INTRODUCTION TO COMMUNICATION
In order to respond to a patient effectively, the medical assistant must be able to communicate effectively. Major components of health care include reducing a patient’s fear and anxiety and helping the patient understand how to promote health and manage illness. To assess a patient’s perception of his or her health status, the medical assistant must be effective at both sending and receiving messages.
COMMUNICATING WITH PATIENTS
Figure 4-1 outlines the basic model of communication. A sender sends a message to a receiver. The message can be verbal, meaning that spoken or written words are used to send the message. It can also be nonverbal, meaning the message is expressed without words through body language, facial expression, and other means. Most messages are sent using a combination of verbal and nonverbal communication. The feedback from the receiver to the sender, also verbal or nonverbal, helps the sender decide whether to initiate a new message, expand on the original message, or clarify the message.
Verbal and Nonverbal Communication
Verbal communication is either oral (spoken) or written. Written communication has traditionally been thought of as more formal than oral conversation—a letter rather than a phone call. Today, however, with the increasing use of e-mail, written communication may be as informal as oral communication.
Nonverbal communication refers to information that is received from body language. Body language is the way a person’s body signals feelings or emotions. For example, hands folded across the chest and a rigid posture may signal anger. Nonverbal communication also includes the secondary communication that occurs during oral conversation. Secondary communication consists of tone of voice, voice pitch, voice volume, and voice quality. Nonverbal communication often provides more information than the words themselves (Figure 4-2).
The response to a simple question such as “How are you feeling today, Mr. Jackson?” may consist only of the words “All right.” The quality of the voice—pinched, pained, flat,
excited, spoken with a deep sigh—gives more information than the words about Mr. Jackson’s physical condition and his state of mind.
Other types of nonverbal communication include facial expression, body position, and gestures used while speaking. These are known as nonverbal cues.
Interference with Communication
Numerous elements can interfere with communication between the sender and receiver. An analogy for interference is listening to the radio. The radio station can be thought of as the sender of a message. The message is sent through radio signals. Any number of outside elements can interfere with the radio station’s signal to the receiver, such as a storm that causes electrical interference in the atmosphere, air traffic controllers switching to a radio frequency that interferes with the broadcast frequency, or the receiver driving
Figure 4-2 Most adults can easily identify the people in these photographs as expressing A, pleasure; B, uncertainty or lack of confidence; C, aggression; and D, confusion.
through a tunnel or over a bridge with steel suspension. In addition, interference can be caused by elements inside the receiver, such as strong emotions, thinking about something else, or needing to concentrate on driving carefully.
Similarly, in communicating with a patient, interference can come from the outside or inside. Examples of outside interference include a distracting environment, noise, and lack of privacy during communication. Examples of inside interference include fatigue, fear, anxiety, anger, or being preoccupied with something else. All of these factors can cause the message to be diluted, changed, or not completely understood by the receiver. Other barriers arise because understanding or senses are impaired.
The ability to identify a patient’s strong emotions or feelings from the nonverbal cues exhibited by the patient may cross cultural boundaries. For example, infants and children from all cultures cry when they receive immunizations. The ability for the medical assistant or a patient to interpret subtle feelings or gestures, however, does not typically cross cultural boundaries. For example, shaking the head from side to side does not always mean “no.” In some cultures it may mean “yes,” or it may be used to express other meanings such as an acknowledgement that the listener has heard what was said.
Individuals who come from different cultures also have a different idea of personal space and may interpret physical touch in a different way. Cultural sensitivity is especially important for communication to be effective. Nonverbal communication that is accepted in the sender’s culture, such as smiling, looking straight into the speaker’s eyes, or lightly touching someone’s shoulder to show concern, may create interference if the gesture has a different significance in the listener’s culture.
First impressions based on personal appearance may influence the way an individual is addressed. For example, it is easy to assume that an individual who looks homeless, who is dressed in dirty clothing, or who has a strong body odor is also uneducated. In the same way, individuals who are dressed in expensive suits often are treated with great respect. It is important to be aware of this tendency and respond to each patient as an individual.
Good listening skills are major components of good communication. Some health professionals are naturally better listeners than others, but listening skills can be learned and practiced.
The most important listening skill is known as active listening. Active listening means being “in the moment” and paying close attention to what is being said without thinking about anything else. Focusing all the attention on the sender of the message is important. To receive a message clearly, the listener cannot allow emotions or thoughts to interfere with the sender’s message.
What a sender says will naturally trigger a response. Letting go of the urge to respond verbally, take over the conversation, and air one’s own views is important. By focusing on the sender, the medical assistant will not be tempted to let his or her own mental responses become spoken responses. It will also prevent the medical assistant from focusing on his or her mental responses, thereby preventing messages from the sender from being received clearly.
Additional guidelines for the medical assistant to demonstrate good listening techniques include the following:
Nonverbal Measures to Facilitate Communication
In the United States, eye contact is important (Figure 4-3). Maintaining eye contact is a sign of interest and involvement. However, being aware that in many cultures it is not respectful to look directly at older people is important. This is especially true in Asian and Native American cultures. Many Latinos also do not look directly at a person they respect, such as a teacher or a physician.
If the patient looks away and the medical assistant continues to seek eye contact, the patient may perceive this as aggression. Maintaining eye contact with someone who is culturally uncomfortable with that nonverbal communication creates a barrier between the two individuals.
For the most part, control of body language is unconscious. Therefore it is important for the medical assistant to be aware of the patient’s nonverbal messages. Being alert to the patient’s body language allows the medical assistant to notice when a patient feels uncomfortable or anxious. When a patient’s words and body language do not match, the body language is usually a more genuine reflection of the patient’s feelings.
Touching a person, even gently, can also be interpreted in many different ways. Moving closer can indicate interest, but it may also be viewed as aggressive. Many adults do not like to be touched by people they do not know well.
Figure 4-3 Photograph showing a comfortable talking distance and eye contact that is typical for the United States.
