Do You Speak the Other Guy’s
Language: Culture, Diversity and
the Bottom Line
Dr. Paul Mendis,M.D., Chief Medical Officer
Neighborhood Health Plan
Boston, MA
Shani A. Dowd, B.A., L.C.S.W.
Dir., Clinical Cultural Competency Training
Harvard Pilgrim Health Care
Boston, MA
US Population by Race/Ethnicity
2000
White 69.1%
African Amer. 12.3%
Amer. Ind. 0.9%
Asian 3.6%
Pacific Is. 0.1%
Latino 12.5%
Two or More 2.4%
© Harvard Pilgrim Health Care, Inc
Racial and Ethnic Distribution of the
Population of the US:
Projected 2030
White, Non-Hisp.
60.5%
African American
13.1%
Hispanic 18.9%
Asian/ Pacific Is.
6.6%
American In./Alaska
Nat. 0.8%
Bureau of the Census, Statistical Abstract of the
U.S. 1997.
© Harvard Pilgrim Health Care, Inc
Leading Causes of Death, by Race and Ethnic
Group, 1996
Rank
White, non- African
Hispanic
American
Latino
Native
American
Asian
American
1
Heart
Disease
Heart
Disease
Heart
Disease
Heart
Disease
Heart
Disease
2
Cancer
Cancer
Cancer
Cancer
Cancer
CVD
CVD
AUI
AUI
CVD
Chronic lung
Disease
HIV/AIDS
CVD
Diabetes
AUI
AUI
AUI
HIV/AIDS
CVD
Pneumonia and
Influenza
Cause
3
of
Death
4
5
AUI =accidents and unintentional injuries
CVD=cerebrovascular disease (stroke, etc.)
© Harvard Pilgrim Health Care, Inc
Source: DHHS, Health,
United States,1998
Health Care Disparities: Asthma
7% of all children in US have asthma
African American children are:
 twice as likely to have asthma
 Three times more likely to be hospitalized with
asthma
 six times more likely to die from asthma
Source: Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Health Care Disparities: Asthma
Among Latinos, asthma prevalence varies by
ethnicity:
 Puerto Ricans have the highest rates: 11%
 Mexican American children have the lowest rates
among Latinos: 3%
Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Health Status
While 16% of white Americans self-report
indicated that they believed they were in only
fair or poor health, :
% of Asians reporting fair or poor health
 40% of Vietnamese
 29% Korean Americans
 11% of Chinese
Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Chronic or Poor Health:
51% of all African Americans have been
diagnosed with at least one of the following
within the past 5 years:
Asthma
Cancer
Heart Disease
Diabetes
Source: Commonwealth Fund
© Harvard Pilgrim Health Care, Inc
High Blood Pressure
Obesity
Anxiety/depression
Health Care Disparities:
HIV/AIDS Treatment
 African Americans are twice as likely as whites to NOT
receive triple drug antiviral therapies.
 African Americans are 1.5 as likely to not get prophylaxis for
PCP
 Latinos are 1.5 times as likely as whites to NOT get triple drug
antiviral therapies
Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Racial/Ethnic Disparities in
Health: Diabetes Outcomes
Diabetes-Related Death Rate, 1996
35
30
25
20
15
10
5
0
28.8
27.8
18.8
11.6
8.8
White
© Harvard Pilgrim Health Care, Inc
Black
Hispanic
Al/An
Asian/Pl
Health Care Disparities: Treatment
for Cardiac Care
Among Medicare Beneficiaries:
 African Americans are 60% LESS likely than whites
to received heart bypass surgery, even when
controlled for income, insurance status and place of
treatment
Kaiser Family Foundation www.kff.org
© Harvard Pilgrim Health Care, Inc
Racial/Ethnic Disparities
in Health:
Cardiovascular Procedures
 Differential use based on race of:
Cardiac catherization and angioplasty
(Harris et al,
Ayanian et al.)
Coronary artery bypass graft (Peterson et al.)
Treatment of chest pain (Johnson et al.)
Referral to cardiology specialist care (Schulman et al.)
