January 2020

Shared decision-making sometimes has snags. You are, after all, the expert on the science. But your patients may believe misinformation they have been told, or may have misinterpreted in something they have read. When you find yourself feeling the need to correct your patient, or saying “that’s wrong/incorrect,” “no,” or “but,” consider instead the following strategy developed by Patty Cason and Abigail Aiken:[1]

1. Find a kernel of truth in what they are saying (if there is one).
2.  Acknowledge whatever correct information they have communicated.
3. Then build on it by adding the information you would like them to know.

Rather than creating a polarizing situation with a “no” or a correction, it is preferable to build rapport and self-efficacy by finding something in what they are saying to agree with and then adding clarifying information.

Example: How to discuss amenorrhea from using contraceptives containing hormones:

Provider: Most people are very happy with their bleeding pattern when they use this method and many of them don’t get their period. How would it be for you if you didn’t get your period while you are using this method?

Patient: My mom said it’s not healthy not to get my period. (Note: at this point you may feel like correcting your patient.)

Provider: Your mother is completely right. When you are not on contraceptive hormones it is important to get your period . It’s so great that you know that if you miss your period when you are not on contraceptive hormones it could mean something’s wrong!  I wish all of my patients knew that if they are not on contraceptive hormones and they miss periods they need to come in to the clinic so we can see what’s up.

Patient: Well, what about if I am using hormones? (Note: People are more likely to be receptive to information if they have asked the question that the information answers.)

Provider: So . . . interestingly, when someone is using contraceptive hormones it keeps the uterus very healthy and keeps the lining very thin. (Show a diagram of a uterus.) Knowing that, how would it be for you to not get periods?

The provider could add the following message:

Provider: Contraceptive hormones actually prevent cancer of the uterus. Knowing that, how would it be for you not to get your period while using this method? Patients go online to find out about things they are interested in so your patient may have learned misinformation about contraception. Rather than correcting the misinformation, you can acknowledge that going on-line to seek information was proactive (i.e., point out the positive) and then share a good website like www.bedsider.org.

“But my friend…”

One of the most perplexing situations is when patients say that something bad happened to a friend or relative (or even to themselves) that you know is not possible scientifically. A strategy that has been shown to resonate with patients is to emphasize that “everyone is different.” This can readjust their frame of thinking to allow for the possibility that the (unscientific) “bad outcome” could be a chance occurrence.

A wonderful sentence to use in this situation might be as follows:

“That’s too bad your friend had that experience. I haven’t heard of that before, and I can tell you it definitely doesn’t happen frequently.”

Empathy

Central to patient-centered communication is the ability to exhibit empathy—verbally and non-verbally—by reflecting and validating a patient’s feelings. Empathy means communicating that one cares about another person’s feelings. You can demonstrate empathy by acknowledging feelings and communicating that someone’s reaction to a situation is normal and common to others in similar situations. Avoid some of the common communications that actually create barriers to effectively expressing empathy:

• Underplaying (or overstating) the intensity of the emotion
• Saying “I know how you feel” I
• Incorrectly “labeling” someone’s feelings

Because each of us has different descriptions for each emotion, it is best not to “label” someone else’s feelings. This is particularly true with negative emotions like anger or anxiety. For example, labeling an emotion by saying “I can see that you are angry” at a time when the patient would have used the word “annoyed” to describe the feeling has the potential to damage rapport. It is possible to be truly empathetic in a more general way.  Here are some phrases to demonstrate empathy without labeling:

• “I can see that was really concerning you.”
• “It seems like that was hard to deal with!”
• “I think anyone would find that situation very difficult to manage.”
• “I can’t even imagine how that must have been for you.

Accomplishing reproductive goals counseling within a patient-centered framework can at times be challenging and take time. So take a deep breath and be the careful and caring clinician you are, knowing that shared decision-making safeguards reproductive rights and helps individuals make the best reproductive choices for themselves.

[1] Cason P, Aiken ARA. Pregnancy through patient-centred reproductive goals and contraceptive counseling. In: Hatcher RA, Nelson AL, Trussell J, Cwiak C, Cason P, Policar MS, Edelman A, Aiken ARA, Marrazzo J, Kowal D, eds. Contraceptive technology. 21st ed. New York, NY: Ayer Company Publishers, Inc., 2018. http://contraceptivetechnology21st.com