The Evolution of Health Literacy and Communication: Introducing Health Harmonics

PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S XX ( 2 0 1 7) XXX –XXX

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The Evolution of Health Literacy and Communication: Introducing Health Harmonics Amy McNeila,⁎, Ross Arenab a

Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA

b

A R T I C LE I N F O

AB ST R A C T

Keywords:

In the last fifteen years, research on the link between health literacy (HL) and poor health

Literacy

outcomes has resulted in mixed results. Since 2004, concerted effort has been made to

Shared decision

improve not only practitioner training, but also the HL of the United States population. And

Chronic disease

yet, to this day, only 12% of adults are considered health literate. Along with increased

Communication

awareness of HL, creation of strategies and initiatives, such as shared decision, plain

Empathy

language, and decision aides, have improved patient-centered approaches to facilitating a

Harmonics

person's ability to obtain and understand health information to the extent that they are

Health

able to affect a level of health autonomy; efforts have clearly fallen short given that during the same amount of time, the unhealthy living phenotype and chronic disease burden persists globally. In an effort to expand and leverage the work of shared decision making and communication models that include all forms of literacy (e.g., food, physical, emotional, financial, etc.) that make up the broad term of HL, we introduce the concept of harmonics as a framework to explore the bi-directional transaction between a patient and a practitioner with the goal of constructing meaning to assist in maintaining or improving one's health. Published by Elsevier Inc.

Contents Virginia Woolf, On Being Ill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Introduction of the Health Harmonics framework . . . . . . . . . . . . . . . . . . . . . . Demystify and deconstruction of the current health transaction model and the need for a Patient perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Virginia Woolf, On Being Ill. . . . . . . . . . . . . . . . . . . . . . . . . Practitioner perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Virginia Woolf, on being ill . . . . . . . . . . . . . . . . . . . . . . . . . Moving forward: harmonic perspective . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . harmonized transaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Statement of Conflict of Interest: see page XX. ⁎ Address reprint requests to Amy McNeil, BA, Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, 1919 W. Taylor Street, 454 AHSB, Chicago, IL 60612. E-mail address: [email protected] (A. McNeil). http://dx.doi.org/10.1016/j.pcad.2017.02.003 0033-0620/Published by Elsevier Inc.

Please cite this article as: McNeil A, Arena R. The Evolution of Health Literacy and Communication:... Prog Cardiovasc Dis (2017), http://dx.doi.org/10.1016/j.pcad.2017.02.003

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Abbreviations and Acronyms CDC = Centers for Disease Control

Statement of conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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HL = Health Literacy U.S. = United States *“He is forced to coin words himself, and, taking his pain in one hand, and a lump of pure sound in the other (as perhaps the people of Babel did in the beginning), so to crush them together that a brand new word in the end drops out.1”

Virginia Woolf, On Being Ill According to the National Assessment of Health Literacy, only 12% of the United States (U.S.) population is considered health literate.2 Since 2004, data collected suggest that roughly 80% of the U.S. population is unable to adequately locate and understand health information to the degree that they are able to take care of their health needs. Concurrently, roughly 26% of the U.S. population works in the healthcare field. Read together, the statistics could imply that even a significant percentage of those working in healthcare are not health literate. This comes at a time when chronic disease (i.e., cardiovascular disease, pulmonary disease, diabetes, cancer, etc.) incidence and prevalence is the primary health crisis in the U.S. and many other countries around the world.3–5 Never before have people needed to understand health information in a manner that allows them to act with some degree of medical autonomy for prevention and, as commonly is the case, treatment of disease. Likewise, now more than ever, patients and practitioners need a framework that captures the complexity of communication, particularly communication fraught with emotion, culture, linguistics, paralinguistics,6 technology,7 religion,8 and education levels. Perhaps, what would be best at this juncture is to acknowledge that the goal should be for effective health communication, by whatever means and skills available, rather than the ability. Moving forward, a new health communications framework should acknowledge that there are many strategies and methods to communicate and each person in the transaction is responsible for organizing and processing a vast amount of information, either explicitly or implicitly, typically in a relatively short amount of time (e.g., a 15 min outpatient clinical encounter). In the end, the ultimate goal in health communication, particularly between a patient and practitioner, remains to improve the patient's health. Recent research indicates that health literacy (HL) can have a profound effect on the prevention and treatment of chronic disease.9–12 At the same time, in the recent healthcare climate, the encouragement of patient participation or patient agency in their own healthcare, from lifestyle behaviors, identifying early signs and symptoms, selecting appropriate physicians, navigating systems to schedule appointments, understanding diagnosis and patient records, to participating

