Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some really remarkable people, hearing what health literacy is, why it matters and ways every one of us can help improve health understanding.

Today, I’m talking with Dr. Dean Schillinger, who is a practicing primary care physician, Professor of Medicine in Residence at the University of California San Francisco and Chief of the UCSF Division of General Internal Medicine at San Francisco General Hospital.

Dean Schillinger also directs UCSF’s research program about health communication with vulnerable populations. He has authored over 200 publications about this work.

Dr. Schillinger also recently co-founded a novel public health campaign called “The Bigger Picture.” This campaign harnesses the voice of young people to help change the social and environmental conditions leading to the epidemic of diabetes in minority youth.

I’ve known and valued Dean Schillinger’s work for many years, starting with his teaching about teach-back. I am delighted he again agreed to be a guest on Health Literacy Out Loud.

Welcome, Dean.

Dean Schillinger: Thank you, Helen. Thank you for your leadership in this topic and for helping us to disseminate important information to our stakeholders.

Helen: Thanks. We’re all in it together, we’ve been in it together, and we’re all doing different pieces of the puzzle.

I learned about teach-back from you, and I’m very sincere about that. Teach-back has become quite the buzzword these days.

In 2003, I interviewed you for a column I was writing. The title was “Opening the Interactive Communication Loop.” I learned so much from you about teach-back. Let’s update that as it was quite a while ago.

Dean Schillinger: It was more than 10 years ago. What’s interesting is that I give talks about health literacy and teach-back is part of it. At every talk, I ask people to raise their hand if they know what the teach-back method is. I’ve seen a consistent and gradual increase in the number of hands that go up. It would be about 1% of the room and then 3% of the room.

These are health literacy conferences where we’re already preaching to the choir, if you will. We’re at about 25% to 40% now where people are raising their hand.

Raising your hand doesn’t mean that you do it, but at least you know what it is and you may even know how to do it. I think we’re making some progress.

Helen: I hear about it too. I give a lot of workshops and everybody wants to know about teach-back. It’s the most recommended strategy of what to do. I’m wondering if we’re all talking about the same thing.

Dean Schillinger: That’s a great question. I wrote that paper that you alluded to in 2003.

Helen: “The Interactive Communication Loop.”

Dean Schillinger: Yes. It was really describing the teach-back method. We drew an association between patients whose doctors used the teach-back method and their diabetes control, suggesting that there was something good about the teach-back method.

I got a couple of letters to the editor in which people were saying, “If patients just did what I told them we’d be fine.”

I think that there a lot of people who believe that teach-back means “if they’d just do what I told them to do we’d all be fine.” It’s really not that, obviously. It’s much more about “are we seeing each other eye to eye and is our understanding matching each other’s understanding?”

It may have very little to do with what our future behavior will actually look like. It’s simply are we sharing the same meaning? Do we have shared meaning at this cross-sectional point in time about a diagnosis, a treatment plan, a barrier or a whole range of issues that come up in the healthcare context? It’s just simply about sharing meaning.

Helen: In the moment.

Dean Schillinger: Yes, in the moment. Obviously it draws upon a lot of knowledge that someone may already have about a condition or trajectory of a disease, but it really is assessing the in-the-moment dialogue and the in-the-moment connection that you’re having with someone, or lack of connection.

Helen: I’m glad you put that time gap in there because to me people are almost looking at it as this great panacea. They say, “If only everyone did teach-back then our healthcare system would be fixed.”

Dean Schillinger: The Middle East problem would go away.

Helen: It’s not quite like that.

You were there at the beginning. How did all of this get started?

Dean Schillinger: A couple of things had started to happen for me at the same time. One was in the research context. I was attending health literacy conferences. At some of the more early conferences there were some leading figures such as the Doaks.

Helen: Len and Ceci Doak.

Dean Schillinger: Yes. He really founded the field.

It’s my memory that they had called out this strategy of ensuring that the learner has acquired the knowledge only if they could rearticulate in their own words what the teacher had taught them. I don’t know if they called it the teach-back method, but I remember that very clearly.

In my clinical life as a primary care doctor, I was increasingly recognizing a couple of things. One is that many of my patients weren’t doing well clinically even though I thought I was providing outstanding care to them.

All of the objective quality-of-care measures were checked off but legs were getting chopped off and heart attacks and strokes were happening, so there was some disconnect that I was seeing.

You asked me to tell a story so I’ll tell a story. I remember almost as if it was yesterday a guy that I took care of who had really severe hypertension. He was a nice guy and we had a nice relationship, but every time he would come back his blood pressure was through the roof.

