College and Research Libraries Reference Communication: Commonalities in the Worlds of Medicine and Librarianship Rachael Naismith Communication between physician and patient is similar to communica- tion between librarian and the library user in many ways. Reference and medical interviews constitute an effort on the part of the professional to both assess an individual's needs and explain a system that may seem complex and new to that individual. A series of issues is discussed, from the standpoint of both the physician's office and the reference desk. This paper presents a series of communication issues and outcomes, describing each as it applies to the physician's office and the reference desk. Avenues for improving communication are suggested. ~P!Jii!!i~ hat we have here is a failure to communicate." This famous l.ine from the movie Cool Hand -~~~ Luke states a problem that is basic to human interaction. What are the results of a failure to communicate? The reference interview is an arena in which communication failure can have a pow- erful negative effect on results. The medi- cal interview is another such arena, one in which researchers have studied there- sults of communication failure in detail. These published results fall under the categories of recall, compliance, medical outcome, and satisfaction. In order that librarians can learn from experts in an- other field, this paper examines the ques- tion of communication problems through a comparison of the reference interview with the medical interview. I want to note that after this article was accepted for publication, a related article appeared in print, Carolyn Radcliff's "Interpersonal Communication with Library Patrons: Physician-Patient Research Models." 1 Radcliff's article offers additional insight into a number of the concepts discussed here. In the aspect of communication, there- lationship between librarian and library user shares certain commonalties with that of physician and patient. Reference and medical interviews entail both find- ing out information and giving out infor- mation. The interviewer often begins by knowing little or nothing about the interviewee's problem, situation, or back- ground. The physician and librarian typi- cally have a limited amount of time to put a person at ease and ascertain his or her Rachael Naismith is Senior Reference Librarian at the Babson Library at Springfield College, Springfield, Massachusetts. She was Head of Reference Services at the Miller Nichols Library at the University of Kansas City at the time this paper was written. 44 needs, which the person may obscure, hide, omit, or have difficulty expressing. After the complex task of question ne- gotiation, the person's needs must be matched with the resources at hand, or the person referred elsewhere. To impart information, both physician and librarian are often faced with the task of explain- ing a complex system to people who may lack their specialized knowledge. In his renowned article on question negotiation, Robert Taylor calls the reference interview one of the most complex acts of human communication. In a description that can be applied to the medical interview as well, he writes, "In this act, one person tries to describe for another person not something he knows, but rather some- thing he does not know." 2 The main focus of this paper is on the physician's or librarian's attitude and be- havior rather than that of the patient and library user. Because of space limitations, nonverbal communication is not dis- cussed. The format of this paper is to dis- cuss a series of communication issues and outcomes, describing each as it applies to the physician's office and the reference desk. A Failure to Communicate An examination of medical literature for the past twenty-five years reveals a wealth of research on the problems inher- ent in the communication between phy- sician and patient. Library literature also reveals a similar emphasis on the refer- ence interview. One recent article dis- cussed the physician-patient communica- tion process in terms of its relevance to librarians, but the authors admit it was a limited review and cited no library ar- ticles.3 In contrast to the Plain English move- ment, which calls for medical and legal communications to be made comprehen- sible to the layperson, there seems to be no comparable grassroots movement for changes in the way librarians communi- cate with users. This could be because li- Reference Communication 45 brarians are doing just fine at communi- cating with library users. However, the number of articles dealing with the refer- ence interview by librarians themselves and the number of recent articles on the failure to meet user needs suggest other- wise. The Role of language One way to examine interactions within the librarian-user and physician-patient dyads is to look at language. As imper- fect as language is, it has the power to shape our experience of reality, even at the level of its smallest denominator-the word. Both the medical and library worlds feature many words that are con- sidered technical language. Philip Ley discusses the problems associated with medical jargon in his comprehensive trea- tise on medical communication, Commu- nicating with Patients: Improving Commu- nication, Satisfaction and Compliance. Ley cites studies that consistently found dis- crepancies between physicians' and pa- tients' interpretations of common medi- cal terms.4 Several physicians have called upon their colleagues to demystify medical ter- minology in dealing with their patients.5 Timothy Anderson and David Helm link the use of jargon to the physician's desire to control the interaction: Language is often used to mystify, to desexualize, to confuse and in- timidate the patient, as well as to reaffirm expertise ... It is through language that social realities are constructed, and through the ex- pression of language that realities can be negotiated. The physician gains in power through his or her access to and control over the "le- gitimate" language of health and illness. Thus patients are urged in their presentation of symptoms and problems to recast their ac- counts in the appropriate nomen- clature-which reinforces the 46 College & Research Libraries physician's mandate to determine the reality. 