Cultural sensitivity is extremely important. For example, some Asians do not like to have their heads or their children’s heads touched. This may present a problem when the medical assistant must measure the head circumference of an Asian infant. If this occurs, the medical assistant should stress to the infant’s parent in a reassuring tone of voice that measuring head circumference is an important health assessment procedure and that there is no disrespect intended in the action.
A gentle pat on the shoulder can be reassuring to a patient, but it is important to notice if the patient becomes tense or appears uncomfortable when touched. If the medical assistant steps back, the patient will usually relax. In the United States, people normally maintain a distance of about 3 to 4 feet for conversation with others, but in other cultures this comfort zone varies.
If the medical assistant must penetrate the patient’s personal comfort zone for a procedure, it may help to make a statement that prepares the patient for movement into the patient’s personal space. For example, when applying a sterile dressing to a wound, the medical assistant might say, “I’m going to have to move in now so I have a better view of the area.”
Case Study 1
Nancy Walker, CMA (AAMA), has called Jennifer Boland, a 32-year-old married mother of three, from the waiting room. Nancy notices that Jennifer is not looking at her, but the patient cooperates with getting her weight and vital signs. When Nancy asks the reason for today’s visit, it seems to take Jennifer a long time to answer. She picks at the sleeve of her jersey and finally says in a low voice that she is afraid she might be pregnant. Her voice cracks a little, and then she wipes one of her eyes. ■
Two types of questions can be used when conducting a patient interview. These include closed questions and open questions. Closed questions are questions that can be answered with one word (e.g., yes or no) or a short answer (e.g., I was born on January 16, 1985). Closed questions are especially effective when the medical assistant needs to obtain specific information.
Examples of closed questions include the following:
Open questions consist of questions that encourage the patient to open up and talk. Examples of open questions include the following:
Open questions are particularly effective in allowing the patient to describe a problem in his or her own words and explain how the patient feels about the problem. Because of this, open questions should be used to obtain a patient’s chief complaint and conduct a patient interview. When using open questions, it is important for the medical assistant to employ active listening techniques.
If the medical assistant asks primarily closed questions, the patient may fail to give important details or mention other problems. If the medical assistant asks directly if the patient has been following a special diet or taking prescribed medication, the patient may feel pressure to agree, even if this has not always been the case. When a patient is encouraged to talk freely, a more realistic picture may emerge.
Keeping the Conversation Going
On occasion the medical assistant will need to employ techniques to keep a conversation going with a patient. For example, the medical assistant may need additional information from a patient, but the patient stops talking. When this occurs, the medical assistant should employ techniques that encourage the patient to continue speaking without steering the conversation in a particular direction. A useful technique in such a situation is to ask the patient an open question; however, “why” questions should not be used. Examples of “why” questions include the following:
“Why” questions tend to make people defensive. Rather than having the patient justify his or her actions, it is important to identify the underlying reasons as to why the patient did not take the medication or stay on the diet. Effective questions that keep the conversation flowing without making a patient defensive include the following:
In answering these questions, the patient may provide clues as to the underlying reasons for not staying with the prescribed treatment plan.
Drawing Patients Out
Active listening includes techniques to draw a patient out and/or clarify what a patient is saying. This is especially important when the patient is trying to cope with strong feelings about his or her medical problems. Refer to Table 4-1 for a full listing of communication techniques that demonstrate active listening.
Avoiding Responses That Inhibit Communication
The medical assistant should avoid communication techniques that exhibit disapproval or blame as well as statements that are challenging or not genuine. If a patient feels that the medical assistant is not really listening, does not understand his or her point of view, or does not validate emotions, the patient may become defensive or stop speaking altogether. The medical assistant’s ability to demonstrate acceptance of strong emotions experienced by the patient is especially important.
When a patient expresses concerns, it is tempting to try to reassure the patient. For example, a patient might express anxiety about the results of a diagnostic test. If the medical assistant reassures the patient that the results will probably be normal, the fact that the patient is worried is not validated and the reassurance implies that the patient’s worry is unreasonable or unacceptable. If the medical assistant confirms that it is difficult to wait for test results, the patient is more likely to feel that his or her feelings have been accepted.
Because the medical assistant’s job is to make the person feel comfortable, it is important to avoid being too casual or familiar with a patient. If a subject is sensitive, but it is important to ask about it, the medical assistant can do so in a somewhat tentative way to make it easier for the patient to reply. The medical assistant can identify what the patient might be feeling, but the patient will not always agree. Many people are not always aware of their feelings and may deny feelings that they are communicating nonverbally. This should be respected. Others are only too glad to have their feelings recognized.
Medical assistants should express themselves honestly, without being judgmental, which means critical or negative. They can disagree with what a patient is saying,
Table 4-1 Communication Techniques That Demonstrate Active Listening
|Using open questions Asking questions that do not expect a particular answer,||“What’s been going on lately?”|
|especially a yes or no answer.||“How would you describe your stomach pain?”|
|Repeating or Saying the same thing as the patient either as a statement rephrasing or a question to encourage agreement, disagreement,||Patient:” It feels like someone is stabbing me in the side.”|
|or clarification.||Medical assistant: “Like a knife in your side…”|
|Translating a Translating the patient’s nonverbal expression of emotion nonverbal message into a verbal expression.||Patient: “All the doctor visits, the medication, the pain—it’s really too much.”|
|into words||Medical assistant: “You sound like you feel overwhelmed.”|
|Reflecting Reflecting is turning a question or statement around to reflect back to the patient; this gives the patient||Patient: “Would you have this surgery if you were me?”|
|confidence to continue.||Medical assistant: “What do you think about having the surgery?”|
|Paraphrasing and Paraphrasing puts the patient’s statement into the summarizing medical assistant’s own words; summarizing restates the meaning but may leave out some of the details. The purposes are to validate that the medical assistant has understood and to encourage clarification.||Medical assistant: “So for the past week the pain has been getting steadily more intense and more frequent, and since this morning it hasn’t let up at all.”|
|Providing silence Simply waiting for the patient to continue; allows the patient to choose whether to continue or choose a new topic.||(Silence)|
|Verbalizing the Saying what the patient seems to mean but has not implied expressed.||Patient: “Usually I don’t mind coming to see Dr. Hughes.”|
|Medical assistant: “But you didn’t want to come today.”|
|Asking for clarification Asking for more detail or a clearer statement; lets the patient know that the medical assistant has not understood and may show the patient how to make the message clearer.||Medical assistant: “It’s not clear to me how often you have been taking this medication. Do you take it before every meal, or just when you are at home?”|
especially if that disagreement will get the patient to elaborate on what is being said. But they should not argue because arguing sets up a competitive situation. Because the medical assistant represents medical authority, the patient can easily feel threatened and unworthy.