He would tell me what medication he was taking religiously but, every time, I would have to add another medication to his regimen.

He was on about nine or 10 blood pressure medications, which is not entirely unusual, but it was odd to me that we weren’t making any headway. Usually you expect some improvement in blood pressure.

I had done the teach-back but now I was going to do the super teach-back, which was saying, “Bring in all of the bottles and show me exactly what you take next time.”It wasn’t really teach-back but it was “show me.”

He brought back a shoebox full of pill bottles, many of which were from the 1990s. There were medications that I hadn’t prescribed in over a decade. I said, “Mr. X, are you still taking these?” Then he said, “Doc, I never told you, but I just don’t like swallowing pills.”

We had been going on with this dance and this assumption that he was taking my pills for a decade. For a whole host of reasons, only some of which I might be able to figure out, he wasn’t comfortable telling me that he wasn’t swallowing them.

The long and short of it is that he’s on two liquid medications now. It’s like pediatric blood pressure pills but liquid form. His blood pressure is perfect on two medications.

There are a number of assumptions that we make as clinicians and a number of barriers that people have in actually disclosing to their clinician either their lack of understanding or their difficulty hearing. There are so many of them. If you multiply that by each other and extrapolate, you have an exponential number of reasons why miscommunication happens.

There’s only one way to know, and that is to not assume and to explicitly have the person show you or tell you.

Helen: What you did, Dean, is the “show me.” You put this in context of the words, as I understand teach-back. It’s the words and repeating that short-term learning that you just did. You’re really uncovering a bigger problem here. A bigger strategy is “show me” and really creating that shared meaning so it’s not just that exchange of information.

Dean Schillinger: That’s right. The “show me” takes it to the next level which is saying, “Let’s see how and if you apply a shared knowledge and a shared language. Now apply it to a behavior.”

It could be saying, “Show me how you inject your insulin,” from the point of drawing it up into the syringe all the way to injecting it, “Show me how you take your pills,” or, “Show me what time of the day.”

Increasingly in medicine now we’re creating more and more technologies where people can bring the hospital to their bedroom. We expect people to be able to use their meter-dose inhaler for asthma, inject themselves with this and that and use pedometers. All of these things require us to really ensure that the person has mastered the skills.

Helen: It’s the skills and the knowledge. You also said it’s not predicting the future. It’s the present and maybe the immediate future.

Dean Schillinger: That’s right. It’s not predicting the future although I could say the absence of it will certainly predict the future. If you don’t have shared meaning, I guarantee there isn’t going to be any adherence to the treatment plan or whatever because it’s in one ear and out the other.

Helen: Shared meaning alone won’t commit to adherence.

Dean Schillinger: No. It sets you up. It sets you up well to say, “Let’s take that shared meaning, make sure we have a therapeutic alliance where you and I trust each other and make sure we’re going to cross the finish line together.”

Ultimately it’s in the hands of the patient and the family living in their home and community to decide and to have the resources to do what we hope they can do.

It’s certainly not a guarantee, but I can say it’s a sine qua non, meaning if you don’t have it you’re not likely to cross the finish line.

Helen: Thanks for that. I’ve never had as in depth a conversation about the meaning of teach-back. Often I focus on the how-to, but I’m thinking that a lot of the Health Literacy Out Loud listeners would like to hear from you some of the how-tos about teach-back.

Dean Schillinger: First of all, let me just make a couple of preface points.

One is that, in our work that we did over a decade ago, we showed that primary care doctors used the teach-back with respect to any kind of new concept only 12% of the time, which is really low.

Those doctors that did use it had patients whose diabetes was better controlled, so there was a suggestion that maybe there’s something like a magic dust in the teach-back.

Until recently, that study had not been replicated, but I recently heard a presentation at one of the health literacy or health communication conferences about a year or so ago.

It was a presentation by a nurse who had studied certified diabetes educators who had taken care of 400 or 500 patients with diabetes and audiotaped their visits. They essentially duplicated the methods we did in our study.

The hypothesis there was that nurses, because of their excellent training in patient education and knowledge of the teach-back method, would apply it much more frequently than the primary care doctors in my study did.

Unfortunately, what she found was that less than 1% of the new concepts conveyed by the diabetes educator to the diabetes patient was accompanied by any form of teach-back, suggesting that we may know what the teach-back is but we’re not doing it. It may be because we don’t want to do it, we don’t know how to do it or we don’t think we’ve got time to do it.

Your question about how to do it is particularly important in light of that recent study.

Helen: Let’s get there, because that’s appalling. Ten years later, even though teach-back is kind of the buzz term, we’re really not doing it in all professions.