6 Schema Theory Only part of the patient's comprehension problem can be explained by lack of fa- miliarity with word meanings. A patient will interpret what a physician says in terms of the patient's own framework of ideas about illness. This concept relates to what cognitive psychologists call "schema theory." Although not using that term, John Locke gave a good description of schema theory in 1689 in his Essay Con- cerning Human Understanding: To make Words serviceable to the end of Communication, it is neces- sary that they excite, in the Hearer, exactly the same Idea, they stand for in the mind of the Speaker. Without this, Men fill one another's Heads with noise and sounds; but convey not thereby their Thoughts, and lay not before one another their Ideas, which is the end of Discourse and Language. 7 Years later, Terry Winograd designed a model of communication (see figure 1) to illustrate schema theory. Briefly, the two participants, the speaker and the hearer, each possess a set of stored schemas, which are collections of knowledge related to a concept. The hearer considers the con- text of the message and compares it to ex- isting schemas. In addition, each partici- pant has a model of the other person, which may consist of opinions about the actual known individual or notions related to personal characteristics such as appear- ance, gender, occupation, and so forth. 8 If the content of the discourse seems familiar, the hearer reacts the same way he or she did before. If the hearer's schemas differ enough from those of the speaker, the intended message is likely to be received incorrectly. This theory ex- plains in part the problems that result from patients not having the underlying January 1996 medical schemas to understand the terms used by their physicians. The same can be said for library users, who often do not share the library schemas so familiar to reference librarians. As much as librarians would like to believe that they eschew jargon, recorded reference interviews show that they use jargon in dealing with library users. A study that Joan Stein and I conducted at Carnegie Mellon University revealed that half the time library users did not under- stand the terms librarians used. In the study, freshmen incorrectly answered multiple choice definitions of library terms such as citation at a rate of 49 per- cent. Because it appears, based on this re- search, that library terms do not fall within library users' existing schemas, li- brarians must take steps to compensate for this communication barrier.9 The Power Perspective Literature cited throughout this article suggests that many physicians emphasize their authority, assert opinions as if they were dogma, maintain emotional dis- tance, discourage patient collaboration, As much as librarians would like to believe that they eschew jargon, recorded reference interviews show that they use jargon in dealing with library users. and promote poor communication with patients. Why? One reason involves a desire for control and power. 10 In general, the physician wields power in the interaction by controlling the dis- cussion and monitoring the amount and type of information given to the patient. This is known as expert power, the use of possessed knowledge to control others. It only works so long as the expert (doc- tor) can keep the patient from obtaining comparable expertise. 11 If the physician retains control of the knowledge, the physician has a dominant role to the subordinate patient. As one Reference Communication 47 FIGURE 1 Model of Communication (Winograd) Speaker's intended meaning Stored Schemas Stored Schemas Hearer's interpretation TEXT or UTTERANCE Goals Previous schemas from this discourse Model of the hearer communication studies writer expiained, "People have been socialized into expect- ing both minimal interpersonal rapport with most health professionals and maxi- mal control, from them." 12 This type of relationship, which the reader might view as paternalistic, may be common, but it may not be what the patient wants or needs. A patient who deviates from the ex- pected silent role may suffer conse- quences, according to some authors. In one hospital study entitled "Good Pa- tients and Problem Patients," Judith Lorber addressed the issue of patients' reactions to physicians' expert power. Physicians considered patients who refuse to be submissive or to follow the 48 College & Research Libraries informal rules of the institution to be problem patients who place more de- mands on busy physicians. Lorber con- cluded that health professionals used medical neglect to "punish" these pa- tients for their nonconformity. 13 Some writers have urged physicians to reexamine their use of expert power, which they claim is detrimental to physi- cians, to patients, and to their relation- ships. Judith Rodin and Irving Janis called for physicians to use, instead, "referent power," the motivating power that de- rives from a person's ability to be like- able, benevolent, admirable, and accept- ing. I4 The issue of power and control relates somewhat differently to the library envi- ronment. Although librarians possess specialized knowledge and therefore ex- pert power, they are not awarded the high income that many physicians receive. In- come, status, and self-image are issues that one encounters regularly in library literature. If the use of power in an occupation is linked to the rewards of professionalism, researchers should not be surprised to see controlling behavior exhibited by refer- ence librarians. The reference interview may serve as a means for control by the reference librarian. A number of library articles have examined one aspect of con- trol centering on the information-versus- instruction debate. This debate, now over thirty years old, features on one side those who see librarians as intermediaries in- volved in every step of providing users with information and, on the other side, those who advocate self-reliance of li- brary users by teaching them how to find information by themselves. 