The responses that should be avoided are summarized in Table 4-2.
Barriers to Effective Communication
Impaired Level of Understanding
Occasionally, a patient with an impaired level of understanding visits the medical office. When this occurs, the medical assistant needs to simplify his or her method of speaking. The medical assistant should use short sentences and simple words. Speaking slowly in a normal speaking tone is important. Raising one’s voice does not help in this situation. The tone of voice should express concern and empathy without being condescending or implying that the patient is not intelligent. Strong and constant eye contact also helps the patient to focus.
It may be necessary to say the same thing more than once, either by repeating it or saying the same thing in a different way. In addition, gestures and demonstration help to reinforce the information.
Those with limited understanding of medical information—children, the elderly (especially those with some degree of dementia), and those who are mentally disabled—need constant reassurance. Giving a direct and complete explanation at the patient’s level of understanding is important. Even young children need to be informed about what is going to be done to them. For instance, if the medical assistant is going to draw blood, it is not enough to say, “I’m going to draw your blood. It’s going to hurt for just a moment.”
It may be necessary to say something like, “I’m going to use this needle to take some blood from your arm. I’m going to put it through the skin, into where your blood is. It will feel kind of like someone is pinching you, but only for a second. Then I’ll put a Band-Aid on it, and it will stop bleeding.”
After an explanation to an individual with impaired understanding, the medical assistant should ask the patient to repeat the explanation back in his or her own words. If the patient simply repeats a small part of the explanation, communication may have been ineffective. If the medical assistant explains a procedure such as a colonoscopy, for example, he or she should then ask the patient, “Can you tell me what a colonoscopy is?” An answer that may indicate
|Table 4-2 Responses That Inhibit Communication|
|Offering false reassurance||Telling the patient that everything will be all right; implies that the patient should not feel anxiety or concern. Especially inappropriate when the medical assistant does not know what will happen.||“Don’t worry; your husband will come through this with flying colors.”|
|Disapproving, blaming||Making a negative value judgment about the patient’s thinking or behavior; by implying or stating that a patient is responsible for his or her health problem, the medical assistant encourages the patient to defend against attack rather than establishing trust.||“You shouldn’t be smoking, you know. No wonder you have trouble breathing.”|
|Challenging||Insisting that the patient prove a statement or belief.||“Just show me something in writing that says people should never take a bath.”|
|Defending||Protecting oneself or someone else from criticism, which implies that the patient does not have a right to have a different opinion.||“Dr. Lawler’s patients never have to wait very long.”|
|Asking for explanations of feelings or behavior||Because patients often don’t know why they feel or act as they do, asking why may be frustrating and cause them to become||“Why don’t you stick to your diet?”|
|defensive.||“Why are you angry?”|
|Belittling or negating feelings||Acting as if feelings are less intense than they are or not even present; this implies that the patient’s feelings are not real or not justified||“You are really making a big deal out of a little cut.”|
lack of understanding is, “It’s when they do a colonoscopy.” The medical assistant can then make another attempt to provide a simple explanation.
A young child or an individual with an impaired level of understanding cannot give informed consent. This must be obtained from an individual who can legally give informed consent for the impaired patient before the medical assistant can proceed.
Many degrees of vision loss exist. Total blindness is the complete inability to perceive light and form. Legally blind is a term used to describe individuals whose vision cannot be corrected beyond 20/200 in the better eye. This means that with glasses, at 20 feet the person sees the same as or less than a person with normal vision sees at 200 feet. A person may be called sight impaired if his or her vision is better than 20/200 but he or she still has low vision or a decreased field of vision.
It is important for the medical assistant to be verbally descriptive when working with a patient with impaired vision. The medical assistant should use touch and guidance when escorting patients who cannot see to walk safely from the waiting room to the examination room and also when helping them around the examination room. Patients with impaired vision usually prefer to take the medical assistant’s arm and follow his or her movements rather than vice versa. To explain exactly where things are, a clock image sometimes helps. Saying that the examination table is at three o’clock tells a blind patient that the examination table is on the right directly to the side.
The term deaf is usually used when individuals cannot hear well enough to use the sense of hearing to process information. However, there are many more individuals whose hearing is impaired than those who are deaf, especially in certain tone ranges or when sound is not loud enough.
Special techniques should be used with patients who are hearing impaired. The medical assistant should speak clearly, slowly, and in short sentences. The medical assistant’s voice should be slightly louder than normal but not so loud that it loses clarity or sounds like shouting. Eye contact is also important when communicating with a hearing-impaired patient. Even if the hearing-impaired patient does not lip-read, most people who lose their hearing learn how to associate facial expression and mouth shape with words they know and recognize.
When beginning a conversation with a hearing-impaired patient, it may be necessary to touch the person gently to get his or her attention. If the patient is wearing a hearing aid, it may be helpful to ask if the hearing aid has been working well for him or her.
Sign language is often used to communicate with the deaf. Hand and finger positions represent letters or words. Several different systems exist, but American Sign Language is the recognized language in the United States.