Let’s get to some of the how-tos. You brought up the issue of time too, so let’s get to the objections of this too.

Dean Schillinger: The first thing I want to say about the how-tos is the how-not-tos if I could. It’s not, “Have I been clear?” “Are we good?” “Any questions?” or, “Do we understand each other?”All of those are spitting in the wind.

They’re really not authentic confirmation of understanding. They simply lead to a standard nod of the head or a “yes, doctor.” There are a variety of reasons of why that’s the case.

Half the time, the patient actually does understand so, sure, that’s fair, but in the half of the time that the patient doesn’t understand, patients do not see that as the opportunity to express that misunderstanding. Those don’t count.

I know that the nurse that did the study of the 1% was hearing a lot of that, as was I in my study. People may believe they’re doing the teach-back but that is not the teach-back.

What the teach-back is, just from a definitional point, is an explicit elicitation on the part of the patient to restate in his or her own words what she heard and understood about what the clinician stated in some domain.

How it’s best done is first by framing it or setting it up. You don’t just go on one knee and ask someone to marry you. You frame it first.

You have to sort of frame it like saying, “I’m about to do something here with you that’s kind of weird so get ready.” You have to have a framing statement.

I go to one of two strategies. If it’s somebody who I know has a spouse, a daughter, a caregiver or whatever at home, and assuming it’s a guy who has a wife at home, I’ll say, “Mr. Jones, when you go home and your wife says, ‘Frank, what did the doctor tell you today?’ what are you going to tell her? I want to make sure I explained it easily for you so you could explain it to her.”

What I do here is I really personalize it through that relationship of the husband and the wife. However, I really put the onus of any misunderstanding on Frank’s part on me because I said, “I want to make sure that I explained it clearly to you.”

If the person doesn’t have a caregiver at home, I just simply say, “Ms. Jimenez, we went through a lot of things today. I want to make sure that I was crystal clear about what we want to do with your medications. Could you tell me in your own words what you’ve taken away from our conversation in terms of what you’re going to do with your medications?”

Helen: You also specified it. You didn’t ask her to give you an entire round of pharmacology.

Dean Schillinger: No. Don’t tell me the passive physiology of kidney disease.

Helen: You just said, “What are you going to do with this?” You frame it.

Dean Schillinger: There’s sort of a preamble to the teach-back where I describe the framing and then there’s the post-talk or the post-amble of the teach-back.

There’s one other preamble thing which is that you have to decide what you really care about at the end of the day that the patient goes home and tells his wife about.

Of all the things you’ve talked about, what are the one, two or three things at most that you want to make sure Frank gets? You have to know those things in your mind when you’re going into the visit and during the visit because those are the ones you want to explain clearly and do the teach-back on.

Helen: You sure don’t do it on everything.

Dean Schillinger: No. If you’ve got seven things in your head, you need to prioritize because we know people can’t remember seven things. Really prioritize first before you say, “When you go home and your wife asks you.” You really need to know what you’re asking them to teach-back.

The post-talk piece really is about what you do with the stuff you get back from patients. You’re going to get about half of the people who say, “Oh, you want me to increase my Metformin to three times a day. You told me that. Why are you asking me that?” You say, “Terrific. I feel like we did some safe medication practice there and we’re good to go.”

The other half are going to give you a wide range of responses. Some people will say, “I have no idea what you’re talking about. What medication?” It’s pretty clear that they were not with you for a lot of the visit. You’re going to have to go back to the beginning and start over about the medication.

Other people will say things like, “Oh, right. It’s that diabetes medicine. You want me to something, right?” I say, “That’s right. I wanted you to change the number of times a day.” They say, “Oh, right. You wanted me to do it three times a day and not twice a day, right?”

Helen: You’re teaching it again.

Dean Schillinger: I’m kind of teaching it again but I’m also letting them get it right by saying, “Yes, we talked about the number of times a day,” and then she says, “Oh, right. You want me to take it three times a day.”

That’s because people who say it and they get it right are going to much more likely remember it than people who get it wrong and get corrected.

Getting something wrong and getting it corrected is not an equation for you remembering. It’s an equation for you to be stigmatized and feel ashamed. Getting something right and getting praise for remembering is an equation for recalls.

You may find also that people start to raise some things that you otherwise wouldn’t have known. They might say, “You told me about that Metformin thing, but I don’t really believe in medications and I’m going to take my cactus leaves and tea.”

It may not be a misunderstanding, but you’re going to reveal, or she would have just disclosed to you, an alternative health belief that you didn’t even know existed. That’s really important for you to know. There will be valuable information that may come back at you.