15 There may be correlations between the attitude that encourages users to depend on the librar- ian for their information needs and the attitude of the physician who controls the dissemination of information. Two other points made with relation to medicine may have relevance to the li- brary. First, the concern expressed about January 1996 relegating the demanding patient to the role of "problem patient" and limiting communication certainly has its correla- tion. At a busy reference desk, a reference librarian might have a similar negative reaction to a verbose, more demanding user. The second important point is the emphasis of referent power over expert power. Users might be more receptive to the likeable, accepting communication style that typifies referent power. Outcome of Communication Failure When the patient or library user cannot comprehend the information that has been given to him or her, or cannot recall or use it, or is so dissatisfied with the in- teraction that he or she does not return, then harm has been done. Medical articles have investigated the negative outcomes of communication failure . Articles study- ing the independent variable of commu- nication focus on its effect on four depen- dent variables: recall of information, com- pliance with instructions, medical out- come or success, and satisfaction. Recall Recall is very important in medicine be- cause, unlike most library situations, in- dividuals acquire information and then leave with the expectation that they will recall what they have learned and follow the instructions at home. Thus, recall is linked to what physicians call "compli- ance." In a study of medical terminology, Lyle Saunders and Richard Larson found that patients were unable to recall medical terms that they did not understand. They concluded: Health practitioners who have facil- ity with medical terms can think faster about medical topics than the patients with whom they are talk- ing. In a discussion the practitioner may have gone on to a new topic while the patient is still trying tore- member precisely what "abdomen" means. Second, practitioners may be better able to remember past dis- cussions and problems than pa- tients because of their greater knowledge of medical language. The patient may have forgotten the explanation received at the last visit because all the terms were new to the patient. 16 In other words, the fact that patient and physician do not share the same schemas impedes the patient's recall of instruc- tions. Ley's study of patient recall found that patients fail to recall many of the in- structions and information they receive. In fact, he found that the number of state- ments that patients forget increases with the number of statements presented. Nei- ther age nor intelligence is consistently related to recall, but existing medical knowledge (schemas) do increase recall. Ley discovered that order is related tore- call, with the last items presented being the ones best recalled. He also concluded that the amount people recall can be in- fluenced by shorter words and sentences, ... recall could be enhanced if the librarian uses shorter words and sentences, explicitly categorizes types of information presented, repeats information, and is specific and concrete. by explicit categorization, by repetition, and by use of concrete language rather than abstract language. Anxiety has a negative effect on recall, with very low or very high anxiety increasing recall problems. 17 Other researchers have studied recall problems in terms of the communication process. One study found that half the in- structional statements patients received and two-thirds of the statements dealing with diagnosis or treatment were forgot- ten and that, in general, there was no con- nection between the loss of information and the passage of time. 18 Reference Communication 49 How do these findings pertain to li- brarianship? Recall has not been heavily researched in the library field, as repre- sented by the Library Literature and ERIC (education) bibliographic indexes. The findings described above could be in- structive to reference staff, who would like library users to recall the information they give them. For instance, recall could be enhanced if the librarian uses shorter words and sentences, explicitly catego- rizes types of information presented, re- peats information, and is specific and con- crete. Compliance The second variable affected by commu- nication problems is compliance. Compli- ance has been a major source of concern in the medical world for many years. One physician suggests that the word itself denotes "orders" followed by "good" pa- tients. He argues that physicians should not use communication to persuade but, rather, to outline possible plans of action so that self-reliant patients can make their own informed choices, for which they will be responsible for the consequences. 19 Several possible reasons exist for pa- tient noncompliance. As mentioned ear- lier, the patient's inability to recall the in- formation is one reason. The patient might also be so dissatisfied with the in- terview, the doctor, or the suggested treat- ment that he or she ignores the instruc- tions. Another reason might be a lack of understanding. The doctor may not have conveyed the instructions clearly, or the patient's schemas of experience vary too much with the message. Health care treat- ments are often complex, and concepts and terms are often new to patients, who may, instead, call upon their own exist- ing schemas with regard to illness. Com- prehension problems may result from the patients' inability to comply with the physician's suggestions. Noncompliance may be unintentional or intentional. Analee Beisecker, in an ar- ticle entitled "Patient Power in Doctor-Pa- 50 College & Research Libraries tient Communication," suggests that pa- tients may modify the prescribed treat- ment as a way to assert their indepen- dence and power. She states, "It should be noted, however, that in some cases, the modified treatment regimens are prefer- able to those prescribed by physicians, because patients are in tune with their own bodies and can perhaps determine a more appropriate dosage of medication than a physician applying standard pro- tocols." 