Because each sign can represent an entire word, a person who uses sign language may be able to communicate as fast as, or faster than, a person who is speaking. Sign language has its own structure and grammar system, so it takes considerable practice to become fluent. A patient who uses sign language to communicate is usually accompanied by an interpreter. If the patient does not have an interpreter, the law requires the office to provide one. Sign language interpretation can be provided by an interpreter. It can also be provided by setting up a video relay service account. Video service links the deaf patient with a sign language interpreter. When a sign language interpreter’s services are being used, it is important that the medical assistant maintain eye contact with the patient. Hearing-impaired and deaf patients are able to obtain information from facial expressions and body language. They may also be able to read lips.
A language barrier interferes with communication when two people speak different languages. Depending on the patient’s facility with English, this interference may vary from slight to severe.
The best way to work around language barriers is with translation assistance. It is preferred to use trained medical interpreters or translators whenever possible. When scheduling an appointment for a patient with a language barrier, the medical assistant should arrange translation assistance at the same time. Sometimes a patient with a language barrier brings a child to translate. The medical assistant should be aware that children are the least reliable interpreters because they have a tendency to skip over medical words they do not understand or cannot translate without realizing that important information may be lost. It may also be embarrassing for a patient to discuss certain medical problems if a child is translating for him or her.
When conversing with a patient through an interpreter, the medical assistant should speak to the patient and not to the interpreter. The medical assistant should allow the interpreter to translate a sentence before going on to the next sentence. The medical assistant should speak slowly and carefully, using simple terms and short sentences. Many people who do not feel comfortable speaking English can still understand much of what is said to them in English.
At times the medical assistant may need to improvise when working with a patient with a language barrier. This may be required during the following circumstances: the office does not have translation services, the interpreter is busy, or the patient’s family member is translating but the patient wants to converse with the medical assistant in private. In these situations the medical assistant should use gestures and pantomime to convey his or her ideas.
Translation assistance is required before a patient with a language barrier gives written consent to an invasive procedure or minor office surgery. The law states that a patient must be fully informed as to the nature of his or her surgery or procedure. Consent forms are usually written in English, but the verbal explanation of the procedure needs to be in a language the patient understands well. If a practice has a large number of non-English-speaking patients, it is a good idea to have routine consent forms and instructional materials translated and available.
Telephone and video translation services can be purchased from several companies. Telephone translation assistance allows the patient, medical assistant, and/or physician to speak to the interpreter using a speakerphone. A video translation service requires a computer, a webcam (small video camera attached to the computer), and a speakerphone and allows all parties to see one another during the conversation.
Case Study 2
When Nancy calls Harold Underwood, a 67-year-old man, from the waiting room, he does not answer until she has repeated his name three times. Because he is a new patient, Nancy introduces herself. He says that he has moved into senior housing nearby so that he can be close to his daughter. Nancy finds that she has to repeat all instructions, and she notices that Harold is wearing a hearing aid in his left ear. When she asks him if he needs help to step up to sit on the examination table, he looks at her blankly. ■
UNDERSTANDING AND MEETING THE NEEDS OF PATIENTS
Patient Expectations of Health Care
Patient expectations depend on many factors including unmet needs and experiences the person has had in the past. Previous interactions with health care facilities also shape a patient’s expectations. For example, if there is a long waiting time, a patient who has always had to spend 30 to 40 minutes in the waiting room will be less upset than a patient who is used to being seen within 10 minutes.
Patients usually want to be seen by a physician in a reasonable amount of time, and they hope that the physician will “fix” whatever is wrong. Patients do not expect to have long-term problems. They want to be treated as if they were cars and physicians were mechanics—“fix what’s broken and get me back on the road of life!”
In addition, people expect physicians to take care of them when they are really sick and not fuss too much over them when they are generally well. People certainly do not want physicians to nag them about changing their lifestyle to improve their health. But physicians are much more likely today to bring up lifestyle issues, such as eating healthy foods in reasonable portions, not smoking, reducing alcohol intake, exercising, and using seat belts. Physicians are well aware that a healthy lifestyle can reduce the amount and intensity of medical care a person needs in the future.
Patients are sometimes so wrapped up in their primary concern—to get relief from pain or other symptoms—that they have difficulty accepting that physicians are often looking for the cause of their illness, not just to alleviate symptoms. This can cause a lot of frustration for patients, especially if no significant relief can be given or if the physician does not seem to think that alleviating the symptoms would be appropriate.
A common example of this is a viral illness such as the common cold. A patient may have a fever, muscle aches, weakness, vomiting, and diarrhea. Once the physician establishes that the patient does not have a more serious condition, the physician may recommend only rest, fluids, and over-the-counter medications (e.g., acetaminophen or ibuprofen for fever reduction and relief of soreness). This
plan of treatment can be frustrating for a patient who wants to feel better and have a speedy recovery.
How Basic Needs Affect the Behavior of Patients
Maslow’s Hierarchy of Needs
Abraham Maslow was an American psychiatrist. In his book titled Motivation and Personality, he defined what has come to be known as “Maslow’s hierarchy of needs.” A hierarchy is an arrangement in order of importance. Maslow describes human needs as a hierarchy with the most important needs at the lowest level. The image of a pyramid is often used to depict this visually, as shown in Figure 4-4. On the bottom of the pyramid (Level 1) are the physiologic needs. These are the basic biologic needs for survival, which include oxygen, water, food, excretion, sleep, shelter, and sexual expression.
On the next level of the pyramid (Level 2) are the needs for safety and security. Level 2 needs include avoiding harm, attaining physical safety, and the emotional security that comes with freedom from fear and anxiety.
On the middle level of the pyramid (Level 3) are the needs for love and belonging. Level 3 needs include both receiving and giving personal affection, companionship with another individual, and identification with a group.
On the fourth level of the pyramid (Level 4) are the needs for esteem and recognition. Level 4 needs include self-esteem, the respect of others in one’s peer group, success in work, and prestige in the community.
Finally, at the pyramid’s pinnacle (Level 5) is the need for self-actualization. This is the fulfillment of each individual’s potential.
