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4. Doctor John and the Surreptitious Assessment—Part 2

An explanation of patient-provider interpersonal relationship models

[If you haven’t already done so, click here to read part 1 of this post]

So, what does my experience as a surreptitious assessor of Doctor John’s communication style have to do with the way pharma, biotech, payor, and patient advocacy organizations engage with their patients?

Each of these entities maintain clinical and support staff who directly engage with patients in conversations regarding their health and wellness. Yet, as discussed in Zen and the Art of Relationship Centricity", these organizations often tend to focus much of their energy and market research on understanding the needs and the journey of only half of that partnership (i.e., the patient). All of these organizations, but particularly pharma, are bound by a set of regulatory and compliance guardrails that dictate how and what their representatives can say, or do, to patients. Therefore, it’s paramount to understand how these regulations impact these entities’ clinicians, educators, and support agents at more than just an operational or clinical level, but also from an experiential and ethical standpoint. For example, when examining the relationship within the context of the role of the pharmaceutical-sponsored clinical nurse educators (CNEs), two of these models become relevant, the informative and the interpretive. As a reminder, the informative model is how Emanuel and Emanual [1] described that patient-provider interaction as one in which the HCP simply provides information while the patient assumes leadership and management of decisions without any imposition of values from the provider. The interpretive is similar in that the patient recognizes the need for the physician to provide technical information and is still the decision maker. However, the patient allows the provider to elucidate their values and assist in the guidance of therapies and medical decisions.

Four models of patient-provider interpersonal relationships

In my research of the communication experiences of pharmaceutical CNEs, I discovered that most of them idealized the same model Doctor John valued, the deliberative one (i.e. both patient and provider elucidate their values and engage in shared decision making). They believed this was the best approach for patient engagement, particularly as it related to their prior experiences from working in hospitals and physician offices [2]. However, given the reality that these CNEs are legally prohibited from providing any sort of medical advice or participating in any type of shared decision-making process, a deliberative approach would not be possible. CNEs understood this. Some of them however, still had a liberal perception of their role, meaning they strove to utilize a more interpretive style of communication. In this way, CNEs understood their role as that of a “counselor”, a term Emanuel and Emanuel also equated to this approach. In my study, CNEs in this camp would use phrases such as “meeting the patient where they are at” as a preferred strategy that was indicative of the interpretive model.

While most CNEs endeavored to engage patients using a communication style aligned to tenets of the interpretive model, realistically many of them found themselves grudgingly forced to adopt a more conservative approach reflective of the informative model—one in which they simply deliver information about the disease state, treatment, and related risks. In this way, CNEs perceived themselves as merely a “technical advisor”. Their attitudes were such that they believed this was the preferred model of their employers and government regulators, given the industry’s stringent focus on liability protection. Even more so, the nature of the compliance regulations themselves provoked a level of influence so strong that many CNEs felt they were left little option for a communication style other than the informative one.

“You always have to have in the back of your mind the rules and restrictions that you need to follow when you’re talking. So, you just can’t be as free in your conversation as you would like to be” -Lois (pharma telephonic nurse educator) [2]
“A person may have a question and we may be able to answer, but we may not be allowed to answer…I feel like I can’t help the person as much as if I were working independent of a pharmaceutical company.” -Bonnie (pharma field nurse educator) [2]
“I feel like the pharmaceutical company we work for are compliance maniacs. I don’t know, I could be wrong about that. But we have so many restrictions regarding compliance it’s hard sometimes to do our job.” -Antonia (pharma field nurse educator) [2]

Interestingly, though it wasn’t a line of questioning I pursued while conducting my study, I would surmise that most of the companies that employed these CNEs weren’t aware of how their educators interpreted their communication role. While CNEs may have been trained in a manner suggestive of an informative approach, I doubt most companies engaged these teams in any discussions about how the CNEs own personal values or ethics would come into play in patient encounters. Many CNEs in my study saw their role as healthcare professionals as sacrosanct—they were charged firstly with always doing what was in the best interest of their patients. These were the ones who leaned toward the interpretive model even when it was clear to them their employers saw their role aligning to the informative approach.

All of this illustrates that those life science companies who employ clinicians to engage with patients need to be aware of how those clinicians’ values and ethics function almost at a visceral level—such is a topic that will be explored in more detail in an upcoming post. Further, if the only on-going assessments of these clinicians are metrics such as net-promoter scores and patient satisfaction ratings, these companies are missing opportunities to better leverage the power of those value-driven clinicians—also of topic of upcoming discussion.

Finally, not to leave you hanging, but I did respond to John’s question of “How am I doing?” I assured him that I greatly appreciated his collaborative nature and personalized approach to my care and how it was in line with contemporary views of interpersonal health communication.

Of course, I should have also let him know that, like him, such assessments have a monetary value. Maybe I’ll ask if he could just take the cost of my service off his bill.

[1] Emanuel, E. J., & Emanuel, L. L. (1992). Four Models of the Physician-Patient Relationship. JAMA: The Journal of the American Medical Association, 267(16), 2221 [2] Barshinger, T.A. (2020) Interpretations of communication experiences of pharmaceutical-sponsored clinical educators (Doctoral dissertation). Retrieved from ProQuest Dissertation and Theses database (UMI No. 28086978)


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