20 Kathryn Rost and other researchers ex- amined the exchange of information in relation to patient compliance. The study reviewed the intake interviews of forty- five patients. When they compared phy- sicians' discourse styles with compliance, they concluded that "exchange that al- lows the emergence during the examina- tion of both the physician's and patient's perspective co-occurs with (if not influ- ences) a patient's decision to follow through with recommendations made during the visit." 21 The authors also suggest that if pa- tients provide information that doctors request and volunteer additional infor- mation, the partnership will be more likely to arrive at a definition of the prob- lem that both partners share. Teaching physicians to invite patient input may enhance outcomes, according to the study. Library literature has not addressed this problem of noncompliance. Librar- ians advise and instruct users, and be- cause they are often physically nearby as users carry out their tasks, there is a sense that users are following through on their directions. Unlike physicians, librarians benefit from this proximity, as they are more readily available for additional clarification and any follow-up questions or concerns. Nevertheless, it would be in- teresting to observe how library users actually implement, or ignore, librarians' suggestions. Given these medical find- ings on recall, the librarian concerned with users following through on instruc- tions should think of the interview as an January 1996 exchange, with both partners working to define and solve a shared problem. Ultimate Outcome or Success The effect of communication on the ulti- mate outcome of the medical or library intervention is of obvious interest to prac- titioners. Researchers found some connec- tion between patient-physician commu- nication and compliance, and medicine assumes a strong connection between a patient's compliance with a medical regi- men and symptom relief. A number of re- searchers have noted improvement in pa- tients (e.g., quicker recovery time, symp- tom relief) stemming from improved compliance resulting from better commu- nication between physician and patient. Based on these articles, increased physi- cian responsiveness and the encourage- ment of patient involvement brought about improved communication.22 One study on outcome, written by Sheldon Greenfield, found significant im- provements in patients' physical func- tioning after they received training in communication techniques designed to increase their involvement in their own care. The study consisted of an experi- mental group and a control group of pa- tients with ulcers. Researchers taught patients in the experimental group to read their own medical records and coached the patients to ask questions and negoti- ate decisions. After the training, patients were more assertive and more involved with the physician during the medical interview. Eight weeks later, patients in the experimental group expressed more satisfaction with their care than the con- trol group, preferred a more active role in decision making, and reported fewer physicallimitations.23 Beisecker also observed changes in patients who were encouraged by re- searchers to take a more active role in the medical interview. The patients she ob- served expressed opinions, asked ques- tions, had a better understanding of their treatment, and appeared better able to follow the treatment, leading to better medical outcomes.24 In library literature, studies of ultimate outcome focus primarily on reference li- brarians' success in answering questions accurately. Accuracy measures consis- tently have found problems in terms of librarians providing library users with correct information. A number of research studies using unobtrusive testing indicate that librarians provide the correct answer only about 55 percent of the time. 25 Observers in the Durrance study were far more forgiving when library staff members had weak interviewing skills or gave inaccu- rate answers than if the staff member made them feel uncomfort- able, showed no interest, or ap- peared to be judgmental about the question. Undoubtedly, these studies alarmed many librarians. Improving reference ac- curacy is an aim that concerns reference librarians and administrators. Some li- braries have been successful in their con- scious efforts to raise staff accuracy rates. For example, Ralph Gers and Lillie Seward studied Maryland public librar- ies and focused on the variable of feed- back. According to the study, librarians who did not solicit feedback from library users supplied correct answers 52 percent of the time. Librarians who asked for feedback, asking users whether their questions had been answered, were able to provide better assistance, resulting in a 76 percent accuracy rate. 26 Answer inaccuracy is only part of the problem, however. Physicians can disseminate accurate information and, for various reasons, the patient still may not have a successful outcome. Poor communication techniques may lead to accurate information not getting through to the hearer. Conversely, good communication techniques can actu- ally result in a satisfied hearer even if Reference Communication 51 the content of the information is not very accurate. One author, Joan Durrance, raised the question, "Does the 55 percent rule tell the whole story?" Durrance reported on a study in which observers rated 266 li- brarians in terms of their reference inter- view skills. Results consistently showed that subjects who gave high scores to the librarians on the interpersonal variables of comfort, friendliness, and interest were almost certain to return to the same li- brary staff member. Those who gave a high ranking to librarians on the skill variables of determining need and inter- viewing ability would also return. Durrance noted that in terms of skill, the study did bear out what other stud- ies have concluded-that librarians fre- quently have poor interviewing skills. Observers in the study determined that only 27 percent of the librarians found out what the questioner needed. Other vari- ables, such as a display of interest, were perceived to rank high in importance. Ob- servers in the Durrance study were far more forgiving when library staff mem- bers had weak interviewing skills or gave inaccurate answers than if the staff mem- ber made them feel uncomfortable, showed no interest, or appeared to be judgmental about the question . This study concluded that accuracy is an im- portant, but not the only, crucial key to the success of the reference interview. 