Lastly, you may discover that somebody just consistently isn’t able to teach stuff back to you. Then you have to wonder, “Do they have some cognitive impairment? Do they have some hearing problems or sensory deficits of the eighth nerve? Is there a language barrier? Is their literacy so profoundly low that they can’t do numbers?”

You have to be very curious around the response that you get. It’s not just a simple dichotomous true/false, yes/no question. It’s really like a very interesting response and you need to tailor your next step based on that response.

Helen: Dean, you’re a busy doc. You’re in practice and doing a zillion other things at the same time. How do you fit all of this in?

You get that response you weren’t expecting, you’re uncovering other problems and you’re finding out they have a whole other world view about this medicine you just want to teach them how to take. What do you do about that time issue?

Dean Schillinger: First, I’ll say that hard-data-wise our study that you alluded to earlier showed that visits that have a teach-back in them were actually a little briefer than visits that didn’t. It wasn’t statistically significant so I’ll say that they were basically the same. They were basically 20 minutes long.

Why is that? They were 20 minutes because guess how many minutes I have for an appointment? I have 20 minutes for an appointment and that’s how much time I’m going to use for an appointment.

You have 20 minutes, 15 minutes or whatever your health system gives you. The question you have to ask yourself is what are you going to do with those 20 minutes?

Sure, I could teach them all about diabetes, I could start them on 17 medications and I could take a train wreck and turn it into a beautiful engine, but if the person is not understanding a word that you’re saying and if you’re talking a different language, it’s a complete waste of time. I should say it’s an ineffective use of time.

Any time there’s miscommunication, it’s like a voltage drop of electricity. You lose energy every time you do that. The fewer voltage drops you can have in the course of a 20-minute visit or the course of a lifetime of caring for someone, the more effective of a clinician you’ll be, whether it’s a doctor, nurse, physical therapist or whatever.

You have to be curious. You have to start developing these habits that over time in an iterative way will turn you into a better communicator so that by the fifth year of doing the teach-back you’re noticing, “More and more of my patients are actually able to teach this stuff back to me now. Have they gotten smarter or have I just gotten better?”

I had something happen to me the other day where one of my patients said, “Doc, aren’t you going to do that teach-back thing on me?” I said, “That’s fantastic. I love that. Thank you.”

Helen: I love that.

Dean Schillinger: That’s what we want. We have that in the airline industry where the control tower says, “Tell me when you’re ready to take off.”

Helen: I love listening to you. You framed where it began. You frame what’s going on. You do it with humor but you do it with humanity too.

This is the last question about this. You did your research more than a dozen years ago on this. What keeps you excited about it? I can hear that excitement still today.

Dean Schillinger: Do you mean about teach-back in particular?

Helen: Yes.

Dean Schillinger: It’s one of the few moments in medicine, unfortunately because of the way we evolved, where you can actually get the patient’s story.

What’s so interesting about medicine is the people, how they arrived where they have arrived, the resilience and the vulnerabilities they have and all of those things.

It’s about maintaining your curiosity. I think the teach-back ultimately is about that. It’s about maintaining your curiosity about people.

In fact, those of us who do the teach-back have begun to do it at the very beginning of the visit. I say, “We talked about a lot of things last time, Ms. Jimenez. What have you thought about those things? How has it gone for you?”

It’s sort of a habit now which has much greater degrees of interactivity and reciprocal exchange than otherwise we’re restricted to do. I think it can be freeing rather than restrictive. I think people think of it as a restrictive practice, but it’s a very freeing practice.

Helen: We’re going to put a semicolon in the conversation now.

This is the second time I’ve interviewed you for a podcast, and I’d love to interview you again. It’s almost like a serial. We keep moving the story forward. We can begin with that shared meaning at the beginning of the next one and move on from there.

I don’t want to take more of your time right now. You have shared so much with us and you do amazing work.

Dean Schillinger: You and I will not be happy until that 1% becomes 90%.

Helen: Yes, or at least in the double digits in the next decade.

Thank you, Dean, so much for being a guest on Health Literacy Out Loud.

Dean Schillinger: Helen, thank you so much.

Helen: I learned so much in this podcast conversation from Dr. Dean Schillinger and I hope that you did too.

Health literacy and using the teach-back and all of the other many strategies he talked about isn’t always easy. For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com.

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Did you like this podcast? Did you learn something new? I sure hope so. If so, tell your colleagues and tell your friends. Together, let’s let the whole world know why health literacy matters.

Until next time, I’m Helen Osborne.