The art & science of prescribing

Compounding the problem is the fact that clinicians’ use of highly technical language doubles when they are pressured for time,²⁰ suggesting that this behavior could become more widespread as the demand for greater efficiency on the part of physicians increases.

Simplify the treatment regimen. It also helps to keep treatment regimens as straightforward as possible. Prescribing multiple medications simultaneously or giving patients a more complicated regimen decreases adherence. In one study, adherence rates of 84% were achieved when the regimen called for once-a-day dosing, but dropped to 59% when patients were instructed to take their medication 3 times a day.²³

Ask the patient to summarize. Using simple terms and clear, succinct explanations promotes understanding, but asking the patient to summarize what you’ve just said is an ideal way to find out just how much he or she grasped. “What will you tell your family about your diagnosis and treatment?” you might ask, or “Tell me what you plan to do to ensure that you follow the prescribed regimen.”

This is particularly important when patients are not native English speakers or when the news is bad. Patients find it particularly tough to understand difficult messages, such as a poor prognosis,²⁴ and are often unaware of their poor comprehension. This was underscored by a study of emergency department (ED) patients, in which 78% demonstrated deficient comprehension in at least one domain (eg, post-ED care, diagnosis, cause) but only 20% recognized their lack of understanding.²⁵

Asking patients if they have any other questions is a crucial step in ensuring complete understanding.^21,26

Take steps to maximize patient recall

Even when patients understand what they’ve heard, research suggests they may not retain it. Overall, 40% to 80% of medical information is forgotten immediately, and almost half of what is retained is incorrect.27,28 This is a serious problem, as understanding and accurate recall increase patient satisfaction and the likelihood of adherence to treatment (FIGURE W1).28,29

There are 3 basic explanations for poor recall: factors related to the clinician, such as the use of difficult medical terminology; the mode of communication (eg, spoken vs written); and factors related to the patient, such as a low level of education or learning disability.^29-32

Being as specific as possible and spending more time explaining the diagnosis and treatment has been shown to enhance patient recall. In an experiment in which patients read advice on how to develop self-control over their eating, the use of simple language and specific instructions, rather than general rules, increased recall.³³ Providing generic information by whatever means does little to improve recall and might even inhibit it.

Linking advice to the patient’s chief complaint, thereby creating a “teachable moment,” is also helpful.³⁴ For example, you might tell a patient with a kidney infection that “Your backache is also because of the kidney infection. Both the backache and the burning during urination should be better about 3 days after you start these pills.”

Watch your affect. How relaxed or worried you appear also influences patient recall. In a recent study, 40 women at risk for breast cancer viewed videotapes of an oncologist presenting mammogram results. Compared to women whose results were conveyed by a physician who appeared relaxed, those who had the same findings presented by a physician who seemed worried perceived their clinical situation to be more severe, developed higher anxiety, and recalled significantly less of what they were told.³⁵

Use multiple means of communication. In a comparison study, patients who received verbal lists of actions for managing fever and sore mouth accompanied by pictographs—images that represented the information presented—had a correct recall rate of 85%; those who received the verbal information alone had a recall rate of only 14%.^36,37

Clinicians tell patients the name of the drug they're prescribing 74% of the time and its purpose 87% of the time, but discuss potential adverse effects and duration of treatment a mere 34% of the time.

A review of recall in cancer patients also found that tailoring communication to the individual—providing an audiotape of the consultation, for instance, or having the patient bring a list of questions and addressing them one by one—is most effective.³⁶ Another study assessed the retention of pediatric patients and their parents when they received either a verbal report alone or a verbal report plus written information or visuals. The researchers concluded that children and their parents should receive verbal reports only when such reports are supplemented with written information or visuals.³⁷

The large body of research on learning and memory has proven useful in designing educational materials for those with poor reading skills. When images were used to convey meaning to 21 adults in a job training program—all with less than fifth grade reading skills—they had on average 85% correct recall immediately after the training and 71% recall 4 weeks later. Although the impact on symptom management and patient quality of life has yet to be studied, these findings suggest that pictures can help people with low literacy recall and retain complex information.³⁸