As health care providers, we want to do everything we can to help our patients achieve wellness. It can be tempting to share all of the information we have learned with them toward that goal of patient education and health literacy. However, all the best information can’t be helpful if our patients can’t act on it because they don’t remember it.
To ensure patients have useful information they can benefit from, it is important to avoid patient education overload. Health care providers should help patients improve their health literacy and use effective 2-way communication to achieve better patient commitment to treatment and satisfaction.
Is More Information Always Better?
Research has consistently found that patients often forget information given to them by their physicians.1 Patients can immediately forget 40% to 80% of the medical information and recommendations they receive. Of the information they remember, only about one-half of it is typically recalled correctly.2 For any recommendation to be effective, patients must be able to remember what it is and how to achieve it.
A lower ability to recall medical information is associated with several factors, including3,4:
- Older age;
- Low health literacy;
- High and low anxiety;
- Large amount of information; and
- Low level of education.
The type, structure, and length of information can influence how much of the information a patient can retain.5 The more recommendations a patient is given, the higher the likelihood they will be forgotten. A 2011 study conducted at a family practice in Slovenia found that there is a higher likelihood that recommendations will be forgotten when patients are given 3 or 4 at one time, compared with just 1 or 2 recommendations. The study authors recommend that if more than 1 or 2 recommendations are needed, a follow-up appointment should be scheduled.4
Effective communication can improve patient satisfaction and recall, ultimately improving patient outcomes.6
A component of optimal health care delivery is ensuring that health information as communicated by clinicians is understood by their patients. The most effective type of communication will differ among patients. Health care providers have the responsibility of providing patients the information they need to achieve health and wellness, and patients have the responsibility of acting on the information.7
Improving patient care and communication should focus on improving patient health literacy. Health literacy refers to an individual’s ability to find, understand, and use health-related information to make decisions and take action. According to the Agency for Healthcare Research and Quality (AHRQ), health literacy in the United States is low, with only 12% of Americans demonstrating health literacy skills adequate to navigate the complex health care system.8
Health literacy is one of the best predictors of a patient’s health. Low health literacy is linked to9:
- Poor management of chronic illness;
- Decreased ability to participate in shared decision-making with health care providers; and
- Lower levels of adherence to medical therapies.
Although health literacy can be an important factor in predicting a patient’s outcomes, clinicians do not necessarily need to evaluate their patient’s level of health literacy. Instead, health care providers should use universal precautions for all patients, regardless of their health literacy level. Universal precautions aim to10:
- Simplify communication;
- Confirm patient understanding;
- Improve the navigability of health care services; and
- Support patients.
Barriers to Patient Education
Health care providers should be aware of what potential barriers may exist for patients to understand medical information.
Recall of medical information is strongly associated with patient education levels. One study found that people with less than a high school diploma recalled approximately 38% of recommendations made during an ambulatory care visit, while people with a college degree were able to recall approximately 65% of recommendations.1
It may not be possible for a clinician to be able to determine patient education levels, but patients with low health literacy often have red flags, such as11:
- Missed appointments;
- Incomplete written forms;
- Lack of adherence to medication;
- Inability to state the name or purpose of a medication;
- Inability to provide a complete or coherent history; and
- Lack of follow-through on testing or laboratory appointments.
Strategies to Improve Health Literacy & Patient Education
Even if a patient has high health literacy, clinicians should still take precautions to ensure comprehension. AHRQ provides a health literacy universal precautions toolkit to help health care providers promote better understanding for everyone.10 The toolkit is available here.
Use Clear Communication
Clear communication can help patients to better understand medical information. Tips for clear communication include12:
- Maintaining a friendly attitude;
- Avoiding the use of medical jargon;
- Using the patient’s own words;
- Speaking at a moderate pace; and
- Avoiding interrupting patients when they are speaking.
Focus on What the Patient Needs To Know
Health care providers should prioritize the information that needs to be discussed. Information should be limited to 3 to 5 key points. Repeating these key points can also help with patient recall.12
Key points should be specific and focus on the steps the patient must take when they leave the examination room and when they return home to successfully follow treatment instructions. Patients are more likely to remember specific advice compared with generalized information.3
Key information should be prioritized based on the patient’s goals. For example, the key points for a patient being seen to diagnose a new condition will be different from those provided to a patient following up on an existing condition.12
Use the Teach-back Method
The teach-back method allows health care providers to ensure that medical information is given to patients in a way they can understand and act on. This method has been shown to help2:
- Improve a patient’s understanding and adherence to recommendations;
- Reduce the number of canceled appointments;
- Decrease the number of callbacks; and
- Increase patient satisfaction.
