"Tell Back- Collaborative Inquiry" for Understanding Med Info
Purpose: The goal of this study was to determine which approach to assessing understanding of medical information patients most prefer and perceive to be most effective.
Methods: Two videos were shown to participants: (1) a physician explaining a medical condition and its treatment and (2) a physician inquiring about patient understanding of the medical information the patient had been given using 3 different types of inquiry: Yes-No, Tell Back-Collaborative, and Tell Back-Directive.
Results: The Tell Back-Collaborative inquiry was significantly preferred over the other 2 approaches.
Conclusions: Patients strongly prefer the Tell Back-Collaborative inquiry when assessing their understanding. We recommend that physicians ask patients to restate what they understand using their own words and that they use a patient-centered approach.
There is considerable evidence that many patients leave medical encounters with a poor understanding of their disease and the recommended treatment. Hewson found that, when patients were asked to explain what had been told them, their explanations included so many gaps and errors that half of the information they had been given was lost. Several early studies substantiated poor understanding of medical information, with reports of lost information ranging from 46% to 63%. More recently, a study of 20 general practices in England reported that misunderstandings associated with actual or potential adverse outcomes occurred in 80% of consultations. A study of patient retention of information given during consent for mammoplasty found that patients were able to recollect on average 3 of 12 pieces of the information given them, or only 25%. In another study, patients were asked immediately after discharge from the emergency department about diagnosis and treatment recommendations; although 79% of patients gave the correct diagnosis, correct treatment information was given by only 49% of patients.
There is a high cost for inadequate understanding of medical information for the patient, the physician, and society as a whole. For patients, misunderstanding can lead to a lack of adherence to treatment recommendations with concomitant adverse health outcomes, as well as decreased satisfaction with the clinician and the medical encounter. Physicians who fail to check for patient understanding of medical information may increase their risk of malpractice claims. Finally, the society as a whole absorbs an estimated $73 billion annually because of misunderstood medical information.
Despite the prevalence of inadequate understanding of medical information and the value of well-understood medical information, physicians do not typically check for patient understanding. A study of audiotaped patient encounters with primary care physicians showed that patient understanding was assessed only 2% of the time. The infrequency of checking for understanding was further documented by the findings of Campion et al in a large study about communication skills of physicians completing 3 years of post graduate training. Campion and his colleagues analyzed data from over 10,000 videotapes submitted by 2,094 physicians as part of their certification examination and found that 44.9% of these physicians failed to confirm understanding in 1 of 5 videotapes. Furthermore, 99.7% failed to confirm understanding consistently across all 5 tapes they submitted. These findings are particularly salient because this was a high-stakes examination and because applicants themselves selected these 5 tapes as their "best" work.
Given the importance of patient understanding of medical information, surprisingly few specific recommendations are available in the literature regarding how to approach this task. The Kalamazoo Consensus Statement, developed in 1999 by 21 communication experts representing medical education organizations in North America, identified checking for understanding as part of the core communication skill of "sharing information", but it did not specify a method for doing so. Although many of the communications assessment tools currently used in medical education include an assessment of whether the interviewer checks for patient understanding, none describe in specific detail how that assessment should occur.
A search of the literature in PubMed using the words "check for patient understanding" yielded 44 articles, none directly related to this study. An exhaustive search of several databases yielded one article, published before the advent of the patient-centered model, with recommendations for checking patient understanding of medical information. In this article, Bertakis reported that patients who were "asked to repeat in their own words the information which they had just been given" showed a significant increase in retention of information and satisfaction with their physicians. Based on this finding, the author provided a general recommendation that this method be used across health care settings. However, no specific recommendations were made regarding how the physician should inquire about patient understanding.
Several authors have suggested an "Ask-Tell-Ask" method to improve patient understanding. This approach entails the following: Ask patients to describe their understanding of their disorders and treatments; Tell them additional needed information in a way that incorporates their perspective; and then Ask what they understand and feel about the information given.
The most recent recommendation was formulated by Weiss as a result of insights gained in his personal practice. He recommended having patients reiterate their understanding of medical information rather than simply asking whether they have any questions. He also emphasized the importance of creating a "shame-free" environment by normalizing the difficulty of understanding medical information and specifically inviting patients to ask questions about anything they do not understand.
None of the aforementioned recommendations have provided a specific approach to physician inquiry about patient understanding, nor have any been tested to determine patient preference. The goal of this study was to determine which approach to assessing understanding of medical information patients most prefer and perceive to be most effective.