in the decisions for treatment and care of diagnosed illnesses or injuries, is at an all-time high.13 Never before, have patients had access to information, from their own health records14 to the vast pool of information found on the Internet. Practitioners from a wide array of disciplines (i.e., nurses, pharmacists, dentists, dieticians, physical/occupations therapists, etc.) are now not only responsible for an ever-growing body of scientific information and the application of that information for each case they see, but also responsible to share the information and decision making process with their patients, who presumably have little to no training in the medical field.11 But what is known about HL? First off, the definitions vary just enough to create confusion on the part of the practitioner and patient. However, if we start our search with the Centers for Disease Control (CDC), we find a definition focused on “the potential a person has to do or accomplish something. Health literacy skills are those people use to realize their potential in health situations. They apply these skills either to make sense of health information and services or provide health information and services to others.15” Broadening the definition of HL, the World Health Organization explains that it “means more than being able to read pamphlets and successfully make appointments. By improving people's access to health information and their capacity to use it effectively, health literacy is critical to empowerment.16” Between the two agencies, we can see that HL improves potential and empowers a person to understand and act on health information with some autonomy. However, both definitions place the entire burden on the patient or consumer of health information. The “how and who” still exist.17How should a person gain the skills to make sense of health information, and who is responsible for teaching them? As research indicates, measuring a patient's HL as an indicator for improved health trajectory6 may not be the best measure. Health literacy clearly has a great impact on health. In fact, studies show that even health practitioners' HL score is inversely associated with high density lipoprotein cholesterol and that nutrition literacy, specifically, had a statistically significant influence on anthopometry measures.18 The authors of this perspective paper are not arguing against HL, rather we are positing that there are various forms of literacy under the health umbrella: nutrition literacy, physical literacy, emotional literacy, and technology literacy are but a few examples of the literacies that influence how one outwardly communicates health-related information to others and absorbs this information to construct their own health behaviors. By only placing the burden of various literacies on the minds and bodies of the patients, we have created a framework (i.e., what is currently known as the field of HL) that disproportionately burdens the person in the most stress, who requires information the most, and has likely had the least amount of training in medicine and sciences.

Please cite this article as: McNeil A, Arena R. The Evolution of Health Literacy and Communication:... Prog Cardiovasc Dis (2017), http://dx.doi.org/10.1016/j.pcad.2017.02.003

PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S XX ( 2 0 1 7) XXX –XXX

Upon review of health communication strategies, HL and shared-decision-making initiatives have made progress in recognizing that patients need assistance understanding health information to the degree that they are able to act in their own interest or comply with their practitioner's medical plan. However, more work is needed to ensure that the patient is ultimately viewed as an equal participant in a transaction of health information.

Introduction of the Health Harmonics framework As we acknowledge the importance of HL and at the same time recognize that the field must evolve to optimize health communication, comprehension and ultimately adherence to interventions, we introduce the concept of health harmonics as an evolved model for communication across the spectrum of one's individual health trajectory. Why the word harmonic? If we consider a basic definition of harmonics: “Each natural frequency that an object or instrument produces has its own characteristic vibrational mode or standing wave pattern. These patterns are only created within the object or instrument at specific frequencies of vibration; these frequencies are known as harmonic frequencies, or merely harmonics19”; in this context, we propose that the patient and practitioner use their own instrument of literacy to create a tone, sound, or language. As such, the resultant conversation is viewed as an organization of literacies, having distinct frequencies based on past experiences and a resultant knowledge base, to construct meaning, or in other words create a harmonic. When we are able to organize and orchestrate all of the different forms of information (much the same way that a musician uses an instrument to formulate frequencies into a specific sound or note), we have begun to assimilate, process,