27 Recently, some libraries began using alternative, more qualitative surveys to evaluate reference service effectively. These methods foster librarian behaviors in a multidimensional way. They measure effectiveness not only in terms of accu- racy, but in terms of factors such as avail- ability, question interpretation, and com- munication. These evaluation instru- ments are discussed in specific terms that can be adapted by other libraries. 28 Satisfaction The final section of this discussion of out- come is devoted to satisfaction, which is 52 College & Research Libraries really another measure of ultimate out- come or success. In 1968, a team of phy- sicians researched doctor-patient interac- tion and patient satisfaction with a sur- vey of 800 parents of children in a hospi- tal pediatrics unit. Researchers asked sub- jects to evaluate the medical interview with their children's physician and to rate their satisfaction level with the physician. Seventy-six percent of the parents were highly or moderately satisfied. Those who made favorable note of the physician's communication skills (mak- ing statements such as "He listened to me," "He explained so well") were dra- matically more satisfied than those who disparaged their pediatrician's commu- nication skills. Several unexpected find- ings emerged. For instance, although par- ents went in to the interview with spe- cific main worries, only 24 percent of these worries were verbalized to the doc- tor. Thus, even if they never raised what most concerned them, they were still gen- erally satisfied. The authors raise an in- teresting point when they say that the measure of patient satisfaction may be suspect "because quacks, faith healers, and so forth are notorious for producing high satisfaction in their clientele, even though the service that is offered is of low quality or dishonest at times." 29 Other researchers found that the amount of informativeness and the display of feel- ings such as empathy were highly corre- lated with satisfaction. It is important to note, as several studies did, that patients vary in their preferences for a physician's behavior. Some prefer more directive ap- proaches than others and prefer acquir- ing information without necessarily ac- cepting responsibility for decision mak- ing. 30 In the library world, some measures of library user satisfaction are part of major evaluation studies. Some authors have questioned the weight ascribed to satisfaction measures. This is because, as was found in one of the medical studies, an individual often expresses satisfaction January 1996 even if he or she walks away with what might be considered inadequate informa- tion. In fact, despite reports of a 55 per- cent accuracy rate, many user surveys in- dicate a satisfaction rating for reference service that surpasses 90 percent. 31 A person's satisfaction level with li- brary staff service can be attributed to at- tention, a friendly attitude, and a few ci- tations. Thus, satisfaction levels are im- portant because a satisfied user will be more likely to want to return to a given library and librarian. But satisfaction is not enough if the results of research are wanting. If the user leaves the library with inaccurate or insufficient informa- tion, it matters little that the person feels satisfied. Several researchers studied satisfaction in conjunction with user success. Charles Bunge and Marjorie Murfin surveyed both users and librarians at fifteen librar- ies. In the area of satisfaction, they found that the one factor that led to users be- coming more dissatisfied was the degree of busyness of the librarian, leading to brief, one-source transactions. 32 Bunge and Murfin also found what they consid- ered to be a greater sensitivity to user feel- ings among successful librarians. In the successful libraries (highest in user suc- cess and satisfaction), the librarians were more aware of communication difficul- ties, reporting difficulties on the same questions where the users reported diffi- culties. In summation, medical and library studies have found that good communi- cation skills and sensitivity to communi- cation problems have an effect on pa- tient/user satisfaction. Measuring satis- faction and improving it via improving communication skills would likely ben- efit any institution, in terms of increas- ing user return rates and overall positive attitudes. A Model for Outcome The author devotes a good deal of this paper to outcome in the medical and li- Reference Communication 53 FIGURE2 Interactions of Communication Outcomes ENVIRONMENT (time, #of staff, collection, etc .) jargon anxiety level style of communication ~ 1 (egJ~e)~ Comprehension ----)? Recall ----)4 Compliance ( ) Satisfaction /1 T~l amount of information presented technique (e .g . , use of repetition categorization, concrete explanations) agreement with diagnosis OUTCOME/ SUCCESS SCHEMAS brary settings. Outcome is affected by communication in various ways. Figure 2 summarizes the interactions between the various factors . The comprehension of the hearer (the patient or the library user) is affected by variables such as the amount of informa- tion presented, the hearer's anxiety level, the speaker's use of jargon, and the speaker's techniques, such as use of rep- etition and categorization of ideas into units that are easier to assimilate. Com- prehension affects recall, which affects compliance or the following of instruc- tions . Recall alone is not always enough to ensure compliance. Other variables that may have an effect on recall are the hearer's agreement with the diagnosis or suggestion, and the speaker's communi- cation style. One type of style that seems to promote compliance is a sharing style, where both parties exchange information. Style also affects satisfaction. Compliance with a good suggestion usually results in success. Compliance can also lead to a sense of satisfaction. Like- wise, satisfaction with an interaction can lead to compliance with instructions. Suc- cess certainly leads to satisfaction, and sat- isfaction can be