Think of the last time you gave instructions to a patient, particularly when it involved medication adherence. You may have said, “I’d like you to take this pill every morning after breakfast. Do you understand?” The patient probably answered “Yes.” But were you sure the patient understood and would remember how and when to take the medication? Of course not. Many patients will say they understand even if they are not sure. Three studies have found that 50 percent of patients leave their medical visit without understanding what their physician told them.1 According to the Agency for Healthcare Research and Quality, patients immediately forget between 40 percent and 80 percent of the medical information they receive during office visits, and almost half the information they do retain is incorrect.2 When it comes to hospitalized patients, a substantial percentage do not understand their plan of care, and physicians frequently overestimate how well patients understand their discharge plans.3
Patients often leave their visits not understanding or remembering their physicians’ instructions, even when they say they do.
The teach-back technique ensures patient understanding by asking patients to repeat their physicians’ instructions in their own words.
Despite evidence that use of teach-back benefits patient outcomes, many physicians do not practice the technique because of a lack of training, concern for time constraints, or fear the patient will take offense.
A SIMPLE SOLUTION
Teach-back is one solution to this common problem. Also called “closing the loop,” this technique involves assessing a patient’s understanding of your recommendations by asking the patient to repeat your recommendations in his or her own words.2 For example, you could ask, “Just to be sure I was clear, how will you take your new medicine?” If the patient’s explanation is not correct, repeat the recommendation and then ask him or her to explain it again. To perform teach-back effectively, you must keep asking your patient to repeat your instructions until he or she can describe them accurately. (See “How to use teach-back with patients.”)
This technique is effective in improving not only medication adherence but also patient understanding of diagnoses, prognoses, physical rehabilitation, and care options, as well as patient outcomes.2 For example, physicians who used teach-back in caring for patients with diabetes reported better glycemic control compared with physicians who did not check patients’ understanding.4 This may be because people are more likely to retain information they verbalize than to remember what they are simply told.
The American Academy of Family Physicians, American College of Surgeons, American Hospital Association, American Nurses Association, Federation of American Hospitals, and The Joint Commission have all endorsed the use of teach-back as a national standard of care. Despite this endorsement, teach-back is not commonly used by clinicians. In one study in which patient visits were audiotaped, physicians assessed patient understanding of their instructions only 12 percent of the time.4 In a national survey, only 23 percent of pediatricians reported using teach-back.5 In another study, although 48 percent of medical residents said they usually or always used teach-back, observations of the residents found that only 22 percent actually used the technique.6 In a separate study, 59 percent of primary care physicians said they used teach-back when explaining colorectal cancer screening, but only 11 percent actually used it when observed with patients.7
HOW TO USE “TEACH-BACK” WITH PATIENTS
This communication technique, which involves asking patients to repeat key information in their own words, helps patients retain what they have learned during their visit. Here’s how to do it correctly:
Explain diagnoses, care options, and medication regimens to the patient in specific, plain language that avoids medical jargon.
Emphasize to the patient that you are not testing his or her knowledge but whether you did a good job explaining the health information.
Encourage the patient to use his or her own words in describing the health information and not to just repeat what you said.
Ask open-ended questions rather than questions the patient may answer with a “yes” or “no.”
If the health information includes a specific action, such as using an inhaler, ask the patient to show you how to perform that action.
Use teach-back after you explain an important concept, and repeat the concept as needed throughout the visit.
Make sure staff members are trained in the teach-back method; nurses or medical assistants could perform teach-back during the after-visit summary.
To begin using teach-back in your practice, start slowly with one or two patients a day. As you become more comfortable, you can expand to additional patients.
Source: The SHARE Approach – Using the Teach-Back Technique: A Reference Guide for Health Care Providers. Rockville, MD: Agency for Healthcare Research and Quality; July 2014. https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-6/index.html.
Why do clinicians so seldom employ the simple and effective teach-back technique?
First, some clinicians worry that using teach-back will add too many minutes to their already time-constrained patient visits. In fact, teach-back takes only one or two minutes if done correctly. Teach-back is not used to emphasize every detail of a care plan; it is reserved for only the most important details, such as medication instructions. In addition, other members of the care team, such as nurses or medical assistants, could perform teach-back as part of the after-visit summary.
Second, physicians may worry that asking patients to repeat back their instructions would be demeaning. However, studies show that patients like teach-back. One study involved 100 patients who watched two videos – one video in which a physician demonstrated the teach-back technique by asking patients to state their understanding in their own words and a second video in which the physician simply asked the patient “Do you understand?” Patients strongly preferred the teach-back video.8
Third, many medical schools do not train students to use teach-back, so they are unfamiliar with the concept once they enter practice. Clinical leaders in hospitals and office-based practices can overcome this problem by training all physicians and staff on teach-back. (Training materials are available as part of the University of California-San Francisco Center for Excellence in Primary Care’s Health Coaching Curriculum.)
Over time, as more physicians use these techniques, patients will better understand their care, and outcomes should improve.