Talking with and about older adult patients: The socializing power of patient-centered communication in an optometry teaching clinic
Hildebrand, Jenna Mae
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In a teaching clinic, healthcare students and their supervisors talk with their patients in the examination room and they talk about their patients during teaching consultations outside the examination room. Effective doctor-patient communication helps to establish management plans that are appropriate for both doctors and their patients. Amid a pressure to provide more patient-centered care, communicating effectively with older adult patients is particularly crucial because the occurrence of health problems and the likelihood of age-based communication barriers and negative attitudes increase with age. This project is a qualitative, collective case study of eye examinations, case presentations and participant interviews. This study took place in the Primary Care Clinic at the University of Waterloo, School of Optometry. Participants included 8 fourth-year optometry students, 5 supervising optometrists, and 10 patients between 60 and 85 years of age. The study involved audio-recording and analyzing eye examinations of older adult patients, case discussions about these patients, and interviews of older adult patients, optometry students and their optometrist supervisors. Data were analyzed using a constant-comparative approach, consistent with grounded theory. This study identified some of the discursive features of and reflections about patient-centered communication during the talk with and about older adult patients. During the eye examinations, optometry students incorporated five types of verbal communication that were consistent with a patient-centered model: Patient Agenda, Social Talk, Analogies, Patient Agency, and Health Promotion & Prevention. Although these successful attempts to incorporate patient-centered communication strategies were evident in the talk with patients, optometry students routinely engaged in seven other verbal strategies that challenged this patient-centered ethos: Closed-Ended Questions, Biomedical and Technical Language, Patient as a Problem, Unacknowledged Patient Voice, Patient Understanding, Doc Talk, and Caregiver Agency. Two types of discursive strategies related to patient-centered care were identified in the talk about older adult patients during novice case presentations: Voice of Optometry and Voice of Patient. The Voice of Optometry incorporated field-sanctioned language strategies including three subcategories: Biomedical, Technical and Judgment. In contrast, the Voice of Patient represented various levels of patient agency: Passive Recipient, Negotiated Agency and Patient Agency. According to their interviews, optometry students received limited explicit training, in both classroom and clinic instruction, on how to talk with and about patients. During their interviews, optometry students and their supervisors made clear distinctions between patient–centered and doctor-centered care. Most of the students and supervisors believed that the optometry profession and the optometry school promoted patient-centered care. Elements of patient voice were represented in the eye examinations, the case presentations and the post-examination patient interviews. During novice case presentations patient voice was often fragmented into sound bytes of the original patient statements or translated into field-sanctioned language. Although many instances of patient education and counselling were evident throughout the eye exams, limited discussion occurred in the novice case presentations between students and their instructors about what to say to patients, In addition, the majority of topics addressed during educational and counselling moments were not discussed during the novice case presentations. Additionally, post-examination patient recall regarding education and counselling was generally limited. Throughout this study, talk about age appeared in four ways: 1) caregivers used age to make clinical decisions during case presentations, 2) caregivers referenced age during counseling and education to explain eye and vision changes, 3) patients commented on the impact of age on themselves, and 4) caregivers spoke about how they considered age when speaking to their patients. While the caregivers generally valued a patient-centered approach, the talk with and about patients was skewed towards strategies that may limit the ability to support this ethos. It is questionable what audience (i.e. patient or supervisor) optometry students value and how this affects their ability to adopt patient-centered communication strategies. Findings from this study suggest that caregivers and their patients might benefit from some changes in the way patient-centered practice is taught and practiced in this optometry teaching clinic. As a greater understanding develops of the strategies of and challenges to patient-centered practices in optometry, it is my hope that optometry training programs as well as optometry professional organizations will further embrace patient-centered practices.