Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St. Pomona, CA

Patient Education: A Must

This week, I write to you from sunny Vancouver, British Columbia, Canada. And it is, in fact, sunny and beautiful. I've never been to Vancouver before, and it's clear the Canadians have done something right with this city. It's a must see. Unfortunately, I'm here not for pleasure but for business. I am attending the Collaboration Across Borders IV conference, which is an every two year meeting for educators in the interprofessional education and practice community. Interprofessional education (IPE) is becoming an ever increasing movement in professional programs that teach healthcare (everything from audiology and dental hygiene to nursing and Patient Education medicine – and, of course, podiatry). One of the important goals of IPE and its cousin, interprofessional practice (IPP), is the reduction of medical error through improved communication both between professions and with patients. And it's at this intersection that the conference's first plenary speaker made a significant impact on me.

The speaker was a lady named Regina Holliday who is an artist and activist. She spent an hour speaking to an audience of 800 people about her dying husband's experiences with the medical profession. It would be impossible for me to express here the emotional nature of her speech, but for those interested click, here for some background. The short of it is, Mrs. Holliday's husband was diagnosed late in the course of metastatic renal cancer and succumbed to his disease, only after going through a terrible ordeal, made unnecessarily worse by various aspects of poor medical care. Mrs. Holliday's experiences are, unfortunately, too common in medicine, and we hear stories quite often about patients treated poorly.

Of all the stories I've heard or read about, one of the common themes is a lack of patient education by the health-care worker. It seems like a no-brainer, but I'm surprised how commonly we do a poor job educating our patients. There are three primary ways this can happen:

We don't tell them anything.
We tell them and expect them to understand, but they don't.
We use medical jargon.

Tonight's Premier Lecture is
In Office Dispensing
Current Concepts Controversies
Blessing or Curse
Marc A. Brenner, DPM

The first two are understandable, considering the short amount of time many of us have with our patients. If you're a busy family practice physician or even a specialist with a jam packed schedule, it is easy to skip this part of the encounter or give it short shrift. The third error is inexcusable. Why would anyone use medical jargon to speak to lay persons? We so soon forget that it took us years to master the vocabulary of medicine. Why would our patients be expected to understand this jargon?

"I never do this," you say? Well, maybe you don't, but I've watched seasoned 40-year physicians use jargon, while their patients nod their head affirmatively. Did the patients understand? Of course, not. How could they? They just don't want to look ignorant in front of the doctor. You know who's ignorant in this case? The doctor. They're ignorant of human nature and rational thought.

It's the second error that is likely most common. We "teach" our patient something, expecting them to understand our clear instructions and information, while in reality, they recall almost nothing we say after the encounter ends. Think about this for a minute. Say you have a patient with plantar fasciitis. We all know that, in reality, truly understanding plantar fasciitis/osis requires extensive knowledge of foot biomechanics (along with the rest of the extremity). Obviously, you're not going to teach a biomechanics class in the 15 minute encounter, so you simplify the conversation with your stock explanation. "There's a ligament on the bottom of your foot..." You might go on to explain calf tightness, foot position, etc. Your patient nods knowingly with a look of "now I get it" in her eyes, and you're satisfied that you've "educated" your patient. Of course, when she leaves, she remembers very little of your teaching after the encounter.

I saw this happen very recently in one of my own patients. I had a patient with symptomatic pes planus, and as part of my care plan, I educated the patient on appropriate shoe choice by demonstrating a very simple 3 step method. Job done, right?

Wrong.

Three weeks later, the patient returned for follow-up with a pair of new but poorly supportive shoes. He did buy new shoes, but didn't recall the three simple steps I'd demonstrated previously. I failed to educate my patient. Whose fault was this? Mine.

What should I have done to improve my patient education and prevent this error?

Let's first list a few options to help improve patient understanding and recall. Most of these will seem obvious (though are unfortunately more rare than we realize).

Don't use jargon.
Take time to speak clearly.
Be blunt only when necessary. Would it be possible to reword "I'm going to cut off the front of your foot"? It may be true, but there are less cruel ways to communicate.
Allow questions from the patient.
Use pictures. If you show radiographs, draw on them. Make it explicit. Want to explain a neuroma? Use a picture to illustrate. That way, you're using multiple methods to educate.
Ask your patient to repeat what you told them. This sounds cumbersome and possibly embarrassing for the patient, but it at least demonstrates they've understood what you've said.
Write it down. Since patients are unlikely to remember a lot of detail (or may not be neurologically capable of remembering) a written version will be helpful to refer to later.
Refresh their memory at the next encounter by quizzing them about what they recall and then clarifying the errors.

Now let's answer my question. What could I have done to prevent this error? I did one thing right by demonstrating the method on the patient's shoes (rather than simply verbalizing). But I should have had him demonstrate the method back to me to reinforce the information and be sure he understood. I could have also dispensed a written version to assist with recall after the encounter. He could have brought this paper with him to the store if he wanted.

This example is somewhat superficial, but consider the same error in a different situation, say postoperatively, when you're telling a patient to remain nonweightbearing on your reconstruction, or appropriately using a removable cast boot, or after you've prescribed a medication with potential complications (which is all of them, of course). Do you really think your patient will remember that the Bactrim you just prescribed can cause Steven's Johnson syndrome or an allergic response and what to watch out for? Perhaps a pre-written information sheet would be a good idea, huh?

It is incumbent upon us to educate our patients, and as physicians, it should be our first priority. Want to know how well you've educated your patients? Quiz them at your next follow-up and see what they recall. You'll be surprised that you may not be as strong an educator as you think.