Why Some Patients Aren't Following Your Instructions

Neil Chesanow


May 29, 2013

In This Article

An Epidemic of Miscommunication

Nearly one half of all adults in the United States -- 90 million people -- have trouble understanding what the doctor tells them about why they are sick and how to comply with their medication regimens, according to the Institute of Medicine.[1]

That's a lot of people -- so many that the chances are good that a few, if not more, of them are in your practice.

Here's the catch, though: It's not easy to tell who these patients are. They're ashamed that they can't comprehend what they are told or given to read, and so they've become masters at faking it.

As such, although you may be articulate, it's likely that some explanations you give to patients about their conditions, how to take their medications, and how to otherwise follow the regimens you prescribe are going in one ear and out the other -- even if you ask, "Do you understand?" and the patient says "yes."

Patients who may have problems with health literacy include senior citizens, young adults, immigrants with a limited grasp of English, people with different cultural belief systems, those with limited education, and persons with visual or cognitive impairment.

But "you can't tell by looking," cautions Helen Osborne, President of Health Literacy Consulting in Natick, Massachusetts. The last people you'd expect to have trouble understanding the doctor -- affluent, articulate, educated professionals -- may also fail to grasp common clinical terms, concepts, and instructions that doctors take for granted are understood.

Even physicians may have trouble making sense of what their doctors tell them. Health Literacy and Patient Safety,[2] a manual for clinicians on communicating clearly with patients that is published by the American Medical Association (AMA), recounts an anecdote about a prominent obstetrician who could not fully understand the explanation he received from an orthopedist about his upcoming orthopedic surgery.

Are You Talking Over Patients' Heads?

When you take the time to discuss a patient's condition or explain how to take a certain medication, of course you want and indeed expect to be understood. And you're aware that most patients aren't physicians, so you simplify things in a way that you believe a nonphysician would be able to understand.

Unfortunately, even with that adjustment, many doctors inadvertently talk way over their patients' heads. That's because physicians often profoundly overestimate what their patients are truly able to understand.

For example, studies show that among patients with limited literacy skills, 26% do not understand when their next appointment is scheduled, 42% do not understand instructions to "take medication on an empty stomach," and up to 78% misinterpret warnings on prescription labels.[2]

In a study of patients with limited health literacy, participants didn't really understand the meanings of words that physicians regularly use in discussion with patients -- for example, "bowel," "colon," "screening test," or "blood in the stool."[3] In another study, 1 in 4 women who said they knew what a mammogram was actually didn't.[4]

Complicating matters, even patients who understand what is said in some circumstances may not in others. Osborne recalls waking up one night with a searing pain in her eye. Disoriented and with only partial vision, she rushed to an eye and ear hospital in Boston. "I go there, I'm really in pain, and I'm scared," she recalls. "It's 3 AM. The person at the front desk hands me this form to fill out. I said, 'What's that?' He said, 'Fill this out in order for the doctor to see you.'"

"I had no idea what that form was," Osborne reflects. "I wanted to be seen. So I signed the document. It would have been much more helpful if the person covering the desk at that hour -- at an eye hospital, for goodness' sake -- had gone over the form with me and helped me fill it out."


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