Doctors' instructions miss mark on lots of patients

What did the doctor say?

All too often, after a visit with a physician, patients can't exactly recall what was said or what they're supposed to do. Even if they've gotten a prescription or written instructions, comprehension may be lacking.

This may especially be true when it comes to emergency department visits.

One study, published over the summer in the Annals of Emergency Medicine, found that 78 percent of 140 patients and caretakers discharged from a Michigan ER did not fully understand the care or discharge instructions they received. And only 20 percent of that group realized that they didn't know what they needed to do.

Most of the confusion involved not understanding instructions for care after leaving the ER.

Much of the problem lies in poor health literacy. Reading tests administered for the federal government suggest that as many as 90 million American adults either can't read or can't understand basic information such as a prescription label or a pamphlet on how to care for a medical condition at home.

Other data suggest that emergency departments may be more likely to attract patients with lower levels of income and education to start with, but the stress of a sudden injury or illness can make comprehension difficult for anyone.

"The bottom line is that we need better strategies for identifying patients who are having difficulty understanding their care and instructions in the emergency department,'' said Dr. Kirsten Engel, an emergency medicine researcher at Northwestern University in Chicago who led the ER study.

"When you're in the emergency department, be honest and don't be afraid to ask questions,'' Engel said. "If you don't understand what the doctor has told you, keep asking until you do."

Even beyond the ER, "it's common for patients to forget half of what they're told in a medical visit,'' said Jordan Silberman, a second-year medical student at the University of Rochester Medical Center in New York, who set up a "hidden microphone" test of 49 family practice doctors.

Actors trained for their roles were sent to the practices complaining of typical heartburn symptoms. According to results published in the June edition of the Journal of General Internal Medicine, not one of the docs summarized their treatment recommendations at the end of the visit.

About half of the physicians repeated their instructions, but some only repeated about 10 percent of the information. Only about a third wrote down any instructions for the patients.

Consumer surveys over the years have shown consistently that they value communications skills and bedside manner in doctors above almost any other aspect of care.

Yet doctors admit they're not always at the top of their game when it comes to either gathering information from a patient or passing along medical advice.

The average internist interviews on the order of 100,000 patients during his or her career, at an average of about 18 minutes a visit. Primary care patients typically bring up three to six concerns at each consultation.

Add in the likelihood that more and more patients have multiple medical problems and that there often are different approaches that might be used to treat the same condition (which the patient may or may not have already researched on the Web), plus patient privacy rules that restrict what can be said around anyone else, and the difficulty of a good exchange mounts.

Researchers at the University of Washington and University of Rochester, recently published a guide for smoother flow of communications between doctors and patients in the Archives of Internal Medicine.

Among their top tips, useful to patients as well as docs:

-- Focus the purpose of a visit at the start. Making a list of problems allows the doctor to confirm what's' most medically urgent and prevents the "one more thing" question at the end of the visit from muddling things.

-- Put things in the patient's perspective. Doctors need to understand medical problems in the context of the patient's life, family situation and cultural beliefs, in order to understand how to best care for them, and what they can expect the patient to be able to do for themselves.

-- End with mutual agreement on what happens next. What steps are a patient willing and able to take to manage illness or prevent disease, and what assistance or follow-up care does the doctor need to plan to help them succeed.

On the Net: http:www.annemergmed.com

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(E-mail Lee Bowman at bowmanl(at)shns.com.)

(Distributed by Scripps Howard News Service, http://www.scrippsnews.com)