This study suggests, like so many others, patients are not getting appropriate information or don’t understand it well enough to make informed decisions. This study also suggests that health care professionals are not assessing patients’ beliefs and knowledge consistently, or correcting misunderstandings. The consequence? A patient who thinks this procedure will prevent heart attacks may agree to have it done, and then stop taking his or her medicine.

We are spending a lot of money on new drugs, new procedures, and new technology to improve health care, while the importance of communication slips out of priority. Is this too low-tech to hold our interest? What good is saving time by skipping a conversation, if we don’t save the patient?

Source: Rothberg, M. B., Sivalingam, S. K., Ashraf, J., Visintainer, P., Joelson, J., Kleppel, R., et al. (2010). Patients’ and cardiologists’ perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med, 153(5), 307-313.

One way I’m using Twitter is to link to recent research relating to patient and family education. For example, here are Tweets I have scheduled to appear in the coming week:

http://tinyurl.com/27cz654 Relationship between treatment adherence and clinical outcomes in patients on maintenance hemodialysis. #nursing

http://tinyurl.com/2fyxueo Addressing patients’ concerns about pain management and addiction risks. #patienteducation #nursing #healthcare

http://tinyurl.com/2fzkope No, you need a conversation to ensure understanding. #healthliteracy #evidencebasedmedicine #healthcare

http://tinyurl.com/27o5jwt Patients’ beliefs about the cause of their depression: only 3.6% stated biological reasons. #patienteducation

http://tinyurl.com/235oroy Comprehensive discussions about chronic medications are uncommon in routine practice. #evidencebasedmedicine

http://tinyurl.com/2embdxo Health literacy screening questions can be used to triage patients at risk for not reading. #healthliteracy #pted

http://tinyurl.com/29ckgvs Postoperative patient education: what type of approach and mode, and at what dose? #patienteducation #surgery

Are you using Twitter now? If so, follow me @notimetoteach. Let me know what your Twitter handle is, too, so I can follow you.

If you want to learn more about Twitter, you can download the booklet, Twitter for Beginners from http://socialmediadiyworkshop.com/2010/02/ebook-twitter-for-beginners/

Some business-oriented administrators who are not health care providers may perceive patient education as a non-revenue producing, unnecessary expense. I suspect they haven’t experienced serious illness yet. Here is my response to that question:

* * * * * *
OK, try to imagine hospital care WITHOUT patient education.

You’re admitted into the hospital and things just get done to you. No informed consent. No warning about what is about to be done to you and why. No information about your problem or what the treatment options are. You get taken to surgery. You wake up not knowing what happened and you hurt. Medicine is given to you without explanation — just take it. No advice about how to take care of yourself after leaving the hospital. No plans for follow-up, no information about who to call if you have a problem. You are just handed some prescriptions written in Latin and told to leave. You have no idea what you can do to avoid going through this again.

Could you possibly have this experience and feel you got the best care possible from medical experts? When you don’t get quality patient education, you know it. You are not involved, and you don’t feel safe or cared for. Patient education is not an extra. It is an essential, but often invisible, part of care.

So now you explain: How does patient education NOT fit into the hospital business model?

* * * * * *

Looking at the business model for a restaurant, I could see how one could focus on the purpose: get food into people. It might be easy to say providing restroom facilities is an unnecessary expense, since it is diametrically off the purpose. However, a different perspective might prove otherwise. Don’t get fooled into thinking patient education is an extra service of health care providers. It IS the service.

I propose a health care organization that focuses on providing the highest quality patient and family education would easily stand out in the crowd as providing the best care. Even if it didn’t offer the most experienced surgeons who regularly publish in peer reviewed journals.

Suddenly, I felt like I had a functional literacy problem. I understood the word “native.” I understood the word “files.” But I had no idea what a “native file” was. I didn’t even have a guess. I did not want to make a mistake, so I emailed the requestor and asked for a definition. I got a polite and helpful response.

For those of you who don’t know, when they said “no native files” they actually meant “send files in the PDF format.” (Or, I learned later from a friend, maybe a JPG would qualify.) A native file is a file that is still in the format of the program in which it was created, like a Word document or a Keynote slide show.

In this situation, I may have experienced what some of our patients sometimes feel like. The words sound familiar, but they have no idea what we are talking about. They have no idea what they are supposed to do. They don’t want to make a mistake — especially if it could physically hurt them. But it’s hard to admit you don’t understand, especially when it’s presented in a way that implies, “Of course you understand this. It’s simple.”

Another reason to ask patients to teach back what we teach them.

©2010 Fran London

You can read details of the Ask Me 3 program at http://www.npsf.org/askme3/for_patients.php

They suggest that if the patient still doesn’t understand, he or she might say, “This is new to me. Will you please explain that to me one more time?”

I agree, every patient should feel comfortable asking these questions. But isn’t it also our responsibility to provide the answers to these questions without prompting? And isn’t it our responsibility to evaluate understanding and have patients teach back to us the answers to these questions? How else would we know they understand? Then, at least, if they choose to not follow our advice, it is an informed choice and not a misunderstanding.

One randomized trial of 20 practices (Galliher, Post, et al, 2010) evaluated whether implementing the Ask Me 3 program improves patients’ question-asking behavior and increases adherence to prescription medications and lifestyle recommendations. Their conclusion: “In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.”

This, to me, means some patient populations ask questions at a lower rate. You know them. They may have poor functional health literacy skills. They may be from a lower socioeconomic group. They may be less educated. They may speak English as a second language, or not at all. I suspect handing these people a brochure that encourages them to ask questions is not enough to overcome disparities in health and health care.

