by Robert H. Margolis
Our patients lead busy lives and many factors work against the likelihood that they will remember what we tell them. Informational counseling is intended to provide the patient with the relevant knowledge necessary to understand the nature of the disorder and the steps recommended for managing it. Personal adjustment counseling helps the patient and family deal with the emotional impact of the information. Both are necessary.
The communications professions, however, have paid little attention to informational counseling and to our patients' memory for the critical information that they need to play an active, positive role in remediation and rehabilitation. Although patient recall has been studied by other health professions, our literature contains almost no references to these studies.
Patient Recall
The working mom whose son broke an ankle yesterday playing soccer, who is worried about missing work, who doesn't have anything for dinner tonight, and whose husband may be laid off next week, is not likely to remember important details about a communication disorder. We seldom know the complexities of our patients' lives and their ability to comprehend and retain important information. But retention of diagnostic information and recommendations are critical to treatment outcomes.
Studies have found that when patients understand the information communicated by a health care provider, it results in significant enhancements of patient satisfaction, compliance with recommendations, and outcomes, and decreases in anxiety, treatment time, and cost (e.g., Thomson, Cunningham, & Hunt 2001). One study showed that physicians underestimate their patients' desire for information and their ability to understand medical findings (Shapiro et al., 1992). When physicians were given specific strategies for enhancing communication, patient recall improved measurably (Ley, 1977). A disturbing finding, however, is that what physicians thought patients would remember did not correlate with measures of actual recall (Anderson et al., 1979). This reinforces the need to provide information in writing, even for patients who appear to be absorbing everything.
Limits On Memory
Patients retain about 50% of information provided by health care providers (e.g. Shapiro et al., 1992). Depending on conditions, 40-80% may be forgotten immediately (Kessels, 2003). When recall was measured at two points, there were no differences in recall measured soon after the consultation and at a later date (Joyce et al., 1969; Reynolds et al., 1981). It seems that patients remember a small proportion of facts and those stay with them for a period of at least several weeks.
Of the information that is recalled, about half is remembered incorrectly (Anderson et al., 1979; Kessels, 2003). So half is forgotten immediately, and half of that is wrong. If you remove 50% of the facts relating to a health problem and distort half the remaining information, the result can be a dangerously misunderstood message that could have life-threatening consequences.
An even more disturbing finding is that patients often forget their medical diagnoses. In one study, patients could not recall 68% of the diagnoses told to them in a medical visit. When there were multiple diagnoses, patients could not recall the most important diagnosis 54% of the time (Scheitel et al., 1996). Some of the diagnoses were serious, even life-threatening conditions such as diabetes, hypertension, and liver disease. In another study, patients and physicians agreed on problems that required follow-up for only 45% of the time (Starfield et al., 1979). When there was disagreement between the physician and patient regarding the need for follow-up, the likelihood of appropriate management was significantly lower.
Factors Affecting Patient Recall
Patient Factors. Intelligence does not affect the ability to retain information (Ley, 1979). However, familiarity with the information does have an effect (Tuckett et al., 1985). A patient who is familiar with hearing loss as a result of prior consultations, an affected family member, or professional knowledge tends to remember more. The degree of understanding of issues related to the diagnosis can have a significant effect. A finding that the patient expects is remembered more than one that is unexpected; a finding that is welcome or desired is more likely to be recalled than one that is unwelcome or unwanted.
Interestingly, patients are better able to recall information when they are in the same emotional and physical state they were in when they received the information (Kessels, 2003). Elderly patients tend to remember less than younger patients. Anxiety can have a positive or negative effect on retention. Moderate anxiety enhances recall but severe anxiety inhibits retention of information. Stress causes "attention narrowing" that interferes with the patient's ability to redirect to a different topic (Kessels, 2003). Denial is a powerful defense mechanism that can interfere with recall of the most obvious findings. One study, for example, showed that patients frequently forgot diagnoses of excessive tobacco use and obesity (Scheitel et al., 1996). Patients who are in denial of their hearing loss, for example, are not likely to accurately convey information provided at the hearing evaluation to family members.
