Article from the Boston Globe’s On Call Magazine, October 2005

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

Mrs. Blue is a 67-year old woman who lives alone. While visiting a friend in a nearby town, she fell and hurt her ankle. Her friend called a cab to take Mrs. Blue to the hospital. In the emergency room, the physician diagnosed a compound ankle fracture and recommended that Mrs. Blue have immediate surgery.

Ankle pain wasn’t Mrs. Blue’s only problem. She was scared and overwhelmed by all that was happening to her. The doctors and nurses were telling her she needed surgery, giving her lots of forms to sign, and constantly asking questions. Some of the questions were about her health – what illnesses she’s had, whether she has any allergies, and what medications she takes. Mrs. Blue did her best to answer accurately but forgot that her primary care doctor started her on two new medications the previous week. Tragically, this was information that the surgical team needed to know.

Mrs. Blue’s story is not uncommon. Patients are often in situations where they are being treated by health providers they’ve just met. Sometimes, as in this case, the patient is the primary source of medical history. Errors can happen when, for whatever reason, patients are unable to clearly communicate important health information.

Providers, too, can cause miscommunication. Whether they’re feeling rushed or distracted, or are simply unaware of problems such as a language barrier, providers may present medical information in ways that patients and their families do not understand. Likewise, provider-to-provider communication can be misunderstood, especially when done at a distance through phone, fax, or email.

Joanne Schwartzberg MD, Patricia Sokol RN, JD, and Katherine Vergara of the American Medical Association (AMA) in Chicago are leading a nationwide effort to improve patient safety through better health communication. Here are some suggestions they have to help professionals communicate more effectively and more safely.

Communication From Patients to Providers

Help patients ask questions. Health messages are not necessarily understood just because a patient says no” when the provider asks, “Do you have any questions?” There may be many reasons why patients don’t ask questions. One can be limited literacy. Schwartzberg says that people who are not advanced readers may have trouble with oral communication because they are not used to the language structure providers use and may have difficulty coming up with words.

Ultimately, Sokol says, health providers have a moral and legal responsibility to make it easy and possible for all patients to speak up. Vergara says that one way to do so is by encouraging patients to use Ask Me 3 as a framework for patient-provider discussion. This framework includes three questions that patients should ask each time they talk with a doctor, nurse, or pharmacist:

• What is my main problem?
• What do I need to do?
• Why is it important for me to do this?

Help patients create easier access to important contacts and medical information. You might want to suggest that patients apply the concepts from ICE (In Case of Emergency), an initiative that encourages the general public to program their cell phones with emergency contact numbers, collectively listed as “ICE.” This way, medical personnel will know who to contact in an emergency. Other ways that patients can improve health communication is by keeping an up-to-date list of all their medications. Sokol also suggests that patients request copies of their medical records. Though there might be a copying fee, Sokol says that these records can be invaluable when someone with a complex medical history, such as Mrs. Blue, is in an emergency situation.

Providers to Patients

Organize in advance what you are going to say. Schwartzberg recommends that providers organize their verbal communication just like they do written information. This means identifying ahead of time the key points to focus on and the order in which to discuss them. Schwartzberg acknowledges that organizing messages is not always easy and may take a little extra time. The benefits in terms of patient safety, however, far outweigh the costs.

Reconcile discrepancies and correct omissions. Despite their best efforts, patients may be unable to report accurate and complete medical histories. One reason may be due to today’s “expanded community of care,” in which treatment is given in multiple settings by numerous providers and caretakers.

When providers first meet patients, Sokol recommends looking for discrepancies in the patient’s history by considering following up on such questions as: Is this everything I need to ask the patient? Who else is the patient seeing? Where else is the patient going for medical advice or treatment (such as a pharmacy-based health clinic)? Asking patients to bring in all their medications is another way to determine if there are any gaps or discrepancies that need to be addressed.

Use the teach-back method. The teach-back method means asking patients to say, in their own words, information they’ve just heard. “The teach-back method is the only fail-safe communication mechanism we’ve got,” says Schwartzberg. While acknowledging that it’s not perfect, Schwartzberg says this technique is an important way for providers to determine whether what they say “gets through” to a patient.

The teach-back method begins with the provider saying something along the lines of “I want to make sure I explained this clearly.” They then ask the patient to talk about (teach back) the topics just discussed. This is also an ideal opportunity for providers to correct any misunderstandings by saying, “You start, and I’ll fill in any missing details.”

Providers to Providers

Healthcare today is often provided by “virtual teams” of providers who may never meet in person and who communicate with each other by telephone, fax, or email. Virtual communication like this is ripe for error since there is little opportunity to correct a misunderstanding. The AMA team recommends that, whether in a hospital, home health, or outpatient setting, organizations put policies in place to confirm that messages are clearly communicated and correctly understood.