Health Literacy

Opening the Interactive Communication Loop

Article from the Boston Globe’s On Call Magazine, May 2003

By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

Providers need to communicate their messages in ways patients can understand. Patients, in turn, should speak up when they don’t understand, or cannot recall and follow instructions. In reality, however, good healthcare communication doesn’t always happen. But healthcare providers can create an environment that promotes understanding.

While many providers try to communicate clearly and simply, they are not always successful. One reason is that providers have their own way of talking and thinking about healthcare that patients do not necessarily share. Dean Schillinger, MD, is an associate professor of clinical medicine at the University of California–San Francisco and the San Francisco General Hospital. He has researched healthcare communication and says that, at best, patients only recall and comprehend about half of the information delivered in a clinical encounter. “It’s a flip of a coin that what you say has sunk in,” he says. For example, Schillinger talks about a woman he recently treated for congestive heart failure. Despite numerous attempts to educate her about this condition, the woman remained convinced she was going to die very soon. Obviously, the word “failure” had a very ominous meaning to her.

The “interactive communication loop” is a technique Schillinger uses to assess whether patients truly understand healthcare messages. This technique involves following up the introduction of a new concept regarding a patient’s health or condition with a rapid assessment of the patient’s recall and comprehension. If the patient does not understand or agree, the provider then restates or tailors the message to make it more accessible for the patient. The provider then again assesses the patient’s comprehension and continues this loop until it is clear that the patient understands.

Schillinger knows that some providers are reluctant to open the communication loop, fearing it will take too much time. But he says he has found the technique is both time-efficient and time-effective. When providers know what patients understand and accept, they can specifically focus on the most important aspects of the message. “Used well and used often,” says Schillinger, “the communication loop is an efficient way to get to where you need to be.” Here are some ways to make the loop work for you and a patient.

Start the loop by helping the patient feel safe. Patients need to feel safe admitting that they don’t understand, says Schillinger. He starts the loop by setting a tone of partnership, perhaps by saying “I want to make sure that you and I are on the same page.” He then asks open-ended questions about new concepts, like “Now that we’ve talked about adding fiber to your diet, what will you look for the next time you buy cereal?” If the patient seems confused or doesn’t know the answer, Schillinger will offer an empathic statement such as “Many people have trouble figuring out which cereals are high in fiber.”

The one question that Schillinger does not use to assess understanding is, “Do you understand?” He says that most patients, whether or not they understand, simply respond by nodding and smiling. He says he has yet to hear a patient say, “No, doctor, please explain this in a better way.”

Ask early and ask often. Don’t wait until the end of appointment to assess whether patients understand or intend to follow through on treatment plans. After each new concept, ask patients to reflect on what was said or agreed upon.

Listen and pay attention. “Listen for the patient’s health beliefs or misperceptions,” says Schillinger. “Often, the solutions lie within the answer.” He talks about a man he had been treating who, year after year, wouldn’t take his medications as prescribed. It was only when Schillinger asked, “Walk me through your day — how are you taking these medications?” that he learned that the man disliked swallowing pills. The solution was easy once the problem was uncovered, says Schillinger. He reports that this man is now being successfully treated with patches and liquid medications.

Tailor your message to be more consistent with what the patient says. Just like with clothes, tailoring means altering the message to fit each person’s frame of understanding. For example, the statement “exercise more” is an untailored message. To tailor this message, use an example of relevance to a specific patient. For someone who likes to swim, you might say “Instead of swimming just once a week like you have been doing, try to swim three times a week for at least a half an hour.”

Use other ways of communicating. Feel free to innovate when you feel at a loss about how to convey concepts or treatment options. Consider using analogies, stories, pictures, or even items in your office. Whichever way you communicate, be sure to assess understanding. Schillinger tells of the time he proudly explained to a woman that her heart was like a pump. While she politely nodded, it wasn’t until several appointments later that she acknowledged she had no clue how pumps work. It wasn’t until Schillinger squeezed water through a surgical glove that this woman finally understood how her heart works.

Consider why the message is not understood. Even when you believe  you have given an adequate explanation, patients still may not understand. When this happens consider if there are other factors such as learning disabilities, communication disorders such as hearing loss, cognitive impairments, depression, limited literacy or language skills, or cultural differences that are getting in the way.

Feel confident that you have done your best to communicate. Make it a practice to open the loop of good communication by continually explaining, assessing, tailoring, and reassessing understanding. “When we get patients to a place where they can make informed decisions,” says Schillinger, “we can feel satisfied that we have done our job well.”

To Learn More

Dean Schillinger, MD, is an associate professor of clinical medicine, University of California–San Francisco and the San Francisco General Hospital. He is also a fellow of the Open Society Institute, which  supports his work with California Literacy. You can reach Dr. Schillinger by e-mail at

Printed Sources

  • Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman A. “Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy.” Arch Intern Med, Vol. 163, January 13, 2003: 83 – 90
  • Tuckett D A, Boulton M, Olson C. “A New Approach to the Measurement of Patients’ Understanding of What They Are Told in Medical Consultations,” JHealth Soc Behav. 1985 Mar; 26 (1): 27-38.

Article reprinted with permission from On Call magazine and published by a division of Boston Globe Media.