Mode of Presentation. Information presented in a simple, easy-to-understand format is remembered better than information presented in a more complex manner. The more information presented, the lower the proportion that is recalled by the patient. Information that is presented first tends to be remembered better-the primacy effect.
Categorizing information can improve retention; some authors discuss the method of explicit categorization (Kessels, 2003; Ley 1977, 1979; Tuckett et al., 1985). Information is organized in specific categories such as explanation of systems, diagnostic tests, results, prognosis, and recommendations. The patient is told that the information will be presented in these categories, each category is announced, and the patient is asked if there are questions before moving on to the next category. The method can significantly enhance recall.
When verbal presentation is supplemented by written and graphical material such as written explanations, cartoons, and pictures, recall can be significantly enhanced.
Recommendations are more likely to be remembered and followed when they are specific rather than general. A recommendation should be a specific statement telling the patient what to do rather than a more general statement of the goal. A recommendation to "stay home from work and rest for two weeks with no strenuous exercise" is more likely to be followed than "get some rest and take it easy for a while."
Clinician Factors. The clinician's communication style can have a significant influence on retention. Information given by clinicians who speak in clear language with simple sentence structure is more likely to be remembered than that provided in complex, scientific language. Clarity of communication requires the clinician to understand what patients wish to learn and their levels of understanding.
To communicate clearly in a manner that promotes retention of information, the consultation needs to be a dialogue in which the clinician listens to the patient. When the patient's ideas are evaded or inhibited, the patient is less likely to remember important information. Even the clinician's anxiety affects recall. Patients remember less when the information is provided by an overtly anxious clinician. Information that is presented in a manner that emphasizes its importance is more likely to be remembered than if it is presented in a matter-of-fact manner. Non-verbal communication is important in reflecting the clinician's state (confident, anxious, distracted, empathetic) and in indicating the importance of information.
A patient may appear to understand but if the understanding is not confirmed by the clinician and the patient is not encouraged to ask questions, the clinician may not be aware that the patient did not understand at all. Information that is unorganized, unclear, or incomplete can be interpreted by patients to confirm their pre-existing beliefs that may not be in concert with the message the clinician is attempting to communicate. Tuckett and colleagues (1985) called this the "illusion of shared understanding." When the clinician is oblivious to the patient's lack of understanding, the entire consultation session may provide little benefit, or worse, do more harm than good.
Accurate recall can be significantly enhanced by proper communication techniques (see sidebar, page 11). But patients still will forget. The best way to ensure that the information gets home is to provide the patient with a permanent record. It is recommended that patients be instructed to write the information as the clinician presents it. Starfield et al. (1979) recommended tape-recording the consultation. Another approach is to provide clearly written, illustrated, patient-specific educational materials that ensure the information is clear, accurate, complete, and available for review and discussion with family members and other professionals.
Patients cannot always bring a family member or friend to a consultation and at the time of the consultation they may not be receptive to important information. They may have prior beliefs that may or may not be realistic or they may be in denial. The research findings discussed in this article indicate that the information we present will not be remembered accurately. If the information is not remembered accurately, we cannot expect the patient to communicate accurately to family members.
Although the professions of audiology and speech-language pathology are solely concerned with the communicative well-being of our patients, our own communication to patients is disordered. We complain that our counseling efforts are not reimbursed, but an analysis of our methods and outcomes would probably not convince payers that we are providing a valuable, reimbursable service when we verbally present complex information in a format that is known to be ineffective. I recommend the following guiding principle for our communication of results and recommendations to our patients: Any information that is important for the patient to understand and remember should be provided in writing.
Robert H. Margolis is professor of audiology at the University of Minnesota School of Medicine. In 2000 he started Audiology Incorporated to develop and market education materials for hearing-impaired patients and their families and to obtain federal funding for the development of automated hearing tests. The "Understanding …" series of patient education materials can be viewed at the Audiology Incorporated Web site.