Effects of Unmet Needs during Illness
Understanding that an individual cannot step up to the next level on Maslow’s pyramid until his or her needs have been fully met at the current level is important. An individual’s current level may shift several times, even in the course of a day, as different needs are experienced. An individual moves up or down the pyramid depending on what needs are currently unmet. Only when lower-level needs are met will the person be able to devote a significant amount of energy or concern to needs that are higher on the pyramid. In fact, a person has all the needs (outlined on the pyramid) all the time but becomes aware of higher-level needs only once the lower-level needs are met.
This has a number of implications for how patients relate to the medical care they receive.
Many patients who come to the medical office are struggling to meet basic needs because they are ill. Health care professionals must recognize any difficulties in that area.
Health and happiness require more than just meeting basic needs, however. Part of the role of health professionals is to foster the meeting of needs beyond physiologic needs. For example, intervening for an abused child or battered woman helps meet needs for safety and security, as well as some sense of love and belonging, by knowing someone cares. Teaching patients how to manage a chronic disease— one that continues to exist over time—helps a person’s self-esteem by making the person feel competent in self-care.
Another area where understanding the hierarchy of needs helps in the health care setting includes learning to recognize situations when attention-getting behavior by patients might be an attempt to satisfy needs for love and belonging, or for esteem and recognition. When people are ill, their usual means for meeting their attention needs (both for love and belonging, as well as esteem and recognition) may be interrupted.
Medical assistants must be able to recognize that they cannot meet all of a patient’s needs. For example, the medical assistant is not a close friend and should not attempt to be one, but recognizing when a patient feels a loss in this area, the medical assistant helps the person to identify his or her feelings and to cope with whatever need is not being met.
Establishing Caring Relationships
A patient who visits the medical office is often fragile, emotionally as well as physically. Illness interrupts an individual’s daily routine and threatens self-concept and self-esteem. A patient who is ill often has a difficult time meeting his or her physiologic needs. One of the primary roles of a medical assistant is to create and maintain a caring relationship with the patient. The medical assistant is often the patient’s earliest, most frequent, and most consistent point of contact with the medical office.
In order to meet a patient’s needs, the medical assistant must first be able to identify the patient’s feelings. In addition, the medical assistant must be able to understand those feelings, not in an intellectual way but in an emotional way. This understanding is called empathy. Empathy is the capacity to make an emotional connection with another
person’s feelings without allowing the emotional connection to become overpowering. Empathy is often contrasted with sympathy. Sympathy is defined as experiencing the same emotions as another. Sympathy is often accompanied by a feeling of pity.
Empathy is more objective than sympathy. Experiencing empathy requires a person to retain perspective and have confidence that strong emotions are not dangerous. The medical assistant must be sensitive to the feelings patients have when they go through the medical office routine. It is important for the medical assistant to be constantly aware that strong emotions may arise when individuals experience a threat such as an illness. By showing empathy to patients, a medical assistant can support them more effectively.
Expression of Caring
Caring can be expressed through words and body language. The medical assistant expresses caring through words, by drawing patients out and letting them tell their story in their own way, in their own time. This was described earlier in this chapter in the section on interviewing techniques. The medical assistant should accept and validate a patient’s feelings. Patients benefit by being acknowledged and having someone else accept them.
Putting It All into Practice
My name is Nancy Walker, and I have been working for an oncologist for the past 5 years. Our patients have many different types of cancer and are at many different stages of their diseases. One thing that they all have in common is that they need a lot of emotional support. We provide this primarily by keeping the lines of communication open. We try to create an atmosphere where patients feel able to discuss whatever is on their minds. Some patients never say the word “cancer,” and they talk about future plans as if they will be in the peak of health. Other patients are amazingly open and frank, even if they have not responded well to treatment. One patient told me that this is the only place she can talk about dying because her husband and her daughter become so emotional that she feels she has to spare them. We do not push patients to talk about anything they are uncomfortable with, but we do make time if patients want to talk about their feelings. The physicians also refer our patients to support groups or counselors because they believe that it is equally important to manage a patient’s emotions and physical symptoms. ■
Caring can also be expressed nonverbally through body language and through the way a medical assistant positions himself or herself during conversations with patients (Figure 4-5). The medical assistant should be positioned at the patient’s eye level and at a distance of no more than 3 to 4 feet. If the medical assistant stands while the patient sits at a lower level, the patient may feel intimidated or inferior.
Typically, the patient sits on the examining table while the medical assistant stands, which has both at almost equal height. If the patient is more comfortable sitting in the examining room chair, the medical assistant can sit on the physician’s stool, which again puts both at about equal height. This is much more friendly than if the medical assistant stands while the patient sits in the chair.
Maintaining eye contact and lightly touching the patient, if it seems appropriate, also communicate interest and caring.
Value of Effective Relationships with Patients
The medical assistant is often the patient’s most frequent, and long-term, point of contact with the medical office. A medical assistant who gets to know a patient well can be of invaluable assistance to both the patient and the physician, through trust established over time.
The experience of being understood and cared for is one of the most important steps in beginning to heal or cope effectively with illness, especially if the patient has a chronic illness. Ideally, each professional the patient comes in contact with at the office will convey this sense, but it is most important for those who are performing procedures. If the patient feels understood, he or she will also develop trust and be able to relax during procedures. This makes the procedure easier and less painful for the patient. It also makes it easier for the medical assistant to perform the procedure.
Personal boundaries or self-boundaries include physical, mental, and spiritual guidelines or limits that a person uses to define how close other people can come without posing a threat to personal integrity. They indicate a sense of being separate from others instead of defined and controlled by others. The medical assistant and other health professionals allow others to maintain the personal physical space that is necessary for them to feel comfortable, and they do not allow others to intrude into their own physical space. They should also have a clear sense of their own responsibility and right to decide how to behave based on clear moral and ethical principles.
It is not uncommon to encounter individuals with mental boundaries that are too weak or too strong. A person who is very unsure about his or her boundaries goes along with his or her companions and is easily manipulated. The opposite type of person maintains rigid control, refuses to be influenced, and usually keeps others at a distance so that no one can get close. Either of these types may be totally self-absorbed, seeing themselves as the center of the universe and treating others as if their only function is to meet their needs.