© Harvard Pilgrim Health Care, Inc
Life Expectancy (in years) at birth and by race and
sex, United States, 1998
80
78
76
74
72
Life Expectancy in
Years
70
68
66
64
62
White
Males
Black
Males
White
Black
Females Females
Source: Health United States, 2000. Bureau of Primary Health Care
© Harvard Pilgrim Health Care, Inc
10 Health Conditions with Greatest
Disparities Between Whites and Members
of Ethnic Communities
COPD
HIV/AIDS
Cancer
Child and Adult Immunizations
Cardiovascular Disease
Pneumonia
Infant Mortality Rates
Stroke
Diabetes
Tuberculosis
© Harvard Pilgrim Health Care, Inc
Percentage of Adults Reporting
Problems with Communication with MD
33% of all Latinos
27% of all Asians
23% of all African Americans
16% of all white, non-Latinos
Source: Commonwealth Fund (www.cwf.org)
© Harvard Pilgrim Health Care, Inc
Communication Problems with MD
Of those reporting problems, one or more of the
following were reported:
 MD did not listen to everything that pt. said
 Patient did not fully understand MD
 Had questions but did not feel comfortable asking
Source: Commonwealth Fund www.cwf.org
© Harvard Pilgrim Health Care, Inc
Latinos Reporting Communication
Problems
43% report Spanish as their primary language
26% report English as their primary language.
Source: Commonwealth Fund \\www.cwf.org
© Harvard Pilgrim Health Care, Inc
Patient Satisfaction
Patient satisfaction increases when clinician uses psychosociallyoriented interview
Psychosocially oriented interview was LEAST frequently used
Perception among physician that takes more time
BUT: Study found that psychosocial interview did not significantly
increase time of the clinical encounter
Roter,DL, Stewart, M., Putnam, SM, Lipkin, M, Stile, W. & Inui, T (1997) Communication patterns of
primary care physicians. Journal of the Amer. Med. Assoc., 277(4):350-56.
© Harvard Pilgrim Health Care, Inc
Malpractice and Physician-Patient
Communication
Specific communication problems were identified in a
sample of malpractice claims. Physicians with no claims
against them were more likely to:
 orient patients to the process of the visit
 use facilitative statements more, e.g. “Go on, tell me more”
 ask patients’ opinions about their medical problems
 use humor, indicated warmth and friendliness
Levinson, WL, Roter, DL, Mullooly, JP, et al. (1997) Physician -patient communication: The relationship with
malpractice claims among primary care physicians and surgeons. JAMA, 277:553-559.
© Harvard Pilgrim Health Care, Inc
Malpractice and Physician-Patient
Communication
Four problematic themes emerged when plaintiffs
depositions were reviewed:
 Deserting the patient
32%
 Devaluing the patient or family views
29%
 Delivering information poorly
26%
 Failing to understand the patient
and/or family perspective
13%
Beckman, HB, Markakis, KM, Suchman, AL and Frankel, RM. (1994) The Doctor Patient Relationship
and malpractice: Lessons from Plaintiff Depositions. Arch. Internal Med., 154: 1365-1370.
© Harvard Pilgrim Health Care, Inc
Malpractice and Physician-Patient
Communication
While 1% of hospitalized patients suffer a
significant injury due to negligence, fewer than 2%
of these patients initiate a malpractice claim.
Patient dissatisfaction is the key element in the
decision to initiate a malpractice claim.
Levinson, WL, Roter, DL, Mullooly, JP, et al. (1997) Physician -patient communication: The relationship
with malpractice claims among primary care physicians and surgeons. JAMA, 277:553-559.
© Harvard Pilgrim Health Care, Inc
The New Millennium
(Health Care Environment)
Health care entities are fewer in number, but larger & more complex in
size, product offerings & geography
E-Health will play an increasingly important role in health care industry
Loyalty to skill/profession, work group, colleagues is shifting for many
providers
Rapid change (revolutionary)
© Harvard Pilgrim Health Care, Inc
Motivations for Addressing Cultural Issues in
Health Care in the United States
Changing demographics
Increasing globalization of US economy
Rising advocacy of health care consumers
Increasing regulatory requirements
Continuing documentation of inequities in access to
health care and health care information and in health
outcomes
© Harvard Pilgrim Health Care, Inc
Meeting Regulatory and
Accreditation Guidelines
NCQA
JCAHO
Office of Minority Health
Department of Medical Assistance
Employer Request for Proposals
Licensure Requirements
© Harvard Pilgrim Health Care, Inc
Meeting Regulatory and
Accreditation Guidelines
Physicians and hospitals who wish to participate in federally
funded medical programs, specific requirements are
articulated in the language of the contract relating to cultural
issues, such as linguistic access:
• Balanced Budget Act of 1997
• Medicare
• Medicaid
© Harvard Pilgrim Health Care, Inc
Commercial Insurers
Increasingly, large employer groups are finding that
their workforces are increasingly diverse in
 languages spoken
 ethnic cultures
 racial groups
 religious groups
 gender
 disabilities
© Harvard Pilgrim Health Care, Inc
What is Cultural Competence?
