Getting airtime: Exploring how patients shape the stories they tell health practitioners

Abstract

Introduction: Effective communication during health encounters is known to decrease patient complaints, increase patient adherence and optimise health outcomes. While the aim of patient-centred care is to find common ground, health practitioners tend to drive the encounter, often interrupting patients within the first minute of the clinical conversation. Optimal care for people with chronic illnesses requires individuals to interact with health practitioners regarding their health concerns, but given these constraints, we know little about how patients strategise conversations with their care providers. This understanding may further our efforts to educate health practitioners and trainees to learn and practice patient-centred care.Methods: A constructivist grounded theory approach with iterative data collection and analysis was used to explore the processes patients use to present and shape their stories for interactions with health practitioners. Twenty-one patients (n = 16 female; 5 male) representing a variety of chronic illnesses participated in semistructured interviews. Using the constant comparative method of analysis, salient themes were ascertained.Results: Patients engage in extensive strategic preparations for productive health encounters. From the data, we identified four related elements comprising patients' process of planning, preparing, and strategising for health encounters: deciding to go, organising to get airtime, rehearsing a game plan, and anticipating external forces. By focusing on the extensive preparatory work patients engage in, our study expands the dimensions of how we understand illness-related work. Assembling personal health information, gathering disease information and achieving equanimity represent the dimensions of this 'health interaction work'. Conclusion:The work patients engage in for health encounters is noteworthy yet often invisible. And work that is unseen may also be undervalued. Acknowledging, illuminating and valuing patients' preparatory work for health encounters add to how we understand patient-centred care, and this offers new targets for us to effectively teach and deliver it.

Commentary: Recognising patient preparation to improve patient‐centred care for diverse populations

“…[10][11][12] While there is less data about sexual and gender minority patients, emerging evidence suggests distrust is also common among these patients due to stigmatisation and inadequate physician competencies in relevant medical issues. [13][14][15] In this context, if the average patient with chronic disease perceives the degree of preparatory work described by Koopman et al 6 -two hours a day!-is necessary for self-advocacy, how do patients who experience systemic racism or other discrimination, or those with DOI: 10.1111/medu.14603 less time and money, lower health literacy, or language barriers, feel or prepare for their care? How do these patients strategize to achieve 'equanimity' and appear credible?…”

“…Emphasis has been placed on two related goals to improve patient-centred care for diverse populations: (1) increase medical learner diversity such that physician workforces better reflect their communities and (2) recognise persistent health inequities among racial and ethnic minority, LGBTQ+, and other vulnerable patients, and develop physician competencies to better meet diverse populations' clinical needs. 18 To this second end, Koopman et al's 6 work broadens potential ways to accomplish this, and many of their recommendations-asking about and acknowledging preparations, fostering discussions about expectations, and creating safe spaces to express vulnerabilities-are particularly applicable to diverse populations. As competency-based education now predominates medical training, strategies used to identify entrustable professional activities (EPAs) for related concepts such as shared decision-making 19 should be adopted to develop explicit EPAs for addressing patients' preparations and health journeys in culturally competent ways.…”

“…In this issue, Koopman et al 6 report a Canadian qualitative study of how patients with chronic disease shape the stories they tell health care providers. They argue that focusing on physician–patient encounters fails to consider the important and time‐consuming, but invisible, preparatory work patients strategically perform on their overall health journeys between episodic encounters.…”

“…There is already evidence more vulnerable patients receive less—and worse—care 16,17 . Given that Koopman et al 6 also identified benefits to this preparatory work, including an empowering sense of control and knowledge and more time during encounters to discuss patient priorities, ability to engage in preparation may function as another social determinant of health. Further research about preparatory work specifically among vulnerable populations due to race, ethnicity, sexual and gender minority status, socioeconomic strata, and intersectionality of characteristics, is needed.…”

“…3 Patient-centred care quality metrics have, however, been elusive; though many indicators are described by health care organisations as informing practices, most are guidelines or recommendations under development and not actually implemented. 4,5 In this issue, Koopman et al 6 report a Canadian qualitative study of how patients with chronic disease shape the stories they tell health care providers. They argue that focusing on physician-patient encounters fails to consider the important and time-consuming, but invisible, preparatory work patients strategically perform on their overall health journeys between episodic encounters.…”