Why Some Patients Aren't Following Your Instructions

Neil Chesanow

Disclosures

May 29, 2013

In This Article

Don't Let Your Work Go to Waste

You've made a good diagnosis. You've prescribed the right treatment. Don't let all that solid work go to waste by letting a patient leave your office without understanding what's necessary to follow the regimen you've prescribed.

Speak slowly; it makes you easier to understand. Avoid medical terms and jargon. A "cardiologist" is a "heart doctor." "Chemotherapy" is "drugs to treat cancer." An "echocardiogram" is "pictures of your heart." "Metastasis" means "the cancer has spread." Pretend that you're speaking to your grandmother, the AMA manual suggests, to give you a sense of what and how to communicate.[2]

"Communicate in a variety of ways to see what works," Osborne adds. "Health messages are hard for many people to understand. In healthcare, we tend to just use the spoken and written word. Help patients understand what you mean by drawing pictographs, using models, explaining with metaphors, using analogies, telling stories, playing videos or CDs, visiting interactive Websites, and using other creative ways to communicate important health information."

Giving patients information in bite-size pieces improves their recall. Most patients can only remember 3-4 key points, Osborne says, so avoid too giving too many details. Repeat each point; repetition also enhances recall.

Health information is filled with confusing numbers that patients and their caregivers often struggle to understand and use. How can you help? Try being visual, Osborne suggests. Instead of instructing the patient to take 1 ounce of liquid, mark how high to fill the drinking cup. Use a divided plate to show food portions. Make meaningful comparisons: For example, 4 ounces of meat is about the size of a deck of playing cards, and 5 pounds is the about size of a bag of flour.

Similarly, many patients wrestle with concepts of time. To avoid confusion, schedule medication around an individual's daily habits. For example, "Take 1 pill after brushing your teeth in the morning and 1 pill after brushing your teeth at night," Osborne explains. "Together with the patient, draw 2 hands on an analog clock to show the proper dosing time. Include pictures or icons representing time, such as sunrise and sunset." Pillboxes sectioned into the day of the week and time of day are the best assurance that patients will take all their medications punctually, particularly those who are on multiple, concurrent regimens.

Use the 'Teach-Back' Technique

It's said that every doctor is also a teacher. But one of the most effective tools to confirm how well patients understand what you say is to reverse roles. Ask them to teach you in their own words what you just said. This is called the "teach-back" technique, and research indicates that it's effective, not just in improving patients' understanding but also for improved outcomes.[5]

For example, studies show that patients with diabetes who were asked by their physicians to recall the instructions the physicians just gave have significantly better control of their disease than patients whose physicians gave instructions but didn't assess patients' comprehension and recall.[5]

The success of the teach-back technique hinges on "the practitioner taking responsibility for the communication, where it belongs," says Osborne. "In asking a patient to repeat in his or her own words what you just said, you wouldn't say, 'I want to see if you understand this.' Instead, you would say, 'I want to ensure that I explained this clearly. When you go home and talk with your husband or wife about this, what will you say?'"

Assuming the onus yourself ("Was I clear?") rather than putting in on the patient ("Do you understand?") is "taking responsibility," Osborne says. "If the patient then doesn't understand, reframe the point you just made in other words. Don't wait until the end of the appointment, when you've already talked about a number of issues. After each point, pause; ask the patient to paraphrase; listen; and, if necessary, reteach the information using alternate approaches."

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