Delivering Bad News in Healthcare

Person Centered Care Overview

• Definition: A way of thinking and doing things that sees people using health care services as equal partners in planning, developing, and monitoring care to meet their needs.
• Key elements:
  • Person First, patient second
  • Provider as a person
  • Persons/families at the center of treatment decisions
  • Persons as experts
  • Providers guide patients through good information
  • Providers deliver services patients cannot perform
• Quadruple aim of person-centered care:
  • Improve patient experience
  • Improve provider experience
  • Optimize costs/value
  • Improve public health
• Three elements of providers' considerations for patients:
  • Understanding
  • Decision making
  • Intervening

Approaches to Care

• Student-centered care:
  • Focuses on student provider gaining experiences
  • Patients' ability to pay
  • Patient is meant to perform specific procedures
• Patient-centered care:
  • Focuses on patient during individual visits
  • Management of disease
  • Body systems are separate from each other and separate from psychological domain
• Person-centered care:
  • Focuses on person in context of personal, social, religious, and ethnic factors in a holistic fashion
  • Future: Offering flexible telehealth, homecare, microbiome analysis, and integrated health information

Life-Course Approach

• Considers factors that act during development and aging that might influence disease onset
• Framework: Risk accumulation and sensitive periods of exposure with underlying socio-environmental determinants
• Pregnancy and postpartum oral health:
  • Perio disease associated with preeclampsia, increased risk of preterm birth, and low infant birth rate
  • Dental care is safe during pregnancy
• Childhood oral health:
  • Fighting against "Primary teeth will fall out anyway" mentality
  • Early childhood caries are the most common childhood chronic disease
  • Linked to poor nutrition, weight loss, iron deficiency, and negative impact on child's behavior, school performance, and overall development
• Adolescence oral health:
  • Becoming more independent from parents
  • Vaping becomes common, increasing risk of periodontal disease and oral lesions
  • Potential injuries from athletics
  • Piercings
  • Lots of sugar
• Young adulthood oral health:
  • Introduction of tobacco and alcohol
  • Increases risks of oral cancer, pulmonary and cardiovascular disease, and depression
• Oral health during middle age:
  • Perio disease is a significant concern
  • Bidirectional relationship between periodontal disease and diabetes
• Oral health during adulthood:
  • Perio disease association with dementia
  • Risk of hospital-acquired pneumonia is higher with missing teeth and heavy plaque

Adverse Childhood Experiences (ACEs)

• Just under half of US children have experienced at least one ACE
• ACE exposure is linked to dental caries, bleeding gums, tooth loss, periodontal disease, and dental pain

Big Data and Person-Centered Care

• Definition: Data that is so large, fast, or complex that it is difficult or impossible to process using traditional methods
• Three V's of Big Data:
  • Volume
  • Velocity
  • Variety
• Big data challenges:
  • Minority communities hesitate to participate in big data research (privacy concerns, longstanding abuse)
  • Present-day concerns (hacking/security breaches)
• Recommendations for Big Data:
  • Incorporate standardized collection for classifications (race/ethnicity, etc.) for all systems collecting big data
  • Enhance surveillance for geographic variables and social determinants of health
  • Advance simulation modeling
  • Build trust to avoid "big brother" perception
  • Invest in data collection in small populations
  • Encourage data sharing
  • Promote data science in training programs for underrepresented societies
  • Assure active efforts are made upfront during both the planning and implementing stages of new big data resources to address disparities reduction

Veterans

• AIDPH mission statement: Empowering community to advance oral health through science, education, and advocacy
• AIDPH vision statement: A justice-oriented oral health system
• AIDPH communities of focus:
  • LGBTQIA+
  • Veterans
  • Disabilities
  • Rural
• Funding for Veteran dental benefits: Congress through Title 38 of Federal code
• Eligibility for VA dental clinics: Only for veterans who are eligible for dental care through the VA
• Recommendations for improving dental care for veterans:
  • Expand eligibility criteria for veterans
  • Advance integrated care for veterans
  • Expand FQHCs and rural access clinics
  • Prioritize trauma-informed care
  • Improve data collection for oral health indicators

Health Literacy

• Definition: An individual's ability to obtain, understand, and use health information to make appropriate health decisions
• Percentage of adults that struggle with health literacy: 90%
• Complications to accessing health care:
  • Applying for and understanding insurance
  • Finding providers
  • Understanding automated telephone menu systems
  • Navigating referrals
  • Following chronic disease management programs
• Impact of low health literacy:
  • Poorer health outcomes
  • Increased hospitalizations
  • Greater use of emergency care
  • Difficulty understanding medication instructions and warning labels
  • Higher health care costs
• Red flags for low health literacy:
  • Frequently missing appointments
  • Forgetting glasses at home
  • Getting angry or impatient
  • Problems with medications
  • Difficulties filing out admission/intake forms
  • Taking written materials home for someone else to review
  • Not asking questions
• Strategies for addressing health literacy:
  • Create a shame-free environment
  • Use plain language and clearly written materials
  • Use the teach-back method

