Internal Discussion: Health and Persuasion
December 2022
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 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 toward 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 to 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" take 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 of 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 of 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 is patient is not moved to a different set of values unless it is something that 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 to 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 that 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 clincian 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 discomfort | Sometimes both the clinician and the patient and supporters are uncomfortable and want to avoid deciding Name the emotion | Make sure it's clear that patient and clincian 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 |