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and produce a new sound. We can also consider this sound to be the construction of meaning, or as pragmatism would have us believe, a new truth. However, for the purposes of this paper, we point to the process that each participant (i.e., practitioner and patient) in the transaction undergoes to orchestrate all of the information known and “crush” it together to communicate in a way that resonates with the other participant in the transaction. It is this awareness and appreciation for the other person engaged in the transaction that might allow each side to recognize the collaboration that occurs in order for two people with differing backgrounds and education levels to construct meaning that can be used to achieve the same goal: optimizing the patient's health trajectory. When a patient and a practitioner have successfully conflated their frequencies of information to construct new meaning, we have a successful transaction or harmonic. Fig 1 illustrates this concept; each participant, the practitioner and patient, have their own set of literacy knowledge. The literacies depicted in Fig 1 are not exhaustive but rather serve as an example of several of the literacies that are important to the health transaction. Each participant in the transaction elicits an outward communicative frequency, vibrating at a given rate. When the participant's communicative frequency cross one another, depicted by the nodes, a shared meaning or harmonic is formed. This imagery allows us to consider how two individuals, with different backgrounds, literary histories, and seemingly different languages might have a chance to construct meaning, at the point of interaction or transaction. Take for example a physician providing guidance to a patient on dietary modifications to improve health. The patient is African-American and lives in Chicago. If the physician's frequency is too generalized, for example discussing the value of adopting a Mediterranean diet, there will likely be no alignment with the patient's frequency on the

Fig 1 – Health harmonics framework. Please cite this article as: McNeil A, Arena R. The Evolution of Health Literacy and Communication:... Prog Cardiovasc Dis (2017), http://dx.doi.org/10.1016/j.pcad.2017.02.003

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topic and no shared meaning will be achieved. Conversely, if the physician takes the approach of having a discussion with the same patient regarding their dietary patterns in a culturally sensitive way, identifying healthy food options the patient readily identifies with, there is a much higher likelihood that the practitioner and patient will align frequencies and form a harmonic (i.e., shared meaning). We use the word ‘transaction’ to indicate the back and forth nature of the communicative process. Each side of the transaction is a complex entity with a multitude of experience, knowledge, beliefs, and biases. At times, it may feel to both parties as though they are speaking two completely different languages, even when they are both technically speaking the same language (e.g., both sides desire a healthier dietary pattern). Practitioners have completed anywhere from two to fifteen years of medical and/or medical training that included learning a particular vocabulary and rhetorical pattern,20–22 and yet, they also know how to speak outside the medical or clinic setting. In this way practitioners are somewhat bilingual. When someone speaks more than one language it is not realistic to think that another person who only speaks one language will be able to speak any other languages. Conversely, shared decision making still assumes that the patients have some level of training, or at least vocabulary, in medical sciences. It also assumes that medical rhetoric20 is primary and lay person language is secondary or obsolete. Interestingly, even those who are trained in the medical sciences still know how use common play rhetoric in their home life. Additionally, we have chosen the word ‘practitioner’ instead of ‘physician’ to acknowledge that this particular problem is not unique to the physician–patient relationship, but also affects, for example, the nurse–, pharmacist–, physical therapist–, dietitian–patient relationships. In fact, some of the most compelling literature currently available in this area is in the fields of nursing23 and pharmacy24–26; it appears that practitioners from multiple disciplines are seeking strategies, practices, methods, and theories to improve their ability to effectively communicate with patients. Likewise, of the research we found from the patient perspective, the patients are overwhelmingly looking for the same thing: a way to have an effective transaction of information with their practitioner so that they can better understand the information they are being given so they can better act on that information.

Demystify and deconstruction of the current health transaction model and the need for a harmonized transaction Currently the mono-directional flow of information between a practitioner and a patient is the common communicative approach in healthcare. In historical and current models, the practitioner is positioned as the interrogator and educator.20 The practitioner asks a series of questions that may or may not be iterative, but are somewhat scripted, and are most often rushed due to time constraints. The information flows