When interacting with an individual who does not respect physical or emotional boundaries, it is important for the medical assistant to recognize what is happening and take appropriate steps to maintain personal boundaries. If possible, this should be done in a straightforward way without acting upset or angry. For example, a patient may act as if he or she is a good friend of the medical assistant and ask for a cell phone number or may ask the medical assistant to meet him or her for lunch. Initially most medical assistants would offer excuses not to comply. If the patient continues to ask for a telephone number, for example, the medical assistant may state calmly that he or she does not give his or her cell phone number to patients.
Emotional Responses to Illness
Patients may feel guilt about their illness. The amount of guilt they feel varies from one patient to another. The amount of guilt that a patient is willing to express, as opposed to the amount that is repressed, varies from one patient to the next.
Some individuals engage in behaviors that are known to be risky to health, such as cigarette smoking, drinking, and drug abuse. These patients sometimes feel guilty about a respiratory disease, but others may display a devil-may-care attitude about their disease. People often know intellectually that their high-calorie, high-fat diet or sedentary lifestyle predisposes them to certain illnesses or conditions. Smokers, for example, have been bombarded with scientifically valid information for almost 40 years about the link between smoking and heart disease, lung cancer, and chronic obstructive pulmonary disease. Yet many of these individuals continue established habits without an outward sense of guilt. It seems as though they have convinced themselves that their risky behavior is not the cause of their disease or that they are somehow immune to the consequences of their behavior.
On the other hand, patients with conditions totally out of their control may experience guilt. For example, someone with pancreatic cancer might say that he could have avoided the disease if he had taken better care of himself, eaten a healthy diet, or gotten more exercise.
As with other emotions, the medical assistant should accept and validate a patient’s description of his or her feelings. If the patient’s previous behavior is partially responsible for current medical problems, the patient requires support and acceptance. If it is unlikely that previous behavior is related to the medical problem, the medical assistant can encourage the patient to discuss the causes of his or her condition with the physician.
Loss of Control
When people are ill, they often have a feeling of a loss of control. This is especially true if they have sought medical care for their condition. In addition to physiologic changes that may be unwelcome, they feel unable to control their schedule and/or environment. Some decisions are made for them. They have to take off their clothes. People get physically close to them and sometimes even touch them. People tell them to do things they do not want to do. They are anxious and become defensive. The medical assistant should respond to the patient’s irritation with patience and kindness. It is important to give the patient choices and make every effort to accommodate the patient’s wishes.
Anxiety is a response to a perceived threat. A person who is moderately to severely anxious is not able to converse coherently and will not pick up nonverbal cues that he or she would normally notice. When working with a patient who is anxious, the medical assistant must first get the person’s attention, slow down the conversation, and then help the person to focus on the conversation. It is important to validate the patient’s concern, which reduces his or her anxiety level. This allows the patient’s energy to be channeled in a more productive way. When patients are anxious, they may not remember what they are told. The medical assistant can help the patient by creating memory aids. For example, the medical assistant can prompt the patient to record a follow-up appointment in his or her appointment calendar. It is also a good idea to write the instructions down or provide the patient with a preprinted instruction sheet.
Severe anxiety can be medically problematic. Physical symptoms occur with a full-blown anxiety attack, often termed a panic attack. An overly anxious person hyperventilates, has an extremely rapid heart rate, and becomes unresponsive. Some people experience numbness in their fingers and toes; others feel a sensation of fluid in their ears. Some people become intensely fearful and have an overpowering sense of dread.
An anxiety attack must be dealt with as a medical issue first. Helping the patient acknowledge the anxiety is important. Acknowledging the anxiety helps a person gain control. In addition, having strong emotions accepted by another person decreases the sense of fear that many people have about their emotions.
If the patient is breathing rapidly, the medical assistant should encourage the patient to take slow, deep breaths. Experts no longer recommend having a patient breathe into a brown paper bag because this may cause blood oxygen levels to fall dangerously low.
If possible, the medical assistant should encourage the patient to validate that anxiety is present without minimizing its significance. If the patient has not experienced severe anxiety before, he or she may not realize the effects it can cause. The medical assistant can explain that any physical symptoms are the result of anxiety and stay with the patient until the symptoms begin to subside. With most patients, the symptoms begin to diminish after 1 or 2 minutes. After the person has returned to a level of relative calm, it may be possible to discuss how the person handles anxiety. The physician may also refer the patient to a counselor to work on strategies to manage it.
Case Study 3
Julie Ann Reynolds is a 20-year-old patient who comes to the office and describes four or five recent episodes of shortness of breath, palpitations, feeling faint, sweating, and nausea. She states that she has just started taking classes at a local university after transferring from a community college. The episodes have occurred mainly in the car on the way to school or shortly after she arrives. She says that on one occasion her heart was beating so fast that she had to pull her car over and wait for about 10 minutes before she felt well enough to drive. She says that she has never had a heart problem, but now she is afraid that there is something wrong with her heart. She also says that her mother is worried about her and has suggested that she get an electrocardiogram and other tests because she might have a serious medical condition. ■
Anger is a natural response to a perceived threat. Anger is often a subconscious response, which means that the patient is unaware of its cause, its intensity, or even its presence. A patient may express anger at a target that did not actually cause the angry feeling. Anger can also escalate quickly if it triggers an angry response from another individual. When dealing with an angry patient, the medical assistant needs to identify the emotion without feeling attacked. If possible, the medical assistant should help the angry person identify the true source of the anger.
