A LEARN model approach in health care for improvising the doctor-patient relationship

INTRODUCTION

India is a multicultural and multilingual society. According to the Census of India of 2001, India has 122 major languages and 1599 other languages. According to the most recent census of 2011, after thorough linguistic scrutiny, edit and rationalization on 19,569 raw linguistic affiliation, the census recognizes 1369 rationalized mother tongues and 1474 names which were treated as ‘unclassified’ and relegated to ‘other’ mother tongue category.¹ Among, the 1369 rationalized mother tongues which are spoken by 10,000 or more speakers, are further grouped into appropriate set that resulted into total 121 languages. In these 121 languages, 22 are already part of the Eighth Schedule to the Constitution of India and other 99 are termed as ‘Total of other languages’ which is one short as of the other languages recognized in 2001 census.²

COVID-19 pandemic has re-ignited the discussions regarding the need of the effective communication across cultures in health care professionals. Patients’ perception towards quality of care they received is very much dependent on the quality of interactions with their caregivers or the treating doctors. The age-old proverb ‘Every two miles the water changes, every four miles the speech’ is really apt for the Indian scenario. For better academic and social adjustment, the language and cultural skills are very important for Practitioner. Be familiar with the local dialect helps in bonding between doctor and patient relationship.

Doctors who use their knowledge and skills to provide effective healthcare for patients of diverse cultural backgrounds are said to be culturally competent. Competence requires a blend of knowledge, conviction, and a capacity for action. Clinical cultural competence includes being aware of a patient's and one's own socio-cultural background and using skills and strategies that focus on culturally appropriate healthcare interventions. It also includes an understanding of the power differential between patients and physicians and how to enable more active partners in patients’ participation in the healthcare system whenever appropriate.³

Cross-cultural communication in an organization deals with understanding different business customs, beliefs and communication strategies. Language differences, high-context vs. low-context cultures, nonverbal differences, and power distance are major factors that can affect cross-cultural communication.⁴

In other words, cross-cultural communication refers to the ways in which people from different cultural backgrounds adjust to improve communication with one another. Cross-cultural communication is the process of recognizing both differences and similarities among cultural groups in order to effectively engage within a given context. In today’s rapidly changing professional world, it’s critical to gain an understanding of how cultural elements influence communication between individuals and groups in the workplace. Developing strong cross-cultural communication skills is the first step in creating a successful work environment that brings out the best in all of an organization’s team members.⁵ When it comes to medical education and profession learning is a never-ending process. Professionals they need to be constantly upgrade themselves, especially the doctors. The LEARN model was originally developed to help physicians and other clinicians working in ethnically diverse communities. However, it has broad applicability in the prevention setting.

Prevention professionals who are aware of their own and their audience’s cultural backgrounds, along with the values that are often implicit in their communities, are better able to achieve mutual understanding and to agree upon culturally appropriate prevention interventions and community participation and engagement for better health. The aim of the study was to improvise doctor-patient communication and the doctor-patient relationship using LEARN model.

The LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) model is a framework for cross-cultural communication that helps build mutual understanding and enhance community engagement.⁶

LISTEN

Assess each person’s understanding of the prevention issue, its causes and potential solutions, and how it impacts them personally. Elicit expectations for the encounter and bring an attitude of curiosity and humility to promote trust and understanding. History taking is an art in medical field that helps in understanding of the disease and its prevention issues, various causes and potential solutions for that and how it impacts the individual at personal level. Probing of relevant and ethical questions to the patient in between. Social behavior was very much influenced and affected by unconscious associations and judgments. An implicit bias is an unconscious association, belief, or attitude toward any social group. Due to implicit biases, people may often attribute certain qualities or characteristics to all members of a particular group, a phenomenon known as stereotyping.⁷