Purpose: The goal of this study was to determine which approach to assessing understanding of medical information patients most prefer and perceive to be most effective.
Methods: Two videos were shown to participants: (1) a physician explaining a medical condition and its treatment and (2) a physician inquiring about patient understanding of the medical information the patient had been given using 3 different types of inquiry: Yes-No, Tell Back-Collaborative, and Tell Back-Directive.
Results: The Tell Back-Collaborative inquiry was significantly preferred over the other 2 approaches.
Conclusions: Patients strongly prefer the Tell Back-Collaborative inquiry when assessing their understanding. We recommend that physicians ask patients to restate what they understand using their own words and that they use a patient-centered approach.
There is considerable evidence that many patients leave medical encounters with a poor understanding of their disease and the recommended treatment. Hewson found that, when patients were asked to explain what had been told them, their explanations included so many gaps and errors that half of the information they had been given was lost. Several early studies substantiated poor understanding of medical information, with reports of lost information ranging from 46% to 63%. More recently, a study of 20 general practices in England reported that misunderstandings associated with actual or potential adverse outcomes occurred in 80% of consultations. A study of patient retention of information given during consent for mammoplasty found that patients were able to recollect on average 3 of 12 pieces of the information given them, or only 25%. In another study, patients were asked immediately after discharge from the emergency department about diagnosis and treatment recommendations; although 79% of patients gave the correct diagnosis, correct treatment information was given by only 49% of patients.
There is a high cost for inadequate understanding of medical information for the patient, the physician, and society as a whole. For patients, misunderstanding can lead to a lack of adherence to treatment recommendations with concomitant adverse health outcomes, as well as decreased satisfaction with the clinician and the medical encounter. Physicians who fail to check for patient understanding of medical information may increase their risk of malpractice claims. Finally, the society as a whole absorbs an estimated $73 billion annually because of misunderstood medical information.
Despite the prevalence of inadequate understanding of medical information and the value of well-understood medical information, physicians do not typically check for patient understanding. A study of audiotaped patient encounters with primary care physicians showed that patient understanding was assessed only 2% of the time. The infrequency of checking for understanding was further documented by the findings of Campion et al in a large study about communication skills of physicians completing 3 years of post graduate training. Campion and his colleagues analyzed data from over 10,000 videotapes submitted by 2,094 physicians as part of their certification examination and found that 44.9% of these physicians failed to confirm understanding in 1 of 5 videotapes. Furthermore, 99.7% failed to confirm understanding consistently across all 5 tapes they submitted. These findings are particularly salient because this was a high-stakes examination and because applicants themselves selected these 5 tapes as their "best" work.
Given the importance of patient understanding of medical information, surprisingly few specific recommendations are available in the literature regarding how to approach this task. The Kalamazoo Consensus Statement, developed in 1999 by 21 communication experts representing medical education organizations in North America, identified checking for understanding as part of the core communication skill of "sharing information", but it did not specify a method for doing so. Although many of the communications assessment tools currently used in medical education include an assessment of whether the interviewer checks for patient understanding, none describe in specific detail how that assessment should occur.
A search of the literature in PubMed using the words "check for patient understanding" yielded 44 articles, none directly related to this study. An exhaustive search of several databases yielded one article, published before the advent of the patient-centered model, with recommendations for checking patient understanding of medical information. In this article, Bertakis reported that patients who were "asked to repeat in their own words the information which they had just been given" showed a significant increase in retention of information and satisfaction with their physicians. Based on this finding, the author provided a general recommendation that this method be used across health care settings. However, no specific recommendations were made regarding how the physician should inquire about patient understanding.
Several authors have suggested an "Ask-Tell-Ask" method to improve patient understanding. This approach entails the following: Ask patients to describe their understanding of their disorders and treatments; Tell them additional needed information in a way that incorporates their perspective; and then Ask what they understand and feel about the information given.
The most recent recommendation was formulated by Weiss as a result of insights gained in his personal practice. He recommended having patients reiterate their understanding of medical information rather than simply asking whether they have any questions. He also emphasized the importance of creating a "shame-free" environment by normalizing the difficulty of understanding medical information and specifically inviting patients to ask questions about anything they do not understand.
None of the aforementioned recommendations have provided a specific approach to physician inquiry about patient understanding, nor have any been tested to determine patient preference. The goal of this study was to determine which approach to assessing understanding of medical information patients most prefer and perceive to be most effective.
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