SPIKES

• What is bad news in dentistry: Any information that adversely and seriously affects a person's view of their future
• Why is delivering bad news difficult:
  • Lack of training/experience
  • Anxiety
  • Burden of responsibility/inadequacy
  • Fear of negative responses and strong emotional reactions
  • Uncertainty about a patient's and family's expectations
  • Fear of destroying a patient's sense of hope
• Patient's regular desire to know about disease:
  • 90% want to know about their illness
  • 30% want to know the exact name of their illness
  • 100% want to know about the chance of a cure
• Barriers to delivering bad news in the clinic:
  • Noise
  • Inadequate time
  • Distance between provider and patient
  • Inadequate/overload of information
• General techniques for improving the delivery of bad news:
  • Use a caring voice
  • Make eye contact
  • Explain again, when necessary, use teach-back
  • Use open-ended questions
  • Be patient
• The Six Steps of SPIKES:
  • Set-up
  • Perceptions
  • Invitation
  • Knowledge
  • Emotions
  • Strategy and summary

Culturally Congruent Communication

• Culture: Groups' values, way of living, norms, customs, and beliefs
• Cultural Identity: Each individual's values, traditions, beliefs, and expectations through a synthesis of their different groups, families, religious organizations, jobs, etc.
• Cultural Safety: An approach that considers how social and historical contexts, as well as structural and interpersonal power imbalances, shape health care experiences
• Cultural Awareness: An attitude that includes awareness about differences between cultures
• Cultural Sensitivity: An attitude that recognizes the differences between cultures and that these differences are important to acknowledge in health care
• Cultural Competency: An approach that focuses on practitioners' attaining skills, knowledge, and attitudes to work in more effective and respectful ways with indigenous patients and people of different cultures
• Cultural Humility: An approach to health care based on humble acknowledgment of oneself as a learner when it comes to understanding a person's experience
• Strategies for achieving culturally congruent communication:
  • Critical self-awareness
  • Personal commitment to understanding differences
  • Exposure and learning
  • Investment of time to negotiate meaning and ensure understanding
  • Anticipation of difficulties
  • Using an interpreter

Trauma Informed Care

• Oral health as a cause of mental disorders:
  • Neuroinflammation
  • Poor nutrition
  • Chronic physiological stresses
  • Stigma
• Mental health manifestations leading to dental issues:
  • Anxiety
  • Bipolar and OCD
  • Depression
  • Eating disorders
  • Trauma
• COVID/Mental Health/Oral Health survey results:
  • 18% respondents rank mental health as poor
  • Individuals with higher MH rating more likely to go to the dentist
  • Those with poorer mental health status have higher rates of unmet oral health needs
  • 47% of those with poor mental health said they were nervous for dental appointment
• Trauma-informed care definition:
  • Delivery of services grounded in an understanding and responsiveness to the impact of trauma, emphasizing physical, psychological, and emotional safety for everyone
• Signs of individuals with past traumatic life events or adverse childhood experiences:
  • Unfavorable general and oral health habits
  • Display dental fear
  • Avoid routine and preventative oral healthcare resulting in poorer oral health outcomes
• Clinical symptoms of history of trauma:
  • Endocrine changes
  • Neglect of oral hygiene
  • Gingival circulation
  • Alteration in salivary flow

Managing Fear in Dental Care

• Education is a key component in managing fear
• Chairside Behavior management involves:
  • Stimuli control
  • Social praise
  • Modeling
  • Behavioral control
  • Tell-show-do
• Relaxation training techniques include:
  • Diaphragmatic breathing
  • Biofeedback
• Other techniques used in managing fear include:
  • Psychoeducation
  • Motivational Interviewing
  • Hypnosis
  • Conative restructuring
  • Exposure therapies (Graded exposure/Systematic desensitization)
  • Pharmacological intervention

Mental Health Professionals

• Psychiatrist: Diagnoses and treats mental illnesses, including pharmacological interventions
• Psychologist: Diagnoses, assesses, and treats mental health issues, but does not provide pharmacological interventions
• Licensed Clinical Social Worker: An MSW who works with patients in various ways
• Mental Health Counselor: A Master's level clinician who works with patients to treat mental health issues under supervision

LGBTQ+ Lecture

Gender Definitions

• Good definition: Emotional, psychological, and social traits that describe an individual as androgynous, masculine, or feminine
• Bad definition: Strictly binary definition based on binary sex

Sex Definitions

• Good definition: Assigned based on infant's chromosomes and genitalia
• Bad definition: Based solely on genitalia at birth, disregarding intersex variations

Sexual Orientation Definitions

• Good definition: Emotional, romantic, or sexual attraction to others, categorized as heterosexual, homosexual, bisexual, pansexual, asexual, or other identities
• Bad definition: One's sexual attraction to either a woman or a man, categorized as heterosexual or homosexual

Nature of Gender and Sexual Orientation

• Spectrum: Validating those who don't fit traditional norms

LGBTQ+ Health Data

• Transgender people experience 2.5 times the violence as cisgender individuals
• Bisexual people experience 7 times the victimization rate as heterosexual individuals and 3 times the rate of lesbian and gay individuals

Challenges Faced by Transgender Patients on Gender-Affirming Therapy

Physical Challenges

• Masculine hormone therapy: Erythrocytosis, weight gain, acne, alopecia, sleep apnea
• Feminizing therapy: CV disease, hepatic toxicity, weight gain, gallstones, dyslipidemia

Sociopsychological Challenges

• Feminine therapy: Mood swings and emotional imbalance
• Masculinizing therapy: Heightened and dampened emotions

Strategies for Inclusivity in Healthcare Settings

• Training and education
• Community engagement and partnerships
• Inclusive language and communication
• No assumptions
• Ask questions
• Admit limitations