It is the ability to deliver effective medical care to people
from different cultures.
By understanding, valuing and incorporating the cultural
differences of America’s diverse population and examining
one’s own health-related values and beliefs, health
providers deliver more effective and cost-efficient care.
© Harvard Pilgrim Health Care, Inc
What is Cultural Competence?
“…the demonstrated awareness and integration of three
population-specific issues:
 health-related beliefs and cultural values,
 disease incidence and prevalence, and
 treatment efficacy.”
Risa Lavisso-Mourey, MD, MBA & Elizabeth
Mackenzie, PhD
© Harvard Pilgrim Health Care, Inc
Diversity and Its Stumbling Blocks
•Literacy and Language
•Class-related values
•Culture related values
•Communication
•Stereotypes
•Racism
•Ethnocentricity
Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture )
© Harvard Pilgrim Health Care, Inc
Patient Cultural Factors
These factors are shown to facilitate immigrants
positive adjustment to medical care in the US:
 A relatively high level of formal education
 Greater generational removal from immigrant status
 Low degree of encapsulation within an ethnic and family
social network
 Experiences with medical services that incorporate patient
education
© Harvard Pilgrim Health Care, Inc
Facilitating Cultural Factors (Cont’d)
 Previous experience with particular diseases in the
immediate family
 Immigration to host culture at an early age.
 Urban, as opposed to rural origin.
 Limited migration back and forth to the home culture.
Harwood, A. (1981) Ethnicity and Medical Care. Cambridge, MA: Harvard Univ. Press.
© Harvard Pilgrim Health Care, Inc
Literacy
 40 to 44 million adult Americans are functionally
illiterate
 50 million have only marginal literacy skills
 72 million cannot read technical reports or news
magazines
Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture )
© Harvard Pilgrim Health Care, Inc
Literacy
One-half of the adult population of the U.S. has basic
literacy deficits:
• 21-23% read no more than 4th grade level
• Unable to read newspaper, follow written
instructions
• 25-28% of adult Americans read at about 8th
grade level
Greatest number of low-literate adults are native born
whites.
Charles, L.T. & Kennedy, D.B. (2000) Social and Cultural Influences on Health. (www.pitt.edu/~super1/lecture )
© Harvard Pilgrim Health Care, Inc
Written Medical Material
Literacy levels vary enormously across class, gender and
age.
Bilingual people often have widely different literacy levels in
the languages they speak
Literate readers may encounter difficulty translating
diagrams which inevitably make use of culturally “normal”
visual concepts
© Harvard Pilgrim Health Care, Inc
Literacy and Gender
Among the Sudanese over 15 years of age:
34.6% of all females are literate
57.7% of all males are literate
Among the Congolese, over 15 years of age:
67.2% of all females are literate
83.1% of all males
© Harvard Pilgrim Health Care, Inc
Written Medical Information
Speakers of the same language may vary in idiomatic
language use based on gender, age, nationality and class.
How the information is dispersed may signal authenticity in
a given culture.
© Harvard Pilgrim Health Care, Inc
Written Medical Material
Literate readers may encounter difficulty translating
diagrams which inevitably make use of culturally “normal”
abbreviations.
Readers may have cultural barriers to receiving certain
kinds of information in writing, or in possessing certain kinds
of written information.
© Harvard Pilgrim Health Care, Inc
Developing Written Materials in
Languages other than English
 Do not assume that highly educated bi-lingual staff,
including physicians, are as literate in their firsat
language as they are in English.
 Do research (focus groups) to determine which
dialects should be used.
 Use simple language, and where possible, easy to
communicate basic concepts.
 All literature must be “back translated”.
© Harvard Pilgrim Health Care, Inc
Back Translation
 Material is translated from English to target language and
target dialect.
 Independent translator who speaks target language and
target dialect translates document back to English.
 Independent translator re-translates document.
 Translation errors are corrected and errors in idiomatic
expression are corrected.
© Harvard Pilgrim Health Care, Inc
Translation of Clinical Condition:
Rheumatoid Arthritis
English:
Rheumatoid arthritis can be acute or chronic. Acute rheumatoid arthritis is
more common during adolescence. The cause is believed to be due to an
over-sensitive reaction of the joints to the Beta Hemolytic Streptococcus.
The most common sites of infection are the throat and tonsil.
English to Chinese to English:
Wet Wind Style Joint inflammation has fast and slow type. The fast type
sees more at small year time. The reason for its up believes to be the
joint’s over-sensitive reaction to the blood-dissolving chain-ball bacteria.