considered an outcome. All of this interplay of factors is sur- rounded by the effects of both parties' existing schemas. In addition, interaction may be affected by the environment, which might ·consist of waiting library users, the number of staff members, the reference collection, rules and procedures, the ringing of telephones, and so forth. Enhancing Communication: Techniques and Training This paper describes some of the out- comes that medical researchers identified as being associated with communication problems. A number of suggestions are offered for avoiding such problems at the reference desk, thereby improving library users' recall of instructions, ability to com- ply with suggestions, ultimate outcome or success, and satisfaction. In terms of specific interview tech- niques and training, medical articles of- fer few details. However, they do offer a body of literature demonstrating in study after study that medical students trained 54 College & Research Libraries in interviewing skills conduct more suc- cessful medical interviews than students without training. Students with training not only elicit a greater amount of rel- evant information from patients, but also are better able to communicate empathy and to detect and respond to patients' ver- bal and nonverbal cues-skills that re- main over time.33 Several types of teaching seem condu- cive to the learning of effective interview techniques. In one detailed article on teaching these skills, B.J. Evans and oth- ers outline an eleven-hour, eight-session course in medical history-taking. The course heavily emphasizes the use of ac- tive learning formats such as discussions, role-plays, and videotaping with real and simulated patients.34 Although librarians can learn from these controlled studies, they can prob- ably learn more about techniques and, to a lesser extent, training from their own literature than from medical literature. For example, two far-ranging and practi- cal books on reference interview tech- niques are Elaine J ennerich' s The Reference Interview as a Creative Art and Catherine Ross's and Patricia Dewdney' s Commu- nicating Professionally: A How-to-Do-It Manual for Library Applications. These books lay out the foundations for better communication techniques, giving ex- amples that are relevant to the reference encounter. 35 A number of detailed articles have been written on specific techniques described in the J ennerich and Ross- Dewdney books, such as active listening and the effective opening and closing of the reference interview.36 Given that such methods recognized in librarianship are effective interview techniques, how do librarians best learn them? A lengthy dis- cussion of teaching methods cannot be given here, but a few suggestions should be made. The medical articles cited at the begin- ning of this section suggested that the poor interviewing techniques of medical students negatively affected patients' out- January 1996 comes. Through training, often involving active learning such as role-playing, vid- eotaping, and the practi'cum or intern- ship, their techniques improved and con- tinue to improve. Library courses that employed the same methods, particularly the use of more than one class session to address The comprehension of the hearer (the patient or the library user) is affected by variables such as the amount of information presented, the hearer's anxiety level, the speaker's use of jargon, and the speaker's techniques, such as use of repetition and categorization of ideas into units that are easier to assimilate. communication issues, seem to have simi- lar positive effects on students' interview- ing skills.37 In general, however, the com- munication barriers and techniques are only briefly touched upon in library schools. In a recent request via the Inter- net listserv LIBREF-L for information on the teaching of the reference interview in library schools, the author received a dozen or so lukewarm responses about such lectures. The most enthusiastic li- brarian comments about classes that pre- pared them for the real-life reference in- terview were multisession communica- tion courses such as those offered at the University of Pittsburgh and the Univer- sity of Michigan. Interview skills can be taught in the workplace. Libraries employed many va- rieties of continuing education. Several sites have implemented peer coaching.38 A reference coordinator or department head might help alert colleagues to com- munication techniques. Articles such as those cited in this article could be routed and discussed at meetings. Good video- tapes on reference skills could be acquired and shown. The best method is probably a combination of approaches, offered on a fairly regular basis. Medicine borrows from other disci- plines when designing communication components for courses, according to some sources. Librarians, too, can learn from other professions. Counseling or even medical curricula can be modified for library schools or continuing educa- tion sessions. Some library authors write about such applications. 39 Conclusions This paper began with a look at some of the communication problems that physi- cians themselves have identified in the patient-physician relationship. Others, too, such as advocates of the Plain English movement, have called upon physicians to simplify explanations, avoid undefined jargon, and avoid using language that cre- ates a distance between patient and phy- sician. The physician's language has also been tied to issues of power and control. The negative outcomes of physicians' communication problems are varied and extensive. These problems and their outcomes are relevant to librarianship, which also fea- tures jargon and an environment that Reference Communication 55 seems to lend itself to complex explana- tions. Like physicians, librarians must choose whether to view the nature of the interview as an opportunity to control in- formation or as an opportunity to ex- change information with the library user. I agree with those who urge experts in the medical and library worlds to rethink their relationships to nonexperts, and to work toward the sharing of knowledge using referent power rather than the mo- nopolization of knowledge, which is of- ten typical of expert power. Some physicians are learning to cul- tivate skills "that respect patients' in- telligence, acknowledge their needs, accept their feelings, value their opin- ions, and promote collaboration in de- cision making." 