Anger is one of the more difficult of the incapacitating emotions to deal with. Anger tests a medical assistant’s empathy and ability to put aside private issues to help patients. The first instinct is to defend oneself against a perceived attack by the angry patient, but this is counterproductive. It is more effective to respond with calmness and control using a quiet voice. Accepting that a patient is angry is not the same as allowing the patient to threaten office staff or other patients. It is perfectly acceptable to set personal boundaries by telling the patient that he or she is acting inappropriately, that he or she is making it difficult for other patients, or that shouting will not be tolerated. To protect the confidentiality of the patient who is temporarily out of control, the medical assistant should escort the patient to a private area. It is also appropriate for the medical assistant to request assistance from the office manager in dealing with an angry patient. Sometimes anger, like electricity, loses intensity when the connection is broken.
The Grieving Process
Any time a disease causes actual or potential loss including loss of function as well as loss of life, both the patient and family go through a fairly predictable sequence of stages called the grieving process. This process was described in detail by the spiritual author Elisabeth Kübler-Ross in relation to individuals with a terminal illness. The terminal phase is defined as when the patient is not expected to live more than 6 months. People go through this sequence over varying lengths of time, and may move from one stage to another out of the order presented here. Although the process is individual, it is important to know that even a dying person can come to a type of acceptance, and after death has occurred there is a time when the grieving relatives and friends will again be able to engage in loving and fulfilling relationships.
The following five steps are those described by Kübler- Ross for the patient with a terminal illness:
The medical assistant should listen to the patient actively, without confronting unrealistic statements. Acceptance of the patient’s need to deny reality provides support for a patient to accept at his or her own pace. The patient and family will start to accept reality when they are ready to handle the strong emotions.
Highlight on Ego Defense Mechanisms
Ego defense mechanisms are unconscious mental processes that offer psychological protection. Everyone uses defense mechanisms at some time or another to protect against being overwhelmed by painful feelings. Although people are sometimes aware of using these mechanisms, usually they operate on an unconscious level—that is, people are not aware that they are disguising or blocking emotions or impulses.
Everyone tends to use defense mechanisms that have been effective in the past to reduce stress or anxiety. When a person first encounters a situation, such as a diagnosis of serious illness, that would provoke strong feelings, a defense mechanism like denial helps him or her avoid feeling overwhelmed and unable to cope. (Denial is unconsciously refusing to acknowledge something that is difficult to accept.) People say things like, “It doesn’t seem real to me” or “This must be a mistake.”
Denial allows the truth to penetrate gradually so the person has a chance to get used to the threat, to seek privacy to experience intense emotion, and to avoid total disorientation. However, if a person continues to use denial without attempting to accept the situation, negative consequences may occur.
The person may not take appropriate actions to respond to illness. Friends and family may respond negatively to the person’s perceived lack of responsibility. And the person may miss the opportunity to grow and strengthen his or her sense of self-worth and ability to cope with adversity.
If a medical assistant can identify a patient’s defense mechanisms and coping patterns, he or she can gain a better understanding of the patient’s underlying fears and concerns. The medical assistant can try to respond to these concerns but should not directly challenge the defenses or label them.
When defense mechanisms are attacked, it takes more energy to defend against threatening emotions. On the other hand, accepting defenses tends to promote a feeling of being understood and may decrease the need for rigidity in the defenses. Example
Mr. Sykes has had to wait for about 45 minutes past his appointment time to see Dr. Lopez. When Kathy, the medical assistant, takes him back to the examination room, he says, “I think you should know that some of the people in the waiting room are really upset about how long they have been waiting.”
Kathy may suspect that this is an example of projection— unconsciously identifying thoughts or feelings as originating in someone else when they really are one’s own thoughts and feelings. She can be helpful to Mr. Sykes by responding in a way that reassures him that it is understandable for a person to be upset when there is an unusually long wait. Responses that are not helpful (because they reinforce Mr. Sykes’s fear that it would be dangerous to express a negative emotion directly) are as follows:
Following is a list of several other ego defense mechanisms, with examples that might occur in a medical office. Remember that using defense mechanisms usually helps people adapt to stressful situations. ■
|Other Ego Defense Mechanisms|
|Selective inattention||Failing to hear or pay attention to information that may provoke anxiety||A patient expresses the belief that his cancer will definitely be cured if he has the primary tumor removed.|
|Regression||Returning to the emotional adjustment of an earlier stage of growth and development||An ill person who could be independent asks for assistance with personal hygiene.|
|Depersonalization||Removing feeling from something that is perceived as stressful||A medical assistant who is assisting with a lumbar puncture on a young child experiences the child as looking like a toy or doll.|
|Rationalization||Assigning logical reasons or excuses for actions that may have been motivated by self-interest or other emotions the person does not wish to acknowledge||A patient might justify not telling the physician that he smokes by saying to himself, “The doctor isn’t interested because he didn’t ask about it.”|
|Repression||Unconsciously excluding unacceptable ideas, impulses, or emotions from awareness||A diabetic patient who hates finger sticks often forgets to test her blood sugar.|
|Suppression||Deciding to put uncomfortable or painful thoughts out of awareness||A patient says, “I don’t want to think about my surgery until the day before.”|
|Displacement||Shifting an emotion or behavior from the original object to a more acceptable substitute||A medical assistant who has just been given a poor evaluation is extremely rude to the next person she talks to on the telephone.|
|Undoing||An attempt to make amends for a feeling or behavior that makes a person feel guilty||A patient notices that she hates the medical assistant’s hairstyle and hair color. Immediately she tells the medical assistant that she has beautiful eyes.|
|Compensation||Attempting to overcome a real or perceived handicap by developing some other ability or trait||A person who thinks that she isn’t very intelligent in school always offers to help the teacher.|
alone. The patient who is withdrawn is more difficult to deal with than the person who is openly angry. In this situation, a medical assistant needs to be available and present with the patient for companionship and to provide a nonjudgmental listening ear. The medical assistant should always strive to maintain communication with a patient in the depression stage. Counseling and support groups may be appropriate referrals for both patients and family members in this stage.
A dying person has a number of fears, such as fear of the unknown, fear of pain, and fear of helplessness. It is a challenge for all health care professionals to accept the difficult feelings of fear.
