I have said many times the key to improving outcomes through patient education is involve the learner in the process and individualize the intervention to the specific needs of the learner. Especially when we feel frustrated, we need to let go of assumptions and return to assessment. The answers are often right in front of us. Here’s another example of the power of listening:
A woman with a genetic clotting disease admitted she didn’t take her prescribed medicine regularly. When the nurse asked why, she learned it was intentional.
The woman said she had to decide each morning whether or not she should take it. Before taking her medicine, the patient needed to calculate the likelihood her husband would beat her that day, based on his anger and alcohol status. She did not take blood thinners on days she felt at risk for developing a bleed.
Treating every patient with the same approach not only misses opportunities, but risks damaging relationships because the patient feels you don’t understand or care. Listen carefully.
Each patient is unique. Each intervention needs to be individualized. That is the art of health care.
Are you having trouble convincing your colleagues to always use teach back? Do they believe poor, uneducated patients can have health literacy issues, but think it’s insulting to evaluate understanding of middle class or higher patients?
The stress of a health threat can seriously compromise cognitive processing. So under other circumstances this particular patient might understand it, but not today, not now. In addition, health care professionals may think they’re speaking in plain language, but it’s really jargon-filled code.
Sometimes you just can’t reach even professionals with logic. You have to go back to assessment. Do they believe all patients who nod affirmatively understand them? Do they believe all articulate patients will ask questions if they don’t understand? Do they realize sometimes the patient thinks he or she understands, but actually doesn’t?
That’s why we always need teach back.
So here’s a little tool to help you reach those colleagues through the affective domain. Skip the logic route and reach them through their innate compassion.
Show your colleagues this video from the Children’s Hospital of Wisconsin of a real mom who thought she understood the doctor, but really didn’t. Then talk about it with them. Explain how a simple teach back would have prevented . . . well, you’ll see.
Advice about health maintenance, like tobacco use, exercise, body mass index, sleep, alcohol consumption, and screening guidelines, is not always consistent with the health care professional’s own practice. A study of 418 completed surveys from physicians, registered nurses, physician assistants and nurse practitioners concluded:
“Our analysis demonstrated discrepancies between patient education and what the provider practiced.”
So what does this mean? Is the health care professional advising the patient to do things he or she doesn’t believe are a priority? Is the health care professional advising the patient to do things without explaining how do succeed?
Of course these discrepancies will come up frequently — getting enough sleep is the first one that comes to my mind. So how do we handle it?
Pay attention when you teach. You don’t have to reveal adherence is an issue for you, too. But notice when you are advising the patient to do something you are not doing yourself. Then think about why you are not doing it, and incorporate that understanding into your conversation. For example, if you don’t get enough sleep, it may be related to too busy a schedule or too much to think about and bedtime. Assess the patient’s challenges, which may not be the same as yours. Then use motivational interviewing to help the patient problem solve. Provide resources when available.
Being aware of your own issues can help you be more sensitive to the plight of the patient. This awareness helps you bring the discussion to a level beyond a pronouncement, like “lose weight,” to a conversation of how to optimize healthy habits now. In a discussion, you may learn the patient doesn’t understand the risks of the behavior, or wants to succeed, but doesn’t know. Your teaching may be ineffective because you only give the patient assignments, without offering the health coaching to guide the patient through the behavior change.
Patient-centered care means health care is a negotiation process. The goal is to optimize health outcomes by working within the skills, resources, and situation presented by the patient. It is not more work. It is the work.