Doctor should focus on seeing people as individuals. Rather than focusing on stereotypes to define people, spend time considering them on a more personal. It is impossible for doctors, nurses, medical technicians, social workers and administrators or anyone else in health care to achieve excellence without cultivating the virtue of humility. Humility helps everyone who attends to patients see them not as biological puzzles needing to be solved, but as unique persons in need of healing, care, understanding and compassion. Humility might best be described as clarity of vision about ourselves, our place in the world and about how we stand in relation to others. It is a clarity of vision that enables the ongoing cooperation without which good health care is seriously impaired.⁸ Sensitive issues of RTI/STI, HIV, family planning and female menstrual related problems always kept at priority and find solutions for them after proper listening the issues related to the particular conditions, so that trust and understanding maintained between doctor and patient. Make a fishbone diagram, also known as cause-and-effect diagram or Ishikawa diagram which helps you to identify the root cause of an issue or effect, in turn which helps where you have to work up with your client or patient.

EXPLAIN

Convey your own perceptions of the prevention issue, keeping in mind that people in the community may understand health or illness differently, based on culture or ethnic background. People have taken pleasure in using traditional beliefs and practices for a long time and got used to it. Thus, it can be made easily acceptable something that has been given by the faith healer to the community. Some practices are effective whereas others may be harmful or ineffective. These beliefs and practices are linked to culture, environment and education. Health workers must have concern for the community's cultural values and beliefs so that they can utilize the harmless practices for effective use as well as eliminate harmful practices.⁹ Cultural background influences entry into the health care system and personal health practices. The ideas of the individuals may be valid and certainly influence their health care behavior. Health professionals must recognize the existence of relativism in regard to modern scientific medicine. Sociologists have demonstrated that the spread of diseases is heavily influenced by the socioeconomic status of individuals, ethnic traditions or beliefs, and other cultural factors. Sociologists agree that alcohol consumption, smoking, diet, and exercise are important issues, but they also see the importance of analyzing the cultural factors that affect these patterns.¹⁰

ACKNOWLEDGE

Be respectful when discussing the differences between their views and your own. Point out areas of agreement as well as difference and try to determine whether disparate belief systems may affect the proposed prevention solutions. Respect is a central concept in medical care but is not well defined. Lack of respect for patients dehumanizes them and may contribute to abuse and ill treatment. Transcultural care should be based on an understanding of the concept of respect which is shared by all concerned. There are three ways in which someone show respect. These are- (a) non-verbal signals such as facial expression and gestures; (b) courtesy, honesty and the use of a communication style that conveys interest and avoids expressions likely to cause offence; (c) acting in a way that shows recognition of the patient’s rights to information and decision making as well as maintaining privacy for procedures and bodily functions.¹¹ In general healthcare settings, the patient’s perception of whether their doctor displays respect towards them has been found to be the best predictor of patient’s overall rating of their view of their doctor.¹² Individual, community and cultural attitudes and beliefs play a crucial role how people decide to accept information, where value may be placed on the source and the sender of the information rather than the content of the information itself.

RECOMMEND

Develop and propose a prevention plan that bridges any gaps in perspective. Recognize and recommend your patient which level of Prevention he/she should require or needed: primordial, primary, secondary, tertiary and quaternary. Patients and doctors often have difficulty staying abreast of diet trends, many of them focus primarily on weight loss rather than nutrition and health. Recommending an eating style can help patients make positive change in their lifestyle and health. From the past there is a major difference in theory and practice and the concept of a theory-practice gap is not new. However, despite many attempts by clinicians and nurse faculty to address the theory practice gap still it remains a key issue.¹³ For example: the tobacco control movement targeted individuals and their behaviors, it evolved into a multilevel systems approach to the problem. Clearly, individual behavior change was the goal, but strategies involving industry, legislation, public health programming and messaging, and the health care system worked together to create that change. None of the strategies implemented as part of the movement worked alone. Finally, you have to develop a plan for behavioral change of your target group or patients so that the gaps are filled.