I believe there should be a discussion between the health care provider and patient before the answer to “what do I need to do” becomes clear. It should include what the options are, their costs, risks, and benefits, including what happens if the patient chooses to do nothing. Then the health care provider and patient negotiate a treatment plan. At that point, “what do I need to do” becomes “what I choose to do.” This is one way we can move from provider-centered care toward patient-centered care.

So encourage your patients to Ask Me 3, but also provide the answers to these questions without prompting. Don’t think Ask Me 3 replaces your need to evaluate understanding by using teach back and return demonstration. Health care communication goes in two directions. Hold up your end, too.

If you want to learn more:
Galliher, J. M., Post, D. M., Weiss, B. D., Dickinson, L. M., Manning, B. K., Staton, E. W., et al. (2010). Patients’ question-asking behavior during primary care visits: a report from the AAFP National Research Network. Ann Fam Med, 8(2), 151-159.

But maybe that isn’t entirely true anymore. Recent research examined the impact of the desirability of content on viewers’ ratings of subjective video quality. Kortum and Sullivan (2010) studied 100 participants and 180 movie clips encoded at nine levels from 550 kbps up to DVD quality. Participants viewed clips that were 2 minutes in length and then were asked about video quality of the clips and desirability of the movie content. They found a strong correlation between the desirability of movie content and subjective ratings of video quality.

Yes, this study considered the quality of video, not the quality of camera work and lighting. But it does show people are not as spoiled as we thought they were. Perhaps the public’s values have been modified by exposure to engaging homemade movies on YouTube and other video-sharing sites. Perhaps now, while surfing through videos online, they are looking for engaging content rather than slick production. Clearly more research needs to be done in this area. Because if, indeed, high quality content persuades viewers to rate the quality of the video higher, we could save money on production by focusing on our messages, ultimately lowering the cost of patient education. That’s good news.

From: Kortum, P., & Sullivan, M. (2010). The effect of content desirability on subjective video quality ratings. Hum Factors, 52(1), 105-118. http://www.ncbi.nlm.nih.gov/pubmed/20653229?dopt=Citation

One way some organizations are trying to communicate with people with low functional health literacy skills is to use pictographs or pictograms in their printed materials. These are pictorial symbols for words or phrases, or statistics in a chart or graph.

Weiss (2007) states that “using pictures, including cartoons or pictographs with verbal explanations and use of models, can greatly increase patient understanding and retention of information” (page 40).

A study by Yin, Dreyer, van Schaick, Foltin, Dinglas, & Mendelsohn (2008) concluded a plain language, pictogram-based intervention used as part of medication counseling decreased medication dosing errors and improved adherence among multiethnic, low socioeconomic status caregivers whose children were treated at an urban pediatric emergency department.

Zeng-Treitler, Kim, & Hunter, (2008) supplemented discharge instructions with free texts with pictographs, and tested them on 13 healthy volunteers. They found the pictograph enhancement resulted in statistically significant better recall rates (p<0.001).

But before you add pictographs and pictograms into your printed materials, test them with your patient populations. Doak, Doak, & Root (1996) warned that when staff tested some computer graphic pictograms with focus groups, patients found them to be cold and unclear. They recommended you use visuals that give a sense of realism and the patient see the action recommended.

Chuang, Lin, Wang, & Cham (2010) discovered pictographs designed by medical professionals may not be optimal for elderly and low-literacy patients. They offered choices of 12 sets of pictographs and found the preference of patients and medical staff was significantly different. Comprehension was significantly different between patients and medical staff for several pictographs.

So yes, pictograms and pictographs can help your patients with low functional health literacy skills understand your printed instructions. But be sure to test them on your patient population. What may seem clear to you may make no sense to your patient. And what may work for your population may not work for each individual patient. Always evaluate understanding with teach back. After explaining to your patient what needs to be done, have your patient teach the content back to you to be sure he or she understands. This gives you the opportunity to correct misunderstandings before they become medical errors.

If you want to learn more:

Chuang, M. H., Lin, C. L., Wang, Y. F., & Cham, T. M. (2010). Development of pictographs depicting medication use instructions for low-literacy medical clinic ambulatory patients. J Manag Care Pharm, 16(5), 337-345.
http://www.amcp.org/data/jmcp/337-345.pdf

Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia: J. B. Lippincott Company. http://www.hsph.harvard.edu/healthliteracy/doak.html

Hill, L. H., & Roslan, M. M. (2004). Using visual concept mapping to communicate medication information to chronic disease patients with low health literacy. Paper presented at the Concept Maps: Theory, Methodology, Technology. Proceedings of the First International Conference on Concept Mapping, Pamplona. Spain.

The Joint Commission. (2010). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL:: The Joint Commission. http://www.jointcommission.org/PatientSafety/HLC/

Weiss, B. D. (2007). Manual for clinicians: Health literacy and patient safety: Help patients understand. 2nd. http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

Yin, H. S., Dreyer, B. P., van Schaick, L., Foltin, G. L., Dinglas, C., & Mendelsohn, A. L. (2008). Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. Arch Pediatr Adolesc Med, 162(9), 814-822. http://archpedi.ama-assn.org/cgi/content/full/162/9/814

Zeng-Treitler, Q., Kim, H., & Hunter, M. (2008). Improving patient comprehension and recall of discharge instructions by supplementing free texts with pictographs. AMIA Annu Symp Proc, 849-853.

http://www.guidelines.gov/resources/patient-education.aspx

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals

Rather than print it, you might want to enjoy it from your computer screen. It’s 102 pages packed with example practices, information on laws and regulations, and links to supplemental information, model policies and educational tools.

For more information go to:
http://www.jointcommission.org/PatientSafety/HLC/

For practical advice on how to meet these standards in real life, in real time, read No Time to Teach.