How the information deficit model helps create unidirectional and paternalistic mode of healthcare communication

Two communication challenges pediatricians routinely face are discussions about vaccines with reluctant parents and weight loss counseling. Communication with parents who refuse vaccines, including the annual influenza vaccination, and parents whose children’s weight and mass body index (BMI) continue to rise is frustrating to even the best of our pediatric trainees. I often sense the frustration our residents experience after encounters with these families. My observation over the years is that communication in these instances is invariably unidirectional; that the messages have not gotten across.

When residents are probed about the reason parents have given for refusing the vaccine or for not adhering to prescribed modifications to diet and activities, they often say, ‘I am not sure’ or ‘I didn’t ask.’ And when probed further about the approach they had used for counseling, many respond with a lengthy explanation about the numerous benefits of the vaccines: how they do not cause the actual disease as much of the public fears (in the case of influenza); how they are extremely safe and produce very few side effects; how an increased number of vaccinated children can create herd immunity; and so on. Similarly, for counseling about weight loss, residents report giving parents detailed explanations about the obesity epidemic in the US, how their children have plotted higher than the 97th percentile on the World Health Organization BMI curve, and how losing weight has countless physical and emotional benefits. Residents share with parents that there is clear evidence that overweight children go on to become overweight adults, how a referral to our nutritionists or endocrinologists will be beneficial, how they can easily cut down on the fat content of milk and change their snacking habits, and on and on.

Patient counseling is the core of medicine, particularly primary care. All of us are taught to not only diagnose and treat disease, but also to provide counseling on health maintenance and disease prevention. In fact, I distinctly remember learning about the etymology of the word doctor as being derived from the Latin ‘docere,’ meaning to teach. We pride ourselves on having acquired large amounts of knowledge and on being able to share the knowledge with our patients and families. We operate on the precept that ‘Knowledge is power,’ believing that the more patients know about disease processes and treatment, the more they are compelled toward prevention or adherence to prescribed treatments. In other words, we believe in the information deficit model of ‘docere’: the assumption that our patients and the public lack key pieces of knowledge and our role is knowledge transfer. We are committed to the notion that arming patients and families with a deeper understanding of medical concepts on the cognitive level will keep them healthy or compel them to treat their disease, leading to a healthier life.

The information deficit model, or simply deficit model, originated by social scientists in the 1970s in the context of discussion about science and technology with the public. The thinking was that if the potentially skeptical public is informed about science and technology, they will be more welcoming and accepting of science and technology in their life [1,2]. Journalists were enthusiastic advocates of this model, incorporating as much information as possible into their reporting in order to educate the masses. However, in the end, the deficit model did not always produce successful results. Both scientists and journalists realized that the public’s attitude is not influenced by knowledge alone [3]. Rather, attitudes depend on myriad factors, including personal beliefs, religion, culture, and community, all of which create an emotional dimension to every piece of information the public receives.

The deficit model plays a significant role in healthcare communication, particularly in creating a unidirectional and paternalistic communication style. In fact, the model’s effects might be even amplified due to the culture of medicine. After long years of training, acquiring vast amount of medical knowledge, honing complex clinical skills, and being acculturated into a field that is traditionally revered, physicians perceive ourselves as experts who work diligently to diagnose, treat, and even cure patients. In many ways, medical training teaches us to be laser focused on outcomes, to work through difficult cases, and to not accept failure. As a result, it is difficult for us to understand why patients do not follow our advice or to adhere to our prescribed plan of care. We feel sure that, after years of rigorous training, examination of scientific evidence behind the work we do, and long hours of practicing our skills, we know better than the public. Naturally we assume that the barrier to patient adherence is our patients’ lack of scientific knowledge. Thus, we must equip them with the information that will compel them to follow our instructions.

It is this type of misguided intention that prevents us from understanding and communicating with our patients. As a result of the deficit model, we fail to appreciate how the patient receives every piece of information through the lens of his or her education level, values, priorities, financial constraints, past experiences, social contexts, and so on. In addition, we underestimate the emotional impact of both correct and incorrect information. For example, when we dismiss misinformation campaigns as fiction intended to trigger fear and anxiety in the public, we miss a crucial opportunity to understand our patients’ thought and decision-making processes. As a result, even as we think ourselves the experts of all things health-related, patients often are not the captive audience we would like them to be.

Lastly, in the age of quick access to Dr. Google, social media, and other readily available online health information resources, patients may have made up their minds about which medical experts to trust and their treatment choices even before their interactions with a physician. Take the case of a parent who refuses the influenza vaccine. Prior to coming to see us, she likely has searched for information online about vaccine safety, heard about side effects from her usual sources of news and information, discussed with her friends and other parents about how the vaccine has caused their children to get sick, and falsely reassured herself that her child could not possibly get sick because he had been healthy without the vaccine the previous two years. In such cases, one can see how bombarding the parent with additional information, even if the information is absolutely factual, is not going to change her mind.

Instead of overloading our patients with more and more information (unidirectional, paternalistic mode of communication), we should start patient counseling with a bidirectional approach (patient-centered or shared-decision making), by first eliciting their perspective. The ask-tell-ask model [4,5] is such an approach. The first ask is the most important, though the least utilized step. The idea is to ask what the patient already knows about the topic, say, the influenza vaccine. Asking the question in an open-ended fashion will likely elicit not only the patient’s cognitive understanding, but also his or her emotional reaction to it. Asking the patient, ‘Can you share what you know about the influenza vaccine?’ or ‘Would you tell me what you understand about the health effects of being overweight?’ can uncover a trove of potential cognitive gaps, hidden fears, and long-felt anxieties about these topics. Using a model such as ask-tell-ask can help overcome the shortcomings of the deficit model.

Additionally, early failures of the deficit model also teach us that connection with an individual on the emotional level is an important aspect of communication and behavior change. A well-studied example is climate change [6]. We know that quoting scientific facts about how human activities have resulted in global warming and sharing data on how future generations will be inheriting the mess we created are not as effective as listening to the individual’s understanding and perception of climate change and engaging in a dialogue about how the changes have and will continue to impact their everyday life. Similarly, for physicians, overloading evidence from the latest studies may not be as effective in changing behaviors as eliciting the patient’s perspective, hesitations and doubts, understanding how the treatment or intervention can impact his or her sense of self and daily life, and then coming to a mutually agreed-upon plan of care.

Even though the deficit model has demonstrated failures in communication on science and technology since its inception in the 1970s, we continue to see it in healthcare. Perhaps the model’s failings should be taught in the healthcare curricula more explicitly. Sharing of data and other scientific information should be presented to physicians and trainees as just one of many ways to connect to and form alliances with patients. Journalists and advertisers have understood the limitations of the deficit model and changed course in order to communicate with their audience more effectively. The time for medical providers to alter our approach is overdue!