Do you use “teach back” or “living room language” when talking with your patients?

Emily Hitchcock

Emily Hitchcock, M.D., faculty instructor, Providence Medical Group - St. Vincent

Health literacy is defined as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (Patient Protection and Affordable Care Act of 2010 Title V). The reality is that without understandable information, patients are less likely to follow through on recommended screening tests, diagnostic studies and chronic disease management.

Where and when is health literacy important?

As clinicians, we all want to improve our patients’ ability to understand their health, and to do that we need to pay attention to our verbal and written communications. Research into the important topic of health literacy—its prevalence (common), its impacts (significant) and its amelioration (possible)—has exploded in the past 15 years. Fortunately, there are basic, but highly effective, concepts we all can integrate into our care. These apply to office visits, after-visit summaries and myChart communications. They also should be used in the hospital during daily rounds, for informed consent for procedures and at the time of discharge.

Any patient interaction—regardless of whether that patient is a rocket scientist, radiology technician or housekeeper—is at risk for miscommunication. Studies have shown that doctors are poor judges of patients’ educational levels and their degree of understanding. In addition, when a patient has a health concern or is receiving serious health-related information, their ability to analyze and distill information is compromised.

Use “teach back” or “living room language” for verbal communication

For spoken communication, the strategies found to be most effective are using plain language and the teach-back method. This will help ensure your patient has properly understood the key pieces of information.

Using plain words, or “living room language” (i.e., the way you would speak in a casual conversation with friends in your living room), sounds self-explanatory and obvious. However, all of us are guilty of slipping into medical jargon (e.g., stable, UTI, modality, hematoma, noninvasive, etc.) when talking to our patients. This is easily corrected by paying attention and thinking of your audience. For suggestions on replacement words, the Centers for Disease Control and Prevention has a plain language thesaurus for health communication.

The teach-back method of communication has shown to improve patient outcomes, as well as patient understanding. (Schillinger et al, 2003). By using the teach-back method, the provider identifies and highlights the few most important take-home messages for the patient. Then the provider asks, “To make sure I did a good job explaining this to you, can you tell me in your own words what I want you to do when you leave the office?” The patient then shares their understanding of the instructions. If needed, the provider makes any corrections and again gets verbal proof of understanding.

TeachBackGraphic

Barriers to the teach back method

Providers’ biggest fears in trying teach back are:

  1. that it will add time to the visit; and
  2. providers certainly don’t want to imply that their patients are stupid or unintelligent.

To address the first concern, it’s true that for the first several visits using the teach-back method may add a few minutes. This is time well spent, however, since you will be identifying and correcting critical misunderstandings that can waste weeks or months of progress while your patient doesn’t follow your instructions. The teach-back method also saves time on post-visit phone calls to clarify confusion. Most providers find that after a little practice, the teach- back adds no additional time to the visit (Schillinger et al, 2003; Kripalani & Weiss, 2006). Some practices integrate teach back into their workflow by having the medical assistant review key points on the after-visit summary with the patient. While this could be done well with a highly skilled and trained medical assistant, in general I believe it’s most effective when done by the provider.

If you’re concerned your patients’ intelligence may be insulted by the teach-back method, my suggestion is to take the burden of communication onto yourself. If your patients don’t understand what you originally told them, it’s because you didn’t explain it clearly enough.

You could say:

  • “I want to make sure I explained the plan clearly. What will you tell your spouse we talked about when you get home?” or
  • “We’ve covered a lot of information. Do you remember the two side effects you may have with this new medicine?”

By acknowledging the complexity of the medical advice and owning your teaching role as a provider, you can identify and correct misunderstandings without risking your provider-patient rapport.

Written communication

What about tackling the issue of health literacy when it comes to written information we share with our patients? When you give a patient an after-visit summary, can they read and understand the information you have so painstakingly written? What about when they’re discharged from the hospital? Can they identify key pieces of information such as “What signs and symptoms should cause me to seek medical help?” The CDC has recommended that all written information for patients be crafted at a sixth-grade reading level or less. This can be more challenging than you think!

The residency program at Providence St. Vincent has addressed this by focusing on training interventions for its internal medicine residents, clinic faculty and hospitalists, with some impressive results. Several years ago Providence Medical Group-St. Vincent initiated a training for all clinic faculty and residents to identify and improve the readability of the after-visit summaries given to their patients. The clinic averaged at around the eighth-grade reading level, with some providers averaging a fifth-grade reading level but others scoring more at the collegiate range.

To address this problem, we launched a project to educate and encourage our clinic providers to write all after-visit summaries at a sixth-grade or lower reading level. The project used a personal detailing strategy with provider-specific information that was plotted on a graph along with the rest of the providers in the clinic, thereby playing on our providers’ natural competitiveness. An average reading grade level for five consecutive summaries was calculated, and that feedback was given to providers in a group conference setting.

The didactic portion of the conference focused on the scope of health literacy, its impact on the Triple Aim and the performance of their peers. Then in a workshop setting, the providers rewrote their patient information using plain language and easy reading principles. Analysis of their performance, with a goal average of sixth-grade reading level or lower, was then repeated at six weeks, three months and one year. The results showed marked improvement.

This now is being piloted as a quality improvement project with the Providence St. Vincent hospitalists by one of our internal medicine residents, Brandon Tullis, M.D. The goal is to improve patient understanding of important information and instructions before discharge. Preliminary results are promising!

Another exciting resident quality improvement project, called “Improving Hospital Discharge Instructions Through the Use of a Standardized Template,” was done in 2016 by Stephanie Griffith, M.D., now chief resident at Providence St. Vincent. The goal of the project was to improve readability of hospital discharge information by restructuring the format using a dot phrase. The new dot phrase used techniques such as large fonts, bulleted information and highlighted key information. The project focused on a trial unit (7 West) with remarkable results, and later was shared with the full hospitalist staff. This not only improved our patients’ ability to better manage their health, but it also brought significant increases in Press Ganey scores.

As we have seen at Providence St. Vincent, using these simple strategies—using plain language in speaking and writing for our patients, confirming our patients’ understanding with teach back method, and formatting our patient instructions in a clear, readable manner—can improve patient outcomes. It’s gratifying to see the careful thought and hard work put in by our providers paying off in better understanding and care for our patients.

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