, including “chronic” and “corticosteroids.” The patient may not understand what each of those words means or how it applies to her health, and then asks yet another yes or no question. The provider also does not indicate that the patient’s complaint about her neck has been heard.
DB: “I took some medications. I’m not sure what it was. I was prescribed something that started with a G, like gluta something.”
CR: “Oh yes, that would be your MS medication. Glatiramer acetate. Do you need a refill for that?”
DB: “No, I have enough.”
Because the provider does not acknowledge the patient’s main concern about pain, she does not bring it up again. The provider continues to use medical abbreviations, yes or no questions, which could confuse the patient.
Patient Conversation: Effective Example
DB: Okay, we’re going to do another role-play, and this time I’m going to play the provider. Cortnee will play Emily, the patient. And this is an example of effective conversation.
“Hey, Emily. I’m here to learn about your needs and any symptoms that are bothering you so we can work together to treat your MS. Our goal is to have your MS symptoms that affect your daily life be as little as possible. So, how are you feeling today, and what types of infections have you had in the past few months?”
So, from the beginning, the provider sets up the conversation, defining the goal of the visit and placing the patient’s needs at the center, as well as asking open-ended questions.
CR: “Hello! That sounds good. I’m struggling with pain and spasms in my neck and back. Over the summer. I’ve been feeling tired, doing simple things like showering. Generally, I’m worried that these symptoms will get worse, and it’s taking a big emotional toll on me. Two weeks ago, I went to urgent care for a urinary tract infection.”
So, just some comments about this interaction from the patient. Since she felt that she was having an encouraging introduction, she speaks more freely and openly about what is bothering her.
DB: “Thanks. It’s really helpful to know about your symptoms. I bet being in constant pain must be really challenging, so it’s quite understandable to be worried that your disease is progressing. We’ll explore different ways to manage your symptoms, such as the pain and fatigue, and things that we can maybe do to prevent progression. But first, getting back to that urinary tract infection [UTI], do you know what kind of antibiotics they gave you at the urgent care?”
So, the provider paraphrased the patient’s complaints and asked another open-ended question.
CR: “They gave me nitro something. It seemed to work well, and my infection was gone in a week.”
DB: “Oh, that’s great. It was probably nitrofurantoin. I’m glad it worked. It’s helpful to know that you’re still having fatigue though. Sometimes with the UTI, that can make some symptoms worse. But if you’re still experiencing fatigue, we want to look at some other considerations. You mentioned that over the summer you felt more tired. Do you recall how you felt when the weather was cooler, like in the wintertime?”
CR: “I remember feeling a little tired throughout the spring, but it’s definitely gotten worse with the warmer weather.”
DB: “Yeah, thanks for that. Symptoms like fatigue can definitely worsen with the heat [11]. Luckily, there are a few strategies that we can talk about that may help. Can you tell me how much water you drink, or do you drink water during the day? Is that your drink of choice?”
CR: “Well, back when I used to exercise more, I would drink a lot of water. But lately, sometimes I’m too tired to get up and fill my bottle, so I’d say only a few pints per day.”
DB: “Yeah, I hear you. A lot of my patients, either they’re too fatigued or because of bladder issues, they just don’t want to drink a lot of water. But drinking water may actually make you feel better. I can see it’s hard to go to all that effort when you’re tired, but if you prepare ahead of time with getting some containers ready in the morning when it’s cool, they’ll be ready for you later, and that might be more easy to comply and drink your water throughout the day.”
CR: “Oh, that’s a good idea. Now that you mention it, I usually do feel a bit better in the morning.”
DB: “That’s great. You know, I understand that receiving this diagnosis of MS can be overwhelming and stressful. It’s good to know that we have a lot of options and strategies today, more than before, to help slow the progression and even better, to help control your symptoms. There are lots of different things that we can do. Would you like to hear more about medications or resources that we might have available to help with your fatigue?”
Again, the provider gives the patient an opportunity to talk more about her fatigue in order to find a potential cause and develop management strategies. Throughout this interaction, the provider is careful to avoid medical jargon and actively listens and is attentive to the patient’s responses and main concerns.
Concluding Remarks
CR: Let’s talk about some takeaway points from our discussion today. Firstly, open communication between patients with MS and providers is absolutely critical to meeting individual patient needs. You want to start with hope and empathy, frame the visit as one of advocacy and partnership, and emphasize the patient’s needs throughout the conversation. Make sure the right questions are asked, as this can alleviate a lot of unnecessary conversations and overcome barriers regarding the label of MS, ensuring that the patient leaves the appointment satisfied. Healthcare providers can equip themselves with these four techniques to ensure comprehensive conversations with their patients. Comprehensive patient conversations and optimizing patient interactions builds a trustworthy foundation for shared decision-making to improve health literacy and patient outcomes [5, 8].
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Acknowledgements
Funding
This podcast, and the journal’s Rapid Service Fee were funded by Novartis Pharmaceuticals Corporation. Authors had full control of the content and made the final decision on all aspects of this publication.
Medical Writing and Editorial Assistance
Medical writing support was provided by Dan Rigotti, PhD, and Jen Xiao, PharmD, of Envision Pharma Group, and was funded by Novartis Pharmaceuticals Corporation. This medical writing support included assisting authors with the development of the manuscript drafts and incorporation of comments. This manuscript was developed in accordance with Good Publication Practice (GPP3) guidelines.
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The authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.
Authors’ Contributions
All authors made substantial contributions to the manuscript concept/design, critically reviewed, and revised the manuscript drafts, and provided final approval of the manuscript and enhanced content as submitted.
Disclosures
Cortnee Roman and Denise Bruen have consulted for Novartis Pharmaceuticals Corporation.
Compliance with Ethics Guidelines
This article does not contain any studies with human participants or animals performed by any of the authors.
Prior Presentation
Material presented in this podcast has been previously presented at the Consortium of MS Centers (CMSC) Annual Meeting, Onsite and Virtual, Orlando, FL, October 25 to 28, 2021, and at the American Association of Nurse Practitioners (AANP) National Conference, Virtual, June 15 to August 31, 2021.
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Data sharing is not applicable to this article as no data sets were generated or analyzed during the current study.
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Roman, C., Bruen, D. Podcast on the Art of the Patient Conversation: Healthcare Provider Perspectives to Improve Outcomes in Multiple Sclerosis. Neurol Ther 12, 711–719 (2023). https://doi.org/10.1007/s40120-023-00446-z
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DOI: https://doi.org/10.1007/s40120-023-00446-z