And the affecting path is most frequently the swallow tube and the flatpeach gland.
© Harvard Pilgrim Health Care, Inc
Linguistic Heterogeneity: Chinese
 Majority of elderly speak Toisenese; most of them also
understand Cantonese.
 Mandarin speakers are likely to be students or
professionals who probably also speak English (except for
the elderly). They tend not to speak Cantonese.
 Cantonese-speaking Chinese also speak Mandarin if they
are educated.
© Harvard Pilgrim Health Care, Inc
Written Medical Material
Materials providing medical instructions need to be carefully
written to avoid dangerous misunderstandings
For Example:
“three times a day”
“insert suppository”
“take with food”
© Harvard Pilgrim Health Care, Inc
Case Example
A fifty-nine year old bilingual Vietnamese immigrant
who had been a farmer in Vietnam and was poorly
educated prior to immigration, interpreted the
direction, “Take with meals,” to mean he should
carry the medication in his lunch pail. He did not
actually take the medication at the time he ate, as
he did not want anyone to know he was ill.
© Harvard Pilgrim Health Care, Inc
The lower the patient satisfaction
with the interaction, the greater the
likelihood of non-adherence
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Perceptions of Time
•How does the patient perceive or organize time?
 Patients who are not regularly employed outside the home are
usually less “clock-bound” in their perceptions of and
organization of time.
 Some patients organize time by tasks, rather than by clock
time.
 In many communities of color, time is organized in a more
fluid and phenomenological manner.
© Harvard Pilgrim Health Care, Inc
Perceptions of Time
• Medications requiring rigid dosing
by “clock time” must be carefully
discussed and reviewed.
• The provider should attempt to
determine how the patient
understands time.
© Harvard Pilgrim Health Care, Inc
Perceptions of Time
In some cases it may be necessary to tie
dosing to an activity or to an event rather
than to “clock time”:
e.g. “Take the medication about the
time your children would come home from
school.”
© Harvard Pilgrim Health Care, Inc
Employ Positive Non-Verbal Behaviors
Lean forward
Silence - LISTEN
Appropriate eye contact
Warm expression
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
The Popularity of
Alternative Medicine
 More than 4 out of 10 people in the United States visited
alternative medicine practitioners in 1997.
 Sharp increase in the number of Americans using it, from 61
million in 1990 to 83 million in 1997, even though many
alternative therapies aren’t covered by insurance.
 Patients’ spending on alternative therapies nearly doubled
from 9.4 billion dollars in 1990 to 17 billion dollars in 1997.
(1998)Trends in Alternative Medicine Use in the United States, 19901997, JAMA , 280: 1569-1575.
© Harvard Pilgrim Health Care, Inc
Demographic Profile of People Using
Alternative Medicine
In addition to patients from many ethnic groups:
•People who are ages 35 – 49
•Very well-educated
•Incomes of about $50,000 a year
•People who are sick:
In fact, 7 out of 10 cancer patients turn to an alternative therapy
as a means of maximizing their hopes of seeing a cure.
© Harvard Pilgrim Health Care, Inc
Use of Herbal treatments
Most patients tend to think of herbal treatments as “natural”
and “safe”…
However a small scale study examining the effects of St.
John’s Wort (n=5) reported:
That patients taking St. John’s Wort & Camptosar (a
chemotherapy agent) showed a 40% reduction in blood levels
of Camtosar
Suppressant effect may last for at least 3 weeks after
discontinuing St. John’s Wort
Source: Boston Globe, April 9, 2002
© Harvard Pilgrim Health Care, Inc
Lack of Trust
In many ethnic communities, there is a distinct lack
of trust of medical institutions:
 African Americans recall the infamous Tuskeegee study which
affected hundreds of African american families.
 Forced sterilization of ethnic minority women was a fairly
common event well into the 1960’s
 In many American medical institutions, ethnic minorities and
poor whites were used as experimental subjects without their
consent.
© Harvard Pilgrim Health Care, Inc
Lack of Trust
•Many ethnic minority patients find it easy to believe that a
provider is experimenting on them
•Many believe that medications used to treat whites are “too
strong for the system” of ethnic people.
•Patients who are being treated for diseases with no
apparent symptoms, find it hard to be compliant with
treatment regimens, especially in the context of abuses in
the medical care system.
© Harvard Pilgrim Health Care, Inc
Provide Information
•Be persuasive as opposed to commanding
•Describe use
•Inform about side effects:
Research shows: This does NOT increase
side effects
•Tell when and how medication will help
•Avoid being too complicated or detailed
•Use “plain” English, avoid technical terms
•Avoid anxious mannerisms (e.g. touching self, shuffling papers, looking
at watch). These may be interpreted as a lack of truthfulness or honesty.
