Map of life expectancy at birth from Global Education Project.

Monday, September 27, 2021

This time I really do know what I'm talking about

I don't often write here explicitly about my own research. I've been writing this blog for something like 15 years now -- actually probably more than that -- so the subject would have been largely exhausted long ago if I'd concentrated on it. But I'm expecting to be interviewed about an aspect of it this afternoon so I might as well get my thoughts together.

I have found that people on average do not accurately remember about half of the important information, recommendations and decisions that happen in a routine medical visit. That's consistent with what others have found. This is a problem for a couple of reasons. The first is obviously that if people don't properly understand or remember how they are supposed to take their medications or change their diet or watch out for certain symptoms or whatever it may be, their health may be compromised. Basically the time, effort and money spent on the visit has been wasted, or worse. 


The second is that medical decisions are usually not straightforward. There are potential benefits from a given medical intervention, but also costs and risks. If we just depend on the physician to tell us what to do we may not end up doing what makes sense for us individually. But if we don't understand the issues, we can't meaningfully share in decision making. There are other possible repercussions, such as transmitting inaccurate information to family and friends, unnecessary anxiety, and more.

The traditional conception of a medical encounter was that there would be one main issue to be processed and dealt with -- the "chief complaint." Medical students were taught to proceed through steps called Chief Complaint, Present Illness, Past History, Family History, Social History, Systems Review, Physical Examination, Other Investigations, Diagnosis, and Treatment Plan. In the real world, that is very rarely what happens. In a typical visit, there are at least five different issues that come up, and there may be as many as 15. And they don't get processed one a time, they get all mixed up, with digressions from one to another and some getting dropped entirely before they are resolved. The more of them there are, the smaller percentage people understand accurately and remember.

How can we improve on this? There are several ways which have actually been recognized for a long time, but doctors don't do them. One is to have a brief discussion at the beginning about the agenda for the visit. What is the patient's list of concerns? What is the doctor's? If it looks like too much to deal with in 15 minutes, what are the priorities and what can wait until later? Another is to use "teach back." Saying to someone "Do you understand?" is a waste of oxygen. The person might think they understand but they have it wrong. Or they may be afraid to say "no" and look like a dunce, or seem to insult the doctor as being a bad explainer. What is useful is to say something like, "I don't know if I always explain things as clearly as I might, so in your own words, can you repeat what we just talked about to make sure we have it right?" But doctors seldom do that either. Another good practice is to do a wrap up at the end. "Okay, we talked about X, we're doing to do this about it, we talked about Y and we're going to do that, we talked about Z and we're going to do the other thing." But doctors don't do that either.

So you, in the role of patient, can try making those things happen, since we've given up on getting doctors to do it. When the doctor asks what your concerns are, and you start to say the first one, the doctor will typically interrupt before you have a chance to state your second and third. Don't let that happen. Speak up and say okay but I have a couple more. When the doctor explains something, say "Is it okay if I repeat that back so we can make sure I got it right?" When the doctor says you're going to get a prescription or recommends a procedure, ask "Okay, can you tell me what the likely benefits are, and what I might expect as far as side effects or risks?" And by the way, when people participate in the decision, they are more likely to remember it correctly. At the end of the visit, you can say "Okay, can we go over again the main things we talked about?"

I can't promise your doctor won't be offended if you do all this, but that's just too bad.


Don Quixote said...

This is a great post, because it describes to a T what actually happens in visits to a doctors office. My partner just had hip revision surgery, so she is going to use these recommendations when she sees her surgeon in a week. He’s very good at what he does, but in this way, she will be able to participate in the decision-making process with more confidence.

Sugarloaf said...

Having been on the patient’s end of many consultations over the past year:
I take a note, in writing, of what the doctor or nurse tells me or advises. Maybe this is an English thing, but I felt very hesitant about doing this at the start. However, “I hope you don’t mind if I make a note of this” was all I needed by way of asking indulgence for this modus operandi. All was fine from then on. I take notes at each consultation. I rely on memory therefore, as little as possible.
Perhaps, in addition to your other useful advice to patients, this could be included.