Health Literacy

Actively Listening for What Patients Do Not Say

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

You’ve just finished teaching a patient about his new blood pressure medication. You focused on only a few key points. You clearly explained why, how, and when he should take his medication and what to do if a problem arises. Then you asked the patient to teach-back (restate) what you just discussed. Seems like you’ve done all you need to do. Right?

Maybe not, says Elyse Barbell Rudolph, who is executive director of the Literacy Assistance Center in New York City. While she’s a big believer in the importance of using teach-back, Rudolph recommends the additional step of actively listening for what patients do not say.

The healthcare value of active listening

Rudolph’s expertise is teaching people who have difficulty reading and learning. In addition to supporting numerous literacy programs, Rudolph also teaches health professionals how to communicate clearly and effectively with patients at all literacy levels. One of the skills she teaches is active listening — paying attention not just to peoples’ words but also their body language, eye contact, and tone of voice.

Not only can active listening help identify gaps in understanding, but it can also pinpoint cognitive or performance problems. Rudolph talks about a recent conversation she had with a certified diabetes educator, who is an experienced and capable teacher, about one of her patients. The educator consistently communicates clearly, supplements verbal teaching with print materials, and routinely asks patients to teach-back lessons just discussed.

But despite all of these strategies, the educator’s patient came back two months later with blood sugar levels that were “through the roof.” The educator asked Rudolph what went wrong, and together they determined that this man had a sequencing disorder (a fairly common problem in people with learning disabilities). He indeed had correctly followed all the educator’s instructions, but just not in the right order.

For this patient as well as others with sequencing problems, the educator now provides step-by-step instructions on numbered index cards. This helps patients see the correct order for performing self-care tasks. The educator also asks patients not just about the actions they will take but also how and when to do them and listens actively to make sure they have the information and understanding they need.

Strategies for listening actively

Rudolph shares these additional ways of using active listening in clinical practice:

  • Don’t be satisfied when a patient’s teach-back is just “pretty good.” Instead, listen for what the patient didn’t say. What was left out can reflect gaps in understanding.
  • Respond specifically to patients’ teach-back. Rudolph says that clinicians owe patients at least one more sentence rather than simply ending with “Okay, thank you.”
  • Reinforce lessons that patients learned well. For instance, you can say, “You got that just right and really understand that one of the most important things you can do is …”
  • Teach key content again when you notice discrepancies. For instance, make a statement such as, “You said that really well, but what I didn’t hear was ….. That’s really important to do, and I want to make sure you know how.”
  • Supplement teaching with good take-home (written) instructions. Rudolph says it is important to choose materials that have informative illustrations, simply stated step-by-step instructions, and vocabulary matching your spoken word.
  • Continue teaching and asking for teach-back until you are assured that patients fully understand. “If patients cannot follow how to do a task with you sitting there, there is zero chance they will do it at home,” says Rudolph.

Active listening can seem like a new skill for health professionals. Rudolph thinks this is so because most clinical training programs emphasize how to talk, not how to listen. She and her colleagues are helping to address the issue by leading communication workshops for public health professionals.

Learning to be an active listener

The workshops Rudolph conducts often begin with a video clip that shows a good example of active listening. One video that she likes to use is the AMA video, “Health Literacy: Help Your Patients Understand”.

In this video, a physician and patient discuss his diagnosis of “hypertension and high blood pressure,” and it’s obvious that the patient hadn’t realized before that these two terms mean the same thing. The physician listens carefully to what her patient says and empathetically responds, “I guess I didn’t do a very good job of explaining this to you.” She then explains the concepts more effectively in order to correct his misunderstanding.

After watching this video, workshop participants practice their own active listening. Rudolph has them break into small groups, each with a “listener,” “educator,” and several “coaches.” The educator’s task is to instruct the listener in a multi-step process. The coaches’ job is to provide feedback to both sides of the conversation. Rudolph intentionally uses a relatively unknown subject, such as how to change a car’s oil filter. This way, participants are not distracted by knowing too much about the content. Rudolph says that most participants find this task hard to do at first but quickly learn how to prioritize teaching and to listen for gaps in understanding.

Admittedly, there are times when a few workshop participants dismiss the value of active listening. That’s when Rudolph talks about lunch, specifically the pizzas that just arrived. She lists all the pizza choices and asks a participant (preferably someone who is a naysayer) to repeat back what she said. Invariably, the person omits at least one or two choices.

Rudolph says she can learn a lot by what is not said. For instance, someone who is a vegetarian often forgets to mention pizzas with meat while an unadventurous eater may not recall pizzas with unusual toppings. Rudolph uses this example to demonstrate the power of active listening — the value of paying attention to what people don’t say as much as to what they do say.

How to find out more

Elyse Barbell Rudolph is the Executive Director of the Literacy Assistance Center in New York City. She can be reached by email at You can learn more about the Literacy Assistance Center by going to their Web site.

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

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