NEGOTIATE

Reach an agreement on the prevention plan in partnership with the community incorporating culturally relevant approaches that fit with the perceptions of health and healing.

The Centers for Disease Control and Prevention’s (CDC) Principles of Community Engagement defines community engagement as the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people. For example: Suppose, if you want to change the lifestyle of your patient by exercise or brisk walk and patient also agreed to follow but because of time and work constraints he/she is not able to do this in morning time so here you seek advise him/her to do it in evening. Make a suitable agree-mental approach without disheartening or disrespecting the cultural backgrounds of your patients.

LEARN model cane be useful for better implementing nutritional standards for a population is a community-based prevention intervention. Changes in social and physical features of the environment constitute valued outcomes for community-based prevention because the distributions of risk factors, health outcomes, and wellness indicators in a population are largely shaped by social and physical environments.

A model for community-based prevention developed in the 1950s and 1960s grew out of efforts to increase both immunization coverage for mass poliomyelitis protection and mass screening for cancer and tuberculosis.¹⁴ One another model that is Health belief model, which was primarily a psychological model developed from community screening and immunization programs, but it became a part of community intervention models.¹⁵

Medical profession has been considered one of the noblest professions. Doctors were honored and perceived as having divine virtues.¹⁶ Their recommendations were accepted as if they were “the word of God”.¹⁷ Physicians seldom explained their medical decisions and certainly did not share decision-making with the patient. Many patients did not expect an equitable relationship and accepted their doctors’ recommendations without question. In 1984 Journal of the American Medical Association article, found that 47% of patients prefer their doctor to make decisions regarding medical issues.¹⁸ Effective communication plays a key role in developing the physician- patient relationship and developing trust.^19,20 Patients who perceive their physician as caring and sensitive to their needs express greater satisfaction with their health care.^21,22 Further, physicians’ attention to patients’ emotional needs has a positive effect on recovery and responsiveness to treatment.^23,24 In the past few decades, the development of patient-centered care is on rise as compare to previous. While the medical profession is one of the most technologically advanced professions, one of the dangers inherent in innovation and technological advancement is that these will come at the expense of physicians’ emotional connection with their patients.²⁵ Undoubtedly, interpersonal communication, whether verbal or non-verbal, has had a great impact on almost every aspect of life. However, people never stop thinking about whether they are communicating in the most effective way or not. Indeed, Communication skills (CSs) require both content (what is communicated) and style (how it is communicated).²⁶

DPC (DOCTOR-PATIENT COMMUNICATION)

It has been a keystone of MC (Medical care). It is the medium through which data is collected, diagnoses are made, plans are arranged, support is given, compliance is achieved, and healing is provided.²⁷ ‘Most complaints about doctors are related to issues of communication, not clinical competency.’ Patients want doctors who can skillfully diagnose and treat their illnesses as well as communicate with them effectively.²⁸ ‘Good communication skills among the doctors are crucial in building a trustworthy doctor-patient relationship that not only helps in therapeutic success by providing holistic care to the patient but also leads to job satisfaction among the doctors’.²⁹ There are several barriers or hurdles to effective communication between patient and doctor. The most important one is a lack of insight due to inadequate training and knowledge in CSs.

Many times, doctors tend to use close-ended questions, interruptions and do not give sufficient time. Other important barriers are related to a lack of privacy, empathy and respect, in addition to ignoring the non-verbal components of communication, such as eye contact. In a heavy burden setting, human failings like tiredness and stress are major contributing factors.³⁰ Language barriers may contribute to medical errors by impeding patient-provider communication. One particularly vulnerable group is immigrants.

Many a times Northern Indian doctors they choose or pick up under-graduation and post-graduation medical colleges for medical sciences studies in Southern regions of India and vice versa after that they may face the major problem while work up or making diagnosis because of the language communication barriers between the doctor-patient from different culture and backgrounds. So, in such scenarios the LEARN model may help the future doctors.