Listening closely to the patient allows the medical assistant to help the patient respond to all hints of deterioration, as well as actual problems, as soon as they become apparent. The patient may need to be seen by several health care professionals while receiving additional care at home. The medical assistant can be helpful by being aware of community resources and by communicating the needs of the patient and his or her family to the doctor. This requires knowledge of insurance benefits and of the types of insurance the office accepts, as well as other sources of funding assistance the patient may be able to obtain.
A patient whose condition has stabilized or whose active treatment has ended but who still requires pain relief, nursing care, and/or comfort measures must receive them at home, in a nursing home, in a rehabilitation center, or in a hospice center. A hospice is an organization that provides comfort, pain relief, and personal care for dying patients.
Most hospices provide nursing care, nursing assistants, and volunteers to visit terminal patients in their homes, working with the families to increase the individual’s comfort once active treatment is no longer effective or desired. There are also some hospice centers, which provide centralized care. In some areas a patient can receive similar services from home health care agencies and visiting nurse associations.
The medical assistant may serve as a liaison to obtain appropriate referrals from the doctor and assist the patient and/or family to locate providers of needed services. Communication on this level must be two-way; if a patient is being seen by visiting nurses, hospice, or other health professionals, the medical assistant may be the person who facilitates communication between the doctor and these other parties.
Cultural Influences Affecting Health Care
Patients often come from cultures that have some level of distrust of Western scientific medicine and/or strong belief in their own medical traditions. In addition to seeking care from a physician, these patients may complement their care by visiting traditional practitioners. In many traditional practices, religion and medicine are tightly interwoven. Both patients and practitioners hope to affect health by influencing spirits or gods in the unseen world. People from many cultures believe in the effectiveness of sacred words, tattoos, or amulets (objects worn to prevent injury or evil), as well as specific rituals that may involve chanting, fire, or even animal sacrifice.
Causes of Illness
Many cultures distinguish between illness caused by bad spirits or evil people and illness with physiologic origins. It is important to not ridicule these theories if patients believe them. When patients feel that health professionals do not respect their beliefs, they may not follow recommendations or return for follow-up care. An open attitude and the willingness to listen to the patient’s beliefs are required in order to establish a relationship of trust with the patient.
Fundamentals of scientific medical practice—such as frequent handwashing to remove invisible organisms, taking medicine when one does not feel ill, and causing pain to healthy children by giving them immunizations—may be foreign to certain traditional practices.
Treatments and Traditional Practices
When patients have different beliefs, it is important for all members of the health care team to keep the lines of communication open. Patients need to be able to discuss other
treatments that are being used. They also need to understand the importance of the treatments being offered by scientific medicine so that they can comply with standard medical treatment regimens in addition to their traditional practices.
As a general rule, the medical assistant should accept any traditional practice that is not dangerous. For example, some patients from Cambodia and other parts of Southeast Asia believe that rubbing the skin with the side of a coin dipped in a camphor preparation is a treatment for colds and headaches. This treatment leaves bruises on the skin but does not cause breaks in the skin. A child with bruises from this type of treatment is not a victim of child abuse, but the bruises might look like abuse. The medical assistant should learn about traditional treatments used by patients in the practice where he or she works.
One area in which family and cultural traditions may be strong relates to diet and herbal preparations. In many traditions, certain diseases and conditions are considered “hot” and others are considered “cold.” The patient may be advised to either eat or avoid certain foods or to take certain herbal preparations in order to restore balance. If the patient can describe traditional treatments, it will be easier for the physician to identify any practices that might be harmful or that might interfere with prescribed medical treatments.
In some cultures there are specific behavioral requirements for women and men. There may be cultural norms requiring women to have a male escort when they leave their homes. In some cultures the oldest male in the family must make important decisions. For some individuals there are also cultural requirements prohibiting the removal of clothing, jewelry, and head coverings, even for medical examinations. Medical assistants must learn about cultural norms and respond with acceptance and sensitivity. If necessary, adaptations must be made so that the patient is not forced to violate personal standards.
|NMEDJpAL PRACTICE and he LAW”|
|The Civil Rights Act of 1964 and its amendments require access to federally funded health programs and services for individuals with limited English proficiency (LEP). State laws require similar access for state programs and services. This has been interpreted as a requirement for some translation services to be provided by all government-funded health care providers. These services include consent forms in the languages of the service population and access to qualified medical interpreters either in person or by telephone. Health care providers are also required to provide sign||language interpreters if necessary under the provisions of the Americans with Disabilities Act. The U.S. Department of Health and Human Services also requires translation services before informed consent can be given for medical research. Before enrolling a subject in a medical research program, it is necessary to provide written consent forms in the language that the subject understands and a translator fluent in English. ■|
|What Would You Do? What Would You Not Do? responses|
|Case Study 1 Page 59 What Did Nancy Do? □ Maintained a warm and accepting posture and a friendly tone||What Would You Do/What Would You Not Do? Review Nancy’s response and place a checkmark next to the information you included in your response. List the additional information you included in your response.|
|□ Used an open response to encourage Jennifer to say more|
|about how she felt about possibly being pregnant.|
|□ Identified verbally that Jennifer seemed a little upset.|
|What Did Nancy Not Do?|
|Did not immediately congratulate Jennifer or respond as if this was good news.Did not immediately assume a businesslike tone of voice and ask closed questions to obtain information.Did not imply that Jennifer was experiencing a different emotion.Did not act as if the patient had nothing on her mind.Did not appear to be in a hurry to finish the interview.||Case Study 2 Page 63 What Did Nancy Do? □ Made sure that Harold was looking at her when she spoke to him.|
What Did Nancy Not Do?
What Would You Do/What Would You Not Do?
Review Nancy’s response and place a checkmark next to the information you included in your response. List the additional information you included in your response.
Case Study 3
What Did Nancy Do?
What Did Nancy Not Do?
What Would You Do/What Would You Not Do? Review Nancy’s response and place a checkmark next to the information you included in your response. List the additional information you included in your response.