CHC Think Tank Deep Dive Summary Internal Discussion: Health and Persuasion

In October we chose to take a Deep Dive on one of the recurring themes for the Center for Health Communication Think Tank: Persuasion in medicine or "Health and Persuasion." We met on October 28, 2022, at 1 p.m.

The conundrum:

How does it feel to know that your healthcare team might be trying to persuade you? How can clinicians use persuasive techniques without being perceived as being coercive? Can we clearly define the rules of the road regarding persuasive communication so that clinicians might feel more comfortable employing these techniques?

Background:

We try to frame persuasion as walking with or guiding the patient in an effort to make this type of health communication more palatable and understandable to clinicians. Yet, we find that there is reticence and concern in many of those we coach.

Dr. David Ring speaks from his experience regarding persuasive communication,

"When I first became aware of this communication taxonomy, I noted the negative connotation it held for me. I think sometimes there is a best option and choosing it will be best for an individual and in that context persuasion makes sense.  A common example is when someone is misunderstanding a symptom.  For instance, painful activity is often misinterpreted as harmful activity, meaning activity that will make the problem worse.  Guiding, or persuading, someone to have a healthier, and in this case more accurate, mindset about that is important, difficult, and treacherous.   

“Other conversations are about choices between reasonable options.  In those situations, it's important that a person be mindful of what matters most to them.  Many people have not reflected on this.  An example in my world is that most people have a core value and preference to avoid surgery if at all possible.  No one wants to be sliced open.  So when a person is leaning towards surgery when non-surgical options are comparable, that person’s choice can be discordant with their own values, and this creates an ethical dilemma for the surgeon.” 

The negative connotation of persuasive communication can set up exchanges where a patient or loved one is left more or less alone to make decisions out of a desire to not unethically influence their choice. The opportunity to connect and guide is there but the clinician holds back because of the negative connotation as well as the very risk of damaging the care relationship in ways that will make shared decision-making untenable.

Dr. Ring shares more of his reflection on persuasive communication with us,  

“There is an aspect of this, where the goal is not to convince, direct, and control.  Rather the desire is to enhance a person's agency.  I feel people seek care when a symptom becomes a concern.  Along with that, there is a loss of agency.  In my usual daily life, I'm in charge of my health.  I can manage it. But at this moment, with the symptom, I have lost control.  And I need someone else to help with this.   

“In the best situation, we get the information from the clinician and return to our agency.  Other times people remain passive and think somewhat magically—'just fix it...I don't need to understand what you do and why.’”  

“In this context ‘persuasion’ takes the form of restoring a person's active role in their health (agency) and helping them understand their body (matter of fact rather than magical thinking).” 

Communication scholar Dr. Laura Brown added the following thoughts:

Persuasion and exerting influence are inherent in decision-making when more than one person is involved. So, maybe another way to defang “persuasion” is to conceptualize it as something that is already always happening from the patient to the clinician. Persuasion happens in both directions. Patients try to and do persuade clinicians in all kinds of ways, which is not “bad” or “good”—simply fact.

 

Why is Persuasion Important in Medicine?

Takeaways	Recommendations	Implementation/Examples
To account for the fact that the human mind is part irrational (fast thinking or autopilot mind) and part rational (slow or critical thinking)	Promote behavioral health in parallel with behavioral economics and behavioral ethics - slow down and rethink	Be prepared for narratives and preferences that are considered (rational) and those that are automatic (irrational)
To reduce the potential for clinician moral injury	Clinician sees a healthier narrative regarding the symptoms	Awareness of the ethical imperative to help people decide based on a combination of what matters most to them and the facts or best evidence
Clinicians want to avoid actions contrary to the patient's interests	Acquiescence contributes to potential iatrogenic, psychological, and financial harm from unhelpful tests and treatments	Awareness of the uneasiness that comes with a gap between medical expertise and the individual's narrative and worldview

 

Getting Comfortable with Persuasion in Medicine

Takeaways	Recommendations	Implementation/Examples
Natural aversion to persuasion	Sense that it is used to diminish autonomy	Awareness of ethical persuasion
Be aware of normal use of persuasion	Awareness of persuasion in everyday communication helps insulate against potential harms	Ex: "I want you to promise me that if you have any questions, you will call me."
Focus on motive/intent: To deceive? To secure compliance? vs. To have a shared decision-making model that is as free from the impact of power dynamics as possible?	Foundation of relationship: truthful, authentic, and respectful	Use the TARES model for ethical persuasion: Truthfulness (of the message) Authenticity (of the persuader) Respect (for the persuadee) Equity (of the persuasive appeal) Social Responsibility (for the common good)

 

Potential Pitfalls

Takeaways	Recommendations	Implementation/Examples
Establish psychological safety and agency	Can you be persuasive with a patient who is not truly free to disagree?	Protect the autonomy of the patient Ensure that the patient is not moved to a different set of values unless it is something they want
Be aware of the power dynamic	What happens to the patient if they disagree? Will the physician label them as difficult or non-compliant? Will they receive less care? What are the consequences of the relationship?	Consider: "What happens when we disagree?"
Don't guess what matters to a patient	Be aware of such substituted judgment We may guess wrong	Help people connect with what matters most to them

 

Practical Steps for Ethical Persuasion

Takeaways	Recommendations	Implementation/Examples
No "yes" until "why"	There is no push for a "yes" until a sufficient and transparent "why" has been offered	Help the patient better understand why the clinician might be pushing for one option more than another
Decrease the power differential	Share the agenda	Repeatedly share the agenda during the encounter
Name the discomforts	Sometimes both the clinician and the patient and supporters are uncomfortable and what to avoid deciding Name the emotion	Make sure it's clear that patient and clinician are together no matter what is decided
Motivational interviewing techniques can spark curiosity	There may be healthier ways to consider the problem	Use "I wish..., I worry..., and I wonder..." to offer alternative frames