from the practitioner to the patient in an osmosis fashion. The patient is seen as a passive receptacle of information that is expected to not only process the information, formulate follow up questions, but also do so in an unnatural environment of the clinic. Further, the patient's emotional state is not taken into the consideration in most instances,27 and health is rarely a non-emotional topic for the average patient. The practitioner asks a series of questions , and despite patient-centered approaches, practitioners oftentimes still use jargon and potentially misinterpreted/unintentional non-verbal cues as well as tone.28 Written information or visual prompts such as icons and images can allow a person to better understand information.29 Decision aides and technology are certainly being used with mixed results. Providing written information to the patient at the end of an appointment and asking prompts such as “Is there anything else?” have shown to be effective. 30 But if we are interested in cognition and the construction of knowledge so that an individual can understand their condition, treatment, and action plan to the level that allows them to experience health autonomy in not only their current state but in their future, we have to conceptualize language, prompts, and aids to better assist the patient at all levels of their care. 31

Patient perspective “Illness is a part of every human being's experience. It enhances our perceptions and reduces self-consciousness. It is the great confessional; things are said, truths are blurted out which health conceals.1”

Virginia Woolf, On Being Ill How do we act as companions or partners to assist the patient to crush sensation with sound to create words that carry meaning to both participants? If we reconsider medical appointments as being closer to “social interactions” we can begin to hope for pragmatism's power to allow the interaction to construct meaning. There are expectations for the way that one speaks, the words that one must use, the amount of time a person is allowed. Much like there are social codes and expectations of how we behave with a family member, a teacher, a colleague, or a supervisor or employer. But what exactly is the social contract with a healthcare provider? From a broader perspective what is the social contract with a healthcare team/system? Here the lines become somewhat ambiguous. Certainly there is a level of formality and even a power structure. However, there is also a monetary exchange that some could interpret at hiring a person for services and information. And yet, there is also a deeply personal side to the interaction, more personal than most other interactions we have. Presumably, we do not speak of, describe, or expose our bodies to most family members, teachers, colleagues, or bosses. The interaction and communication transaction that occurs between a patient and practitioner exists somewhere between the public and private. A social interaction may imply that a process is less “crushing” and more of a blending of experience with an auditory stimulus that behaves more like a harmonization of sounds that blend to create a new

Please cite this article as: McNeil A, Arena R. The Evolution of Health Literacy and Communication:... Prog Cardiovasc Dis (2017), http://dx.doi.org/10.1016/j.pcad.2017.02.003

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sound. When a patient begins their effort to communicate their health information to a practitioner, they may rely on narratives32 or stories to explain their symptoms. In their 2010 article describing the importance of physician's non-verbal communication, Silverman and Kinnersle remind their readers of the importance of looking their patient in the eyes before typing on their computers as the most basic of way of connecting with their patients.28 Citing the article from Macinowicz et al., Silverman and Kinnersley reiterate that patients are exceptionally perceptive at reading clinician non-verbal communication, particularly when their voice, tone, eye contact appeared to be in conflict with the message being delivered. Patients reported being particularly aware of tactics physicians use to stop conversations or discourage the patient from asking questions. Most often, even in the dawn of HL and patient-centered care,33 the current situation in the healthcare setting remains one where the patient is a passive recipient of information. They are queried with a list of seemingly open-ended questions, but in actuality are asked a series of closed-ended questions that can only allow for a certain set of responses. This form of questioning may seem as though it saves time, and time of course is the limiting factor for most physicians and practitioners; however, are close-ended questions the most accurate way to collect health information from a patient? One may posit the answer to this question is no; close-ended queries may leave a treasure-trove of information related to the patient health journey, perceptions, willingness to adhere to medical treatments, etc. behind. One may further posit that, if this information was discovered by a different form of communication, healthcare outcomes and the patient's satisfaction with their healthcare experience would be dramatically improved.

Practitioner perspective *“In illness words seem to possess a mystic quality.”