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Determine the Patient’s View of the
Medication Regimen
 Ask the person: Do you think there will be any
problems with the medication?
 Have you taken a medication similar to this in the
past?
• Provide Information
• Provide Strategies
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Causes of Non-Adherence
Health Beliefs:
 Person’s perceptions of
• Seriousness of the illness
• Outcomes of non-treatment
• Perceived ineffectiveness of treatment
 Lack of social support
 Social discouragement
 Adverse effects
 Lengthy or complicated treatment regimens
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Causes of Non-Adherence
Poor Communication
•
•
•
•
Minimal medical supervision
Insufficient instruction
Poor Feedback
Interactions with health professional
 perceived as unfriendly
 perceived as unconcerned
 little interaction
 unilateral interaction
Source: Cohn, E. R. (2000) Communication to Promote Therapeutic Adherence. (www.pitt.edu)
© Harvard Pilgrim Health Care, Inc
Patient Satisfaction
 Patient satisfaction increases when clinician uses
psychosocially-oriented interview
 Psychosocially oriented interview was LEAST frequently used
 Perception among physician that takes more time
 BUT: Study found that psychosocial interview did not
significantly increase time of the clinical encounter
Roter,DL, Stewart, M., Putnam, SM, Lipkin, M, Stile, W. & Inui, T (1997) Communication patterns of
primary care physicians. Journal of the Amer. Med. Assoc., 277(4):350-56.
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical
Information
Many languages lack terms equivalent to our medical terminology:
 When interviewed in English, patients sometimes responded positively to
questions, even when they were confused by the terminology used in the
interview.
 When interviewed in their language of origin, lack of understanding was
more readily identified.
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in
Multiethnic Health Surveys, Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical
Information
Questions that created problems for respondents included
those in which:
 The concept or wording was unclear
 The translation was difficult
 The concept or wording was culturally inappropriate
 The request for sensitive information led to
untruthful responses
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical
Information
Questions which worked better were those which:
 used clearly defined concepts
 used clear and simple language
 asked for factual information
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical
Information
Survey questions which were identified as most problematic
were those which attempted to elicit:
 socio-demographic information
 preventive behaviors
 attitudes and beliefs
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical
Information
Consider the question “When did you have your
last check-up?”
Focus groups were conducted in Spanish, English,
Cantonese and Vietnamese.
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical
Information
“When did you have your last check-up?”
Focus group feedback revealed:
 Latinas felt that most Latina respondents would lie, because
they knew they were “supposed” to get check-ups, whether
they did or not.
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Linguistic Access: Eliciting Clinical
Information
Focus Group feedback: “Last Checkup?”
 Chinese women wondered why one would go to a doctor if
one was healthy. They felt that Chinese respondents might
associate regular check-ups with a presumption of illness,
may not answer truthfully, even if they did indeed have a
check-up.
 Vietnamese women had trouble understanding the concepts of
“routine” and “check-up” though most answered the question
in the affirmative when interviewed in English.
Pasick, RJ.,Stewart, SL, Bird, JA & D’Onofrio, CN (2001) Quality of Data in Multiethnic Health Surveys,
Public Health Reports, Supplement 1, Vol. 116:223-243
© Harvard Pilgrim Health Care, Inc
Communication: Soliciting the
Patient’s Concerns
Communication is at the heart of the clinician
patient encounter:
 Physicians actively solicited patient concerns in
75.4% of interviews
 Patients’ initial statement of concerns was completed
in only 28% of interviews.
 In 24.6% of visits, the physician did not ask the
patient about his/her concerns.
Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s agenda: have we
improved? JAMA, 281(3):283-287
© Harvard Pilgrim Health Care, Inc
Communication
The average visit length was 15 minutes.
The average patient who came with one or more
concerns used only 32 seconds to complete their
review of concerns.
No patient used more than 129 seconds.
Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s
agenda: have we improved? JAMA, 281(3):283-287
© Harvard Pilgrim Health Care, Inc
Communication
When patients were allowed to complete their initial
statement of concerns, there were fewer
spontaneous statements of concerns which
occurred after the history taking portion of the
interview (14.9% vs. 34.9%)
Marvel, MK, Epstein, RM, Flowers, K & Beckman, HB (1999) Soliciting the patient’s
agenda: have we improved? JAMA, 281(3):283-287
© Harvard Pilgrim Health Care, Inc
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