Physicians who are aware of their own and their patients’ cultural backgrounds, along with the values that are often implicit in current medical models, are better able to achieve mutual understanding within the patient encounter and to focus on culturally appropriate health care interventions.^31-33 Providing care in a language that a family does not speak well is a known risk factor for negative effects on health outcomes.³⁴ Research on doctor-patient communication has generated considerable evidence that effective communication can improve outcome measures such as patient satisfaction, adherence to treatment, and disease outcomes^35,36

Effective communication is difficult even in the best of times. However, the COVID-19 pandemic has certainly made it more challenging in many ways. There are three basic channels of communication, verbal, non-verbal and paraverbal. Research suggests that of these three, most in-person communication happens through the non-verbal channel (i.e.; ‘body language’). Wearing a mask, however, eliminates our ability to read most of a person’s facial expressions. This, of course, hampers effective communication.³⁷

Culture is central to effective COVID-19 messaging for community engagement. Culture may appear neutral, but its power to define identity and communities as a collective is based on values expressed through institutions such as health care, education, and families.³⁸ Culture shapes language, which in turn shapes communication both in message delivery and reception.³⁹ Rapport building via the use of empathy and effective communication skills is critical to forming effective and trusting relationships with patients. Empathy has demonstrated importance in the positive building of relationships.⁴⁰ Empathy can also increase the patient satisfaction, trust, coping skills, and compliance with therapy, while also enriching the doctor-patient experience.

To control the spread of virus during pandemic several measures were suggested by the health officials. This led to the significant change in cultural, social and the day-today ways of living behaviors of the people. COVID-19 has shaken up the socio-cultural framework of the various countries. Cross-cultural exchange refers to the communication between native speakers and non-native speakers, as well as any people with different language and cultural backgrounds.⁴¹ Cross-cultural exchange can develop empathy and eliminate cultural centralism. One of the main reasons of communication failure, in cross-cultural exchange is that if there is no empathy, people from different cultures cannot correctly understand the values of others. Communication is a cyclical process of interaction, which includes the sender, the receiver and the message itself. Because of cultural differences, people from different cultural backgrounds bring their different values, beliefs and customs into the communication process.

They interpret information from another culture according to their own cultural background, which leads to inaccurate understanding of each other's information, and thus may lead to bad judgments and decisions. Before the 20^th century, the communication between people of different cultures was limited by time and space constraints and the existent means of information transmission or technology. But in the 21^st century, with the science and technology, both modern transportation and communications technologies has developed rapidly over at faster pace. So, the importance of cross-cultural exchange or communication has come being in to light in the era of globalization and modernization.

CONCLUSION

Communication skills have been described as the most important tool for a health professional. Community-engaged communication is much important for acknowledging in the community with culturally relevant and authentic solutions. Doctors try to find out the influential cultural differences in themselves and their patients. Be careful about the biases and values that you may be bringing to medical encounters. Build awareness of differences in communication style (e.g., verbal and nonverbal) that may influence the care of the patient. Adapt the role of silences in each patient encounter. They may represent discomfort with a topic or uncertainty about a question being asked, paying special attention to nonverbal cues that can help to determine whether a differential power relationship is hindering communication. Try to apply a tailored treatment plan approach that involves the patient’s immediate family, extended family or other community members, as appropriate. Recognize that a ‘high-context’ communication style may be a family’s cultural norms and stay attuned to tone, body language and other nonverbal cues. Find out the various diversities exists within ethnic and cultural groups as much as between groups, and avoid generalizing or stereotyping cross-cultural encounters. Assess the literacy levels of patients or families and adjust the use of written materials accordingly. Use simple language, so that patient easily understanding what he/she is suffering from, avoid using medical terminologies when conveying your message to the patient. So, the LEARN model is a framework or approach for cross-cultural communication that helps in building the mutual understanding and enhancing the community engagement, which may be helpful or useful for improvisation of doctor-patient relationship.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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