Virginia Woolf, on being ill From the practitioner's perspective, there may be several factors that impact a patient encounter. Time allotted for clinic visits and job responsibilities outside of actual patient care is a challenge for achieving a harmonized patient interaction.34 What HL asks a practitioner to do, is assess, assimilate, educate, and apply health information, and yet that is not enough. Health literacy models currently ask practitioners to also teach a patient the skills necessary to be health literate, and yet practitioners are rarely taught methods for teaching. The responsibility for improving HL resides on multiple levels. It is certainly within scope of practice for individual health practitioners. In their definition of HL, the CDC states that it is the responsibility of the health practitioner to improve the HL of patients under their care.15 We must work together to ensure that health information and services can be understood and used by all Americans. We must engage in skill building with healthcare consumers and health professionals. Adult educators can be productive partners in reaching adults with limited literacy skills.”35

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Yet, health practitioners may not fully appreciate their role in assessing and approving a patient's HL. Traditionally, educational training for health professionals do not receive formal and substantive training in this area.36 Simply stated, practitioners are not well-trained in “how to have a conversation” with a patient and ensure that what is being relayed is being understood.22 Even more important than understanding, will the information being relayed be utilized to make the appropriate choices with respect to one's personal health journey?37 For example, when a practitioner informs a patient, who has led a sedentary lifestyle for decades, on the benefits of regular exercise, how often does the practitioner take a moment to think about how the word “exercise” is being interpreted by the patient? Does the patient see “exercise” as something athletes partake in and is therefore an unattainable behavior given their own health status and past discomfort with exercise? Would the word “movement”, in replacement of “exercise”, be a more welcoming word that can be used to start a conversation and hopefully result in a harmonic (i.e., shared meaning)?38,39

Moving forward: harmonic perspective In a harmonic transaction of communication, the goal is a collaboration between patient and practitioner that results in the construction of meaning. Different than the mono-directional or transaction that historically occurs, harmonics cannot happen without two participants responding to one another and building from the information provided by each side. Each harmonic will be slightly different because the participants will change. In other words, the practitioner may remain the same, but the patient will change, thus bringing with them literacies, experiences and language that is different from a previous patient. However, the goal remains the same: collaborate to construct meaning. Harmonics recognizes that at the center of health miscommunication lies an inequality of appreciation of expertise. While the practitioner has traditionally held the role of “expert”, the patient is rarely ever recognized as an expert of their own personal history.40 In order to avoid such miscommunications we need a reconciliation between what is learned in medical school and what is learned as personal experience. In other words, a patient may not have medical training, and therefore appear to be health illiterate; however, they may be highly socially-, emotionally-, financially-, physically-, nutritionally literate, along with being an “expert” in their own life. Harmonics does not assume that a patient is tabula rasa or that they learn by osmosis from a practitioner. Harmonics reminds that a patient's life experiences can be accessed through open-ended questions, more casual conversation topics that allow for personal identification.28 A person adept in a harmonic transaction will be aware of multi-literacies and education, may use elements of motivational interviewing, narrative inquiry, dialogic to orchestrate the modes communication. Eventual training models in harmonics will include an awareness for language codes, and code-switching. Harmonics is similar to shared decision making as it involves the patient as an active participant in the decision

Please cite this article as: McNeil A, Arena R. The Evolution of Health Literacy and Communication:... Prog Cardiovasc Dis (2017), http://dx.doi.org/10.1016/j.pcad.2017.02.003

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making process. Like shared decision making, it acknowledges that patients should be involved in the way that decisions are made and should have a say in their health care plan. Both harmonics and shared decision making seek to reduce the patriarchal approach to practitioner centered modes of communication and shift to patient-centered approaches. In this way, shared decision making is one strategy toward harmonics. One might think of harmonics as the shared construction of meaning, i.e., harmonics. However, in contrast to shared decision, harmonics does not ask the patient to meet the practitioner; in harmonics both sides are asked to be aware and respectful of the process each participant is going through in order to construct meaning from the transaction. In this way, harmonics is an authentic, non-scripted, reciprocal, bi-directional transaction of information that not only values the input of both sides, but also it sees both sides as having expertise in a particular facet of the health related issue being discussed. Criticism of shared decision points out that the patient is still required to learn how to speak like a practitioner, understand the vocabulary of a practitioner, and engage a practitioner in a rhetorical pattern more similar to a clinician than the patient's natural speaking or contextual patterns.41 Harmonics, however, recognizes and acknowledges that to achieve the shared goal of constructing meaning, both the patient and practitioner must be aware of the orchestration of language (both verbal and non-verbal), or one might say, the orchestration of literacies that must occur by both parties to construct meaning. Health People 202042 calls for improving the HL of all citizens, a goal we very much support. Food literacy, physical activity literacy, healthy living literacy, pharmacological literacy, health insurance literacy, financial literacy just to name a few components of what it takes to be capable of locating and thinking critically about information to be used to support one's own health needs to be interwoven into the fabric of the educational curriculum from pre-K on in the same way that history, literature, and math are currently woven into the curriculum. However, shared decision making assumes that not only are patients health literate, they are also able to understand and use information in an environment that is not similar to their own.41,43,44 Harmonics does not ask the patient to assume the role of a healthcare practitioner, but does ask patients to actively attempt to see the practitioner as a collaborator and a partner in their shared goal of improved health. Harmonics does not ask the practitioner to be solely responsible to educate the patient, but reminds the practitioner to place themselves in the patient's situation to construct meaning. In this way, the patient and practitioner attempt to interject empathy into the transaction to eliminate conflict that perceived nonadherence13 and jargon6,45 promotion. Bi-directional empathy, or attempting to understand where the other person is coming from, is a corner stone of pragmatism and therefore a cornerstone of harmonics. At the root of harmonics resides the philosophy of pragmatism.46 Like HL, the word ‘pragmatism’ carries several definitions, but to help us with an understanding of what it means to socially construct meaning, we look back to William

