By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting
On Call Magazine, January 10, 2008

You just walked ten minutes each way to pick up four needed items at the grocery store. Now that you’re home, you realize you forgot one of them. This forgetfulness is likely due to limits of your working memory, which, according to Mark Hochhauser, PhD, refers to the amount of information your brain holds temporarily in its “memory buffer.” This information commonly stays there for only as long as you need it to perform a task. Then it quickly decays and is forgotten. For instance, if you look up a phone number to make a call, that number will fade from your memory once the call is made.

But working memory is just one of three types of memory — the other two being short-term memory and long-term memory — and people can have problems with any of them, especially as they age. When that happens, those problems can affect an individual’s ability to comprehend health information. As Hochhauser, who is a psychologist and readability consultant in Golden Valley, Minnesota, says, “Patients can’t understand what they can’t remember.” That means it’s up to healthcare professionals to find ways to make the information patients need more memorable.

Where’d that memory go?

Short-term memory can only hold three to five items of information at a time for about a minute or less. In order to be retained, those items need to be transferred into long-term memory, which can store unlimited amounts of information for days or even decades. People rely on long-term memory throughout their life. When you use information you obtained in school to solve a problem at work years later, you’re using your long-term memory.

Memory problems tend to increase as people age. An example would be difficulty retrieving information you know you have. Hochhauser describes that all too common feeling of watching a movie and knowing you know the actor but not remembering from where. Then suddenly you wake up in the night knowing exactly which movie she starred in. “The memory is there.” Hochhauser says, “but you cannot find it when you want it.”

Unless you are on Jeopardy, not being able to recall an actor’s credits doesn’t usually cause a major problem. But not being able to recall what you’re healthcare provider said about managing your asthma can have serious consequences. Here are some suggestions for making health information more memorable and, therefore, more understandable.

Connect new pieces of information to old

It is much easier to remember unfamiliar or new information when it is linked to something familiar. Healthcare providers can do this by introducing new information within a known context. One way is to use a metaphor or analogy. For instance, you might explain an aneurysm by comparing it to a leaking garden hose.

When you use a metaphor like this, speak first about how these two concepts are alike — both vessels can burst. Then explain how they differ — garden hoses can leak anywhere while an aneurysm happens only in certain parts of the body. The differences contain the new information you want your listener to remember. You can learn more about using metaphors or analogies in health settings in an earlier In Other Words column .You can also learn more about medical analogies on the Altoona Family Physicians Web site.

Chunk information

Studies show that people can only hold on to about three to five pieces of information at a time before they either lose it or store it in their long-term memory. This explains why phone numbers today are so hard to recall. Hochhauser says this task was much easier before area codes. Then, we only had to remember 7 numbers – three numbers, a dash, and then four. Now with ten digits (3 for the area code) this task is much more difficult. In fact, for most people, keeping 10 numbers in mind is impossible. We do it, though, by “chunking.” Instead of remembering ten individual digits, we remember area code (three numbers functioning as a single item), exchange (three numbers), and extension (four numbers).

Learning from this experience, healthcare providers can help patients better remember health information by “chunking” it into shorter segments. For instance, patients are more likely to succeed at remembering which high-fiber foods to buy if they think in terms of breakfast foods, dinner foods, and then snack items rather than trying to remember all items in a single list.

Write down important information

Most people can better remember spoken information when they have a written (visual) reminder of the conversation. But in healthcare settings, Hochhauser says, too often the only written documents patients leave with are prescriptions.

Ideally, patients would take notes during even routine medical appointments. This way, they would have a way to remember all their new data, including weight, height, blood pressure, and any new diagnoses or follow-up instructions. But realistically this is unlikely to happen. Providers can assist by writing a brief summary of what is discussed and giving a copy of that information to the patient.

Hochhauser says that given how quickly memory decays, this summary should be written during or very soon after appointments. “The memory may be gone even if you wait one-half hour, even less if something stressful was discussed.”

Use memory aids

Hochhauser advocates using multiple methods for helping people remember. For example, memory can be enhanced by combining any of the following:

• Encouraging patients to audiotape appointments. This way, patients have a reminder to listen to at home.
• Inviting patients to bring someone with them to important appointments. As Hochhauser says, “two brains are usually better at remembering than one.”
• Using mnemonics. One way to do this is to create a word or phrase that uses the first letter of each word in a string of important words. For instance, “DASH” instead of “Dietary Approaches to Stop Hypertension” (a program from the National Institutes of Health).
• Making lessons easier to learn. This is especially important when patients must remember and use a number of new concepts. For instance, when talking about foods to eat, providers can help by creating a booklet with sample breakfast menus that already take into account the target number of fat, proteins, and carbohydrates.

Use teach-back to confirm understanding

Teach-back is a technique that asks patients to explain what they’ve just heard. It helps by revisiting key concepts throughout appointments and again at the end and providing an opportunity to clarify issues the patient may have missed or found confusing. This reinforces learning. Hochhauser says that patients are too often considered “non-compliant,” when really the problem is they just didn’t understand and therefore could not remember what was said. To learn more about teach-back see my November column.

Appreciate your memory limits as well

It’s not just patients and older adults who are sometimes forgetful. All of us have limits to the amount of information we can remember. Hochhauser and I both have had recent experiences in which our healthcare providers forgot something we discussed. While fortunately neither matter was critical, Hochhauser and I each became acutely aware of how human it is to forget.

How to find out more

Mark Hochhauser, PhD, is a readability consultant from Golden Valley, MN. You can reach him by email at MarkH38514@aol.com.

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.