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

You just prescribed a potent drug that could be very helpful for your patient’s condition. But as she leaves your office, you question whether this patient really understands the instructions you just gave. While you hope you did a good job explaining, you are concerned because any errors she might make could be life-threatening.

The only way to know for sure whether patients understand is by asking. One technique to do just that is the “teach-back,” in which providers ask patients to state in their own words (i.e. teach back) key concepts, decisions, or instructions just discussed.

• Many providers begin with statements such as, “I want to make sure I explained this clearly. When you go home today, what will you tell your [friend or family member] about [key point just discussed]?”
• If patients cannot restate your instructions correctly, then explain again by drawing pictures or using simpler words.
• Use the teach-back again and repeat this process until you confirm that the key message is correctly understood. If you know you explained this well but after two or three tries the patient still does not “get it,” then look for other explanations (beyond your teaching) about why the message was not understood.

Joanne G. Schwartzberg, MD, is director of the Program on Aging and Community Health at the American Medical Association (AMA) in Chicago, and a strong proponent of the teach-back technique. She is also a leader of the growing health-literacy movement who says the movement is prompting providers to question whether patients are ready and able to be confident and capable self-managers.

Self-management and health literacy are “two sides of a coin,” says Schwartzberg. She explains that an important part of health literacy is acting on information, not just reading and understanding it. Many studies show that about half of all patients do not correctly follow medical instructions. Schwartzberg says this number is likely to be even higher for older patients who are diagnosed with multiple conditions. The teach-back technique is a proven way to assess and confirm understanding, and Schwartzberg talks about ways providers can make it a routine part of their practice.

Learn how to use teach-back

Despite recent research showing the many benefits of teach-back, surprisingly few providers actually use it every day. Schwartzberg thinks this is because clinicians may not be familiar with the teach-back method or may find it difficult to change their communication style.

Schwartzberg leads many workshops for clinicians in practice. To teach the teach-back, she asks workshop participants to select a medical instruction they give to patients all the time and are comfortable saying. She then asks participants to select three key points of this instruction and use the teach-back to explain the concept to a colleague sitting nearby. Schwartzberg says there are often lots of giggles when people first try this and realize how hard it is to organize teaching into a limited number of points that someone else can remember.

Confirm what patients are saying to you as well as what you are saying to them

Periodically throughout patient encounters, providers should summarize and restate key aspects of what patients are telling you. For instance, you might say, “I just want to make sure that I heard you correctly. When you said [key point], I understood that to mean [x]…. Is that correct? Is there something I missed?” Doing this, you not only confirm (or not) that messages are correctly understood but also demonstrate your commitment to helping patients feel that they’ve been heard. In addition, this line of questioning models the teach-back technique so that patients are not surprised when you ask them to repeat back what you just said.

Document that messages are understood, or if not, make a plan

For patients who do not understand your message, the next step might be to give a referral to a patient educator, encourage them to bring a family member or friend to the next appointment, or make an appointment for a follow-up visit or phone call.

Adding teach-back to your busy schedule

Admittedly, the teach-back technique may seem like yet another obligation to add to an already too-full schedule. Schwartzberg is sensitive to the realities of clinical practice, with too many patients who need to be seen in too little time. She says that the teach-back is not time-consuming and, at most, only takes a minute or two. But as with anything new, this technique may take a little practice to master.

Schwartzberg suggests that clinicians begin by using teach-back with only the last patient of the day, just once or twice a week. This eliminates the worry of inconveniencing other patients. Once clinicians are more confident of their skills, then the teach-back can be used more often.

Patients and providers both feel better when they confirm understanding. Rather than hoping that patients correctly learned what to do, providers can be reassured that at least they understood what was said: “They came for help and I helped. I know that this patient understands what I just said.”

How to find out more

Joanne G. Schwartzberg, MD, is the director of the Program on Aging and Community Health at the American Medical Association in Chicago, Illinois. You can reach her by email at joanne.schwartzberg@ama-assn.org

You can learn more about health literacy and the teach-back technique in the AMA Foundation’s Health Literacy Kit available at http://www.ama-assn.org/ama/pub/category/9913.html. It includes:

• Health Literacy and Patient Safety: Reducing the Risk by Designing a Safer, Shame-Free Health Care Environment. Monograph #OP424907.
• “Health literacy and patient safety: Help patients understand.” An instructional video that includes a demonstration of using the teach-back in clinical practice.

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. Her column appeared regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.