James' pragmatism as a model of plurality and social construction of knowledge. “Many persons nowadays seem to think that any conclusion must be very scientific if the arguments in favor of it are derived from twitching of frogs' legs—especially if the frogs are decapitated—and that—on the other hand—any doctrine chiefly vouched for by the feelings of human beings—with heads on their shoulders—must be benighted and superstitious.47” We argue that a patient's experience is not superstitious, but necessary if we are to achieve adherence or authentic change in behaviors. Within pragmatism, we have two individuals whose explicit common goal is to create, or construct, a new truth from the knowledge each individual knows to be true. Other fields, nursing in particular have argued for the foundation of their practice to be based on James' theory of pragmatism38,48,49; however, much like Arena, et al.50 have argued for a non-hierarchical model for healthcare, we argue here that pragmatism be present in all practitioner's practice with their patients in their pursuit of harmonics.

Conclusion We are in the midst of major shifts in the way we view health priorities and how healthcare is delivered. Chronic disease prevention and treatment are at the forefront on a global scale. Moreover we are increasingly recognizing that the healthy living medicine is essential to both chronic disease prevention, which is preferable, and chronic disease management. To do so, an evolved form of practitioner–patient communication must be put forth and implemented. Using a full spectrum of modes of communication, verbal and non-verbal, written, drawn, and videoed allows for conversational flexibility that allows both parties to listen closely and respond with questions as well as statements that may allow for a more authentic transaction of information that leads to a shared construction of meaning. The authors hope that the framework proposed herein, health harmonics, is a starting point for this communicative evolution.

Statement of conflict of interest There is no conflict of interest of any of the listed authors.

Appendix *It is not uncommon to use literary quotes in a science or medical article. The quotes typically signify some other meaning, provide a metaphorical depth, or lend language to the further the reader's understanding of the subject matter. Often, authors will choose quotes as a way to contextualize the jargon laden, in-depth complexity of scientific thought. We chose to structure our argument around these quotes to provide a different view or meaning, provide metaphorical language to paint a picture of a concept, but more importantly, to overtly reintroduce the humanities to the sciences, particularly the health sciences, as a reminder that when we

Please cite this article as: McNeil A, Arena R. The Evolution of Health Literacy and Communication:... Prog Cardiovasc Dis (2017), http://dx.doi.org/10.1016/j.pcad.2017.02.003

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discuss a practitioner and a patient, we are in fact discussing two humans. Perhaps that is the most important feature of harmonics, it never allows one to forget that while each participant in the transaction of health information may have the title of practitioner and patient while they are engaged in this particular transaction, they are still each a human with complex thoughts, emotions, experiences, knowledge, and goals. If harmonics does nothing else, it reminds all that removing the title to have a deeply personal conversation with another human is ultimately the goal.

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Please cite this article as: McNeil A, Arena R. The Evolution of Health Literacy and Communication:... Prog Cardiovasc Dis (2017), http://dx.doi.org/10.1016/j.pcad.2017.02.003