|Barrier||Example from transcript||Patient-centered communication strategy||Other facilitators||Outcome|
|Lack of knowledge about CRC||
Example 1: 66-year-old, Spanish-speaking Hispanic male
PCP: I also would like to talk to you about the colonoscopy. Have you had it done in the past? Would you remember what it is about?
PCP then explains colonoscopy.
PCP: You can think about it, if you would like to have it done, this test, but it is possible.
PCP returns to CRC discussion after giving shots.
PCP: Okay, what do you think of the possibility of having done the colonoscopy test?
P: It would be good, right?
PCP tries to schedule GI appointment at best time for patient.
|Shared power/common ground||GI appointment scheduled|
|Anecdotes of negative experiences with influenza vaccine||
Example 2: 66-year-old Spanish-speaking Hispanic woman from Puerto Rico
PCP: I don't know if you want to get the shot against the flu?
P: Ay no!
PCP: Why not?
P: I have never gotten it before because I heard it gives people...My brother in law got it and he was in the hospital for more than a month with the flu, with fever, vomits, he got everything. 'Ay, cunada don't do it' (sister-in-law, don't get the flu shot!) so I never got it. No, no, I won't do it.
PCP tries to convince patient that reaction is a very rare event, recommends strongly, gives patient a chance to think about it during the visit.
Later in visit: PCP: And what have you thought about the shots?
P: (laughed) Ay doctor, I am not frightened by the injection, I am afraid of the reaction, such as fever or something like it.
PCP: Would you like to try it, the reactions are rare, but you are the one who has to make the decision.
PCP negotiates which arm to apply shots, given that she has arthritis in one arm – decides shots should go in bad arm so will still have one good arm.
PCP: Very well, congratulations!
|Shared power/common ground||
PCP initiates discussion of influenza vaccine|
Revisiting the topic throughout the encounter
|Patient receives vaccine during exam|
|Mis-understanding/misinformation about cost of influenza vaccine||
Example 3: 66-year-old Spanish-speaking Hispanic man (Salvadoran)
PCP explores patient's reason for not getting flu shot: Patient doesn't think he will get the flu. Also, doesn't want shot because is worried will get billed for it (last year he received a bill for it, and for PCP visit, has Medicare only). PCP decides to change way will bill for visit; not as PE but for cholesterol and stomach problems.
PCP: Ah...what else...if I can give you the shot without any charge, would you have done it today?
Later in visit PCP assesses patient's literacy in English, gives Medicare website to patient (patient's son reads English and has Internet).
Cultural competence (assesses English literacy before giving patient written information)|
PCP addresses incorrect beliefs/mis-information
|Influenza vaccine is given during exam|
|Dependence on others for transportation makes return visits more difficult to schedule||
Example 4: 66-year-old Spanish-speaking Hispanic woman (from Dominican Republic)
PCP tries to make appointment at a convenient time for patient.
PCP: When do you prefer the appointment?
P: In the afternoon. In the morning she is working (referring to her daughter sitting next to her).
PCP: What time is good for you? (Asking patient's daughter.)
Adapting to each patient's needs|
Facilitates scheduling of colonoscopy
|Colonoscopy was scheduled|
|Patient does not speak English||
Example 5: 69-year-old Spanish-speaking male from El Salvador
PCP is talking in Spanish to patient, but PCP doesn't speak fluent Spanish.
|Cultural competence||Influenza vaccine given during appointment; CRC screening not discussed, but patient has GI appointment in 2 days for weight loss|
|No symptoms of colorectal cancer||
Example 6: 66-year-old Spanish-speaking Hispanic woman
PCP: There is one test you haven't done, this is a test called "colonoscopy," have you heard of this test?
P: You told me last time, you asked me to think about it, but...
PCP: What did you think? You didn't like the idea.
P: I don't like the idea. I imagine it is because I am feeling fine, maybe because I think illness gives you signs.
PCP: The problem is that illness gives you signs when it is too late, and we have found that the way of finding out about it when there is still a cure for it, and this is the main purpose of this test. If you don't want to have this test done, there is another way of doing it, an easy way, I don't know if you have seen our cards, we will do this test every year. This is another way, it is not as good as the colonoscopy, but it is a way to do an evaluation, if you wish we can do it [FOBT]. In the lab you will get the cards and take them home with an envelope to send them back.
|Shared power/common ground||Revisiting the topic between encounters||Patient does not return FOBT cards. When called several months later, she reported that she did not complete the cards because she has been ill. She also assumed her colon was normal because she had had many tests prior to her recent knee surgery and felt that if she had a colon problem those tests would have detected it.|
|No specific barriers (communication strategies used in normal course of visit)||
Example 7: 87-year-old Spanish-speaking Hispanic woman (from Colombia)
(Patient has lung, heart conditions.)
Observer asked to leave room, tape turned off at one point. Patient hugged PCP, was crying. PCP not rushed at all, took her time. PCP very friendly toward patient, paid attention, listened carefully.
|Empathy||Patient did get flu vaccine during exam; not in age range for colonoscopy|
Example 8: 66-year-old Spanish-speaking Hispanic woman from Dominican Republic (same patient as example 4)
PCP: ...after you had the surgery, this is nothing. (Trying to give comfort to patient while applying the shots.)
P: These shots hurt a lot: I think they make them for horses...I don't think you ever had one doctor, you should have one. (Laughed)
PCP: Yes, yes, I did it already. (Laughed.) Somebody else gave it for me. (Laughed)