Education Columns

By Amanda Kost, MD; Daniel Ruegg, MD; Sharon Dobie, MD, Department of Family Medicine, University of Washington

Ask any physician and they know the health literacy of a patient significantly impacts their ability to manage their health. Yet, despite this, most physicians do not implement strategies to assess and improve patient understanding. If physicians have their own low literacy experience, they can gain new insight into how a patient with low health literacy copes when faced with a situation they do not understand and the obstacles low health literacy create to patient understanding and adherence. It can open a physician’s eyes to their contribution to the “continuum of confusion”¹ many patients face in the health care environment.

An exercise in which participants teach each other key information from cooking recipes quickly induces a low literacy interaction for a majority of people, even experts in the kitchen. Why a recipe? It is remarkably similar to a patient interaction—it is a lot of information, often assuming a foundation of knowledge, inside of which are specific instructions required for a good outcome. Even a simple recipe requires detailed knowledge about ingredients, how to put them together, and what cooking method to use. This is similar to a medication prescription, where a patient needs to know, minimally, the name of the drug, the dose, and when to take it.

Participants are given a recipe and three or four key pieces of information they must communicate to the learner. For example:
1. The name of the recipe—Risotto With Porcini Mushrooms
2. Key Ingredient One—Arborio rice, two cups, cooked on medium heat.
3. Key Ingredient Two—Dried porcini, mushrooms, reconstituted, stirred in after 10 minutes.

The teacher reads the recipe to the learner and uses any method they want (including what they would usually use in clinic) to help the learner remember the key points. The facilitator then quizzes the learners on their retention of key points. Learners begin to use coping mechanism similar to what we see in our patients: they look for help from other people, they do the best they can and guess at key points perhaps giving inaccurate or incomplete information, or they give up. They experience a range of emotions familiar to many patients, including shame, frustration, and anxiety. Likewise, the teacher realizes that despite their best efforts, their explanation did not help the learner truly understand the information.

The group learns a simple intervention—the teach-back. It involves asking the learner to explain in their own words their understanding of the key points of the information. In clinic this might be, “We’ve covered a lot today, and I want to make sure I’ve explained things well. Can you tell me what you understand the plan to be?” The teacher can correct misinformation and ensure that the learner masters important points. Although shown to be the most effective assessment of patient understanding, the teach-back is the method most infrequently used by physicians to see what patients understand.^2,3 Many physicians show resistance to implementing the teach-back, most often because they fear it will take too much time.^4,5 In the recipe exercise, teachers can see the dramatically improved comprehension of the learner when they present a second recipe and use the teach-back to assess for understanding and reinforce concepts. They can see that the dividend of increased comprehension is well worth the time invested.

This exercise helps physicians recognize that the teach-back can be practically implemented. Sessions held this year during clinic retreats and at the Scientific Assembly of our state academy received overwhelmingly positive reviews, with future sessions planned for medical students at our university and for clinic managers at our academic medical center. In one session, a physician said she realized she had not been trying to teach her patients the equivalent of one recipe but instead would give a Thanksgiving dinner’s worth of information without checking at all to see if the patient understood.

We often have a sense that we can explain our way to patient comprehension. Ironically, more explanation can confuse patients because they cannot figure out what information is truly important. Even if everything is done right medically, if your patient does not understand what they need to do, things can go horribly wrong. So please, try this. Gather everyone together from your clinic to have his or her own low literacy experience. Then take that experience with you into the exam room, stop explaining, and start asking for a teach-back.

References
1. Boone S, Winship D, Wynia M. Health literacy and patient safety: help patients understand. American Medical Association Foundation, August 2007.
2. Farrell MH, Kuruvilla P, Eskra KL, Christopher SA, Brienza RS. A method to quantify and compare clinicians' assessments of patient understanding during counseling of standardized patients. Patient Educ Couns 2009;77(1):128-35.
3. Farrell MH, Kuruvilla P. Assessment of parental understanding by pediatric residents during counseling after newborn genetic screening. Arch Pediatr Adolesc Med 2008;162(3):199-204.
4. Turner T, Cull WL, Bayldon B, et al. Pediatricians and health literacy: descriptive results from a national survey. Pediatrics 2009 Nov;124 Suppl 3:S299-S305.
5. "Teach back:" a tool for improving provider-patient communications. In Focus 2006;April.