40 The library world also must heighten its awareness of the issues presented here, through library schools placing greater emphasis on in- terpersonal communication, through on-the-job training, through quality- based evaluation, and, most important, through a commitment to lower the communication barriers between li- brarians and library users. Notes 1. Carolyn J. Radcliff, "Interpersonal Communications with Library Patrons: Physician-Pa- tient Research Models," RQ 34 (summer 1995): 497-506. 2. Robert S. Taylor, "Question-Negotiation and Information Seeking in Libraries," College & Research Libraries 29 (May 1968): 180. 3. Lynda M . Baker, "Physician-Patient Communication from the Perspective of Library and Information Science," Bulletin of the Medical Library Association 82 (Jan. 1994): 36-42. 4. Philip Ley, Communicating with Patients: Improving Communication , Satisfa ction and Compli- ance (London: Croom Helm, 1988) : 25 . 5. Barbara M. Korsch and others, "Gaps in Doctor-Patient Communication," Pediatrics 42 (Nov. 1968): 862; Donna M. Musialowski, "Perceptions of Physicians as a Function of Medical Jargon and Subjects' Authoritarianism," Representative Research in Social Psychology 18 (1988): 3- 14; Barbara Wilson, "Improving Recall of Health Service Information," Clinical Rehabilitation 3 (1989): 275-79; Stuart G. Finder, "Attitudes and Discourse: The Words of Medicine," Journal of the American Medical A ssociation 268 (Nov. 4, 1992): 2449, 2453; Larry Westreich, "Doctors and Lan- guage: How We Confuse Our Patients," Journal of the A merican Medical Association 265 (Jan. 2, 1991): 117. 6. Timothy W. Anderson and David T. Helm, "The Physician-Patient Encounter: A Process of Reality Negotiation," in Patients, Physicians, and Illness: A Sourcebook in Behavioral Science and Health, ed . E. Gartly Jaco (New York: Free Pr., 1979): 266 . 7. John Locke, An Essay Concerning Huma n Understanding (Oxford: Oxford Univ. Pr., 1975). Quoted in Talbot J. Taylor's, "Do You Understand? Criteria of Understanding in Verbal Interac- tion," Language and Communication 6 (1986): 171. 56 College & Research Libraries January 1996 8. Terry Winograd, "A Framework for Understanding Discourse," in Cognitive Processes in Comprehension, eds. Marcel Adam Just and Patricia A. Carpenter (Hillsdale, N .J.: Erlbaum, 1977): 63-88. For a good exploration of linguistic processing, see Stuart Glogoff' s, "Communication Theory's Role in the Reference Interview," Drexel Library Quarterly 19 (spring 1983): 56-72. For a discussion of schema theory as it relates to libraries, see Barbara Doyle-Wilch and Marian I. Miller's "Mediation and Schemata Theory in Meaningful Learning: The Academic Librarian's Role in the Educational Process," Reference Librarian 37 (1992): 121-27. 9. Rachael Naismith and Joan Stein, "Library Jargon: Student Comprehension of Technical Language Used by Librarians," College & Research Libraries 50 (Sept. 1989): 543-52. 10. Dean C. Barnlund, "The Mystification of Meaning: Doctor-Patient Encounters," Journal of Medical Education 51 (Sept. 1976): 722. 11. John Cullen, The Structure of Professionalism (New York: Princeton, 1978): 180; Frank H . Spaulding, "Image of the Librarian/ Information Professional; A Special Libraries Association Presidential Task Force," IFLA Journal 15 (1989) : 321; Judith Rodin and Irving L. Janis, "The Social Power of Health-Case Practitioners As Agents of Change," Journal of Social Issues 35 (1979): 60-81; John Thibaut, The Social Psychology of Groups (New York: Wiley, 1959): 109. 12. Paul Arntson and David Droge, "Addressing the Value Dimension of Health Communi- cation: A Social Science Perspective," Journal of Applied Communication Research 16 (1988): 6. 13. Judith Lorber, "Good Patients and Problem Patients: Conformity and Deviance in a Gen- eral Hospital," Journal of Health and Social Behavior 16 (June 1975): 74-76 . 14. Rodin and Janis, "The Social Power of Health-Care Practitioners as Agents of Change." 15. Many articles have been written on this topic, including: Brian Nielson, "Teacher or Inter- mediary," 183-89; James Rettig, "Self-Determining Information Seekers," RQ 32 (winter 1992): 156-63; James Rice, "Library-Use Instruction with Individual Users: Should Instruction Be In- cluded in the Reference Interview?" Reference Librarian 10 (spring/summer 1984): 75-84. 16. Lyle Saunders and Richard F. Larson, "Medical Vocabulary Knowledge among Hospital Patients," Journal of Health and Human Behavior 2 (summer 1961): 86-87. 17. Philip Ley, "Memory for Medical Information," British Journal of Social and Clinical Psy- chology 18 (1979) ): 252-53. 18. C. R. B. Joyce, and others, "Quantitative Study of Doctor-Patient Communication," Quar- terly Journal of Medicine, New Series 38 (1969): 192. 19. Warner V. Slack, "The Patient's Right to Decide," Lancet 2 (July 30, 1977): 240. 20. Analee E. Beisecker, "Patient Power in Doctor-Patient Communication: What Do We Know?" Health Communication 2 (1990): 109. 21. Kathryn Rost, William Carter, and Thomas Inue, "Introduction of Information During the Initial Medical Visit: Consequences for Patient Follow-Through with Physician Recommenda- tions for Medication," Social Science and Medicine 28 (1989): 321. 22. William B. Stiles, "Evaluating Medical Interview Process Components: Null Correlations with Outcomes May Be Misleading," Medical Care 27 (Feb. 1989): 212-20; Sheldon Greenfield, Sherrie Kaplan and John E. Ware, "Expanding Patient Involvement in Care: Effects on Patient Outcomes," Annals of Internal Medicine 102 (1985): 520-28. 23. Greenfield and others, Ibid, 526. 24. Beisecker, "Patient Power in Doctor-Patient Communication," 117. 25. Ralph Gers and Lillie J. Seward, "Improving Reference Performance: Results of a State- wide Study," Library Journal110 (Nov. 1, 1985): 32-35; Peter Hernon and Charles McClure, "Un- obtrusive Reference Testing: The 55 % Rule," Library Journal111 (1986): 37-41; Peter Hernon and Charles McClure, "Library Reference Service: An Unrecognized Crisis-A Symposium," Journal of Academic Librarianship 13 (May 1987): 69-80; Charles A. Bunge and Marjorie E. Murfin, "Refer- ence Questions-Data from the Field," RQ 27 (fall1987) : 15-18. 26. Gers and Seward, "Improving Reference Performance." 27. Joan C. Durrance, "Reference Success: Does the 55 Percent Rule Tell the Whole Story?" Library Journal114 (Apr. 15, 1989): 35-36. 28. Carole A. Larson and Laura K. Dickson, "Developing Behavioral Desk Performance Stan- dards," RQ 33 (spring 1994): 349-57; Terry L. Weech, "Who's Giving All Those Wrong Answers? Direct Service and Reference Personnel Evaluation," Reference Librarian 11 (fall/winter 1984): 109-22; David A. Tyckoson, "Wrong Questions, Wrong Answers: Behavioral vs. Factual Evalua- tion of Reference Service," Reference Librarian 38 (1992) : 151-73; Evaluation of Public Services Per- sonnel, ed. Bryce Allen. (Urbana : Univ. of Illinois, 1991); Janet Dagenais Brown, "Using Quality Concepts to Improve Reference Services," College & Research Libraries 55 (May 1994): 211-19. 29. Barbara M. Korsch, Ethel K. Gozzi, and Vida Francis, "Gaps in Doctor-Patient Interaction and Patient Satisfaction," Pediatrics 42 (Nov. 1968): 866. Reference Communication 57 30. Analee E. Beisecker and Thomas D. Beisecker, "Patient Information-Seeking Behaviors When Communicating with Doctors," Medical Care 28 (Jan. 1990): 19-28; Richard L. Street Jr., "Analyzing Communication in Medical Consultations," Medical Care 30 (Nov. 1992): 976-88. 31. Tyckoson, "Wrong Questions, Wrong Answers," 38; P. J. Hansel, "Unobtrusive Evalua- tion: An Administrative Learning Experience," Reference Librarian 19 (1987): 315-25. 32. Bunge and Murfin, "Reference Questions-Data from the Field," RQ 27 (fall1987): 15-18. 33. D.R. Rutter and G.P. Maguire, "History-taking for Medical Students II -- Evaluation of a Training Programme," Lancet 11 (1976): 558-60; G. P. Maguire, D. Clarke, and B. Jolley, "An Ex- perimental Comparison of Three Courses in History-taking Skills for Medical Students," Medi- cal Education 11 (1977): 175-82; G. P. Maguire, P. Roe, D. Goldberg, and others, "The Value of Feedback in Teaching Interviewing Skills to Medical Students," Postgraduate Medicine 8 (1978): 695-704; A. Werner and J. M. Schneider, "Teaching Medical Students Interactional Skills," New England Journal of Medicine 290 (1974): 1,232-37; A. D. Pool and R. W. Sanson-Fisher, "Under- standing the Patient: A Neglected Aspect of Medical Education," Social Science and Medicine 13 (1979): 37-43; C. M. Engler and others, "Medical Student Acquisition and Retention of Commu- nication and Interviewing Skills," Journal of Medical Education 56 (1981): 572-79; G. Alroy, R. Ber, and D. Kramer, "An Evaluation of the Short-term Effects of an Interpersonal Skills Course," Medical Education 18 (1984): 85-89; B. J. Evans and others, "Measuring Medical Students' Com- munication Skills: Development and Evaluation of an Interview Rating Scale," Psychology and Health 6 (1992): 213-25. 34. B. J. Evans and others, "Lectures and Skills Workshops as Teaching Formats in a History- taking Course for Medical Students," Medical Education 23 (1989) : 364-70. 35. Elaine Zaremba Jennerich, The Reference Interview as a Creative Art (Littleton, Colo.: Librar- ies Unlimited, 1987); Catherine Sheldrick Ross and Patricia Dewdney, Communicating Profession- ally: A How-to-Do-It Manual for Librarians (New York: Neal-Schuman, 1989). 36. Nathan M. Smith and Stephen D. Fitt, "Active Listening at the Reference Desk," RQ 21 (spring 1982): 247-49; Thomas P. Peck, "Counseling Skills Applied to Reference Services," RQ 14 (spring 1975): 233-35. For interesting articles that discuss listening and negotiating the user's first question, see Thomas Lee Eichman, "The Complex Nature of Opening Reference Ques- tions," RQ 17 (spring 1978): 212-22; Geraldine B. King, "Open and Closed Questions: The Refer- ence Interview," RQ 12 (winter 1972): 157-60; Brenda Dervin and Patricia Dewdney, "Neutral Questioning: ANew Approach to the Reference Interview," RQ 25 (summer 1986): 506-13; Chris- topher W. Nolan, "Closing the Reference Interview: Implications for Policy and Practice," RQ 31 (summer 1992): 513-23. 37. Marsha D. Broadway and Nathan M. Smith, "Basic Reference Courses in ALA-Ac- credited Library Schools," Reference Librarian 25/26 (1989) : 431-48; Robert E. Brundin, "The Place of the Practicum in Teaching Reference Interview Techniques," Reference Librarian 25 I 26 (1989) : 449-64; Edward J. Jennerich and Elaine Zaremba Jennerich, "Teaching the Ref- erence Interview," Journal of Education for Li- brarianship 17 (fall 1976): 107-11; W. Bernard Lukenbill, "Teaching Helping Relationship Concepts in the Reference Process," Journal of Education for Librarianship 18 (summer 1977): 110-20. 38. Schwartz and Eakin, "Reference Service Standards, Performance Criteria, and Evalua- tion," 4-8; Ralph Gers and Lillie J. Seward, "I Heard You Say ... Peer Coaching for More Ef- fective Reference Service," RQ 22 (1988): 245- 60. 39. Barron Holland, "Updating Library Ref- erence Services through Training for Interper- sonal Competence," RQ 17 (spring 1978): 207- 11; Peck, "Counseling Skills Applied to Refer- ence Services." 40. Barnlund, "The Mystification of Mean- ing," 723. •:• Over 90 Titles •:• Beginning in 1956 •:• Published Three Times a Year CHRISTIAN PERIODICAL INDEX Index covers a broad spectrum of knowledge from an evangelical Christian perspective. The State A of the rt sn1art Leaders in the Information Industry providing subscription services, article delivery and library automation software. • REMO Mouse driven serials management system. • Ross Online ordering, claiming and searching of journal and publisher databases. • Renewal Express PC-based system to analyze current serials holdings and plan for the future collection development. • Financial Planner Lotus format- ted worksheet to analyze previous spending history and plan future budget allocations. • UnCover The fastest most compre- hensive service for fax delivery of journal articles available today. • BACKSERV An Internet list devoted to the informal exchange of serial back issues among libraries. READMORE ACADEMIC SERVICES 700 Black Horse Pike, Suite 207 Blackwood, NJ 08012 Phone: l-800-645-6595 Fax: 609-227-8322