The teach-back method should be framed as a test of how well the health care provider explained knowledge instead of a test of the patient’s knowledge. Instead of asking yes or no questions to confirm knowledge (such as, “Does that make sense?”), use open-ended questions where the patient must summarize recommendations in their own words.2
Examples of starter phrases that can be used in the teach-back method include2:
- “We covered a lot today. To make sure I explained things clearly, can you describe 3 actions you agreed to take today?”
- “This is a new diagnosis for you. To make sure you understand, can you tell me what this condition means?”
- “I’ve noticed lots of people have trouble remembering how to use their medication. Can you show me how you use your medication?”
Health care providers should check for understanding throughout the patient encounter instead of waiting until the end. Incorrect or incomplete understanding should be corrected immediately before moving on.2
Some providers may feel that the teach-back method feels awkward or time-consuming when they first incorporate this method into their practice. However, when used over time, it can improve patient outcomes and satisfaction without increasing the length of a visit.2
Use Alternative Teaching Styles
The use of different types of patient education materials may encourage effective retention of information among patients with different learning styles. Although oral communication is a faster way to share information, written communication may result in better patient recall. Ideally, information should be provided in more than 1 form.3
Health care providers should consider having patient education materials available in different formats, such as13:
- Printed materials;
- Pictographs and infographics;
- Slide presentations;
- Group classes; and
- 1:1 teaching.
It is important to evaluate a patient’s ability to effectively use the educational materials they are given. Materials should be provided in a language the patient speaks and ideally in their native language.14
Written materials should be easy to understand. The average US adult reads at approximately an 8th-grade level, but up to 20% of adults read at or below a 5th-grade level. Written materials should be written at a 5th- or 6th-grade level to ensure all patients can understand the information.14 Pictographs or drawings serve as a useful form of communication for all patients, especially when literacy is unknown.3
Before using technology, it is important to make sure the patient is able to use it. For example, if a patient is instructed to watch a YouTube video, they should have access to a computer and know how to search for the video.14
It may help to keep a tally of which materials are given to patients most often or how often the office runs out of each printed material.
Measuring Patient Education Outcomes
The continuous measuring of outcomes is important to improve the health literacy of patients. One of the fastest and easiest ways to measure outcomes is to ask for patient feedback. Feedback can be obtained verbally during the encounter or by a written survey at the end of a visit. Examples of feedback questions include15:
- “Which parts of today’s visit did you find clear and easy to understand?”
- “Which parts did you find confusing?”
- “What information has been helpful for you?”
- “Is it clear what you need to do based on the information given to you today?”
Other methods for receiving patient feedback include15:
- Suggestion boxes;
- Shadowing patients during visits and while using health tools (such as a patient portal); and
- Walkthroughs with a person unfamiliar with the practice.
The rate of patient adherence to treatment can also indicate the efficacy of communication. Studies show that patients with chronic conditions such as hypertension and type 2 diabetes who are satisfied with their provider’s communication are more adherent to their treatment.16,17
Patient Education & Health Literacy is Key
Patients are only able to take action on medical recommendations they understand and remember. Health care providers are responsible for improving health literacy by providing recommendations in a way that patients can understand.
1. Laws MB, Lee Y, Taubin T, Rogers WH, Wilson IB. Factors associated with patient recall of key information in ambulatory specialty care visits: results of an innovative methodology. PLoS ONE. 2018;13(2):e0191940. doi:10.1371/journal.pone.0191940
2. Use the teach-back method: tool #5. Agency for Healthcare Research and Quality. Updated September 2020. Accessed July 18, 2023.
3. Watson PW, McKinstry B. A systematic review of interventions to improve recall of medical advice in healthcare consultations. J R Soc Med. 2009;102(6):235-243. doi:10.1258/jrsm.2009.090013
4. Selic P, Svab I, Repolusk M, Gucek NK. What factors affect patients’ recall of general practitioners’ advice? BMC Fam Pract. 2011;12:141. doi:10.1186/1471-2296-12-141
5. Richard C, Glaser E, Lussier M-T. Communication and patient participation influencing patient recall of treatment discussions. Health Expect. 2017;20(4):760-770. doi:10.1111/hex.12515
6. O’Keefe M, Sawyer M, Roberton D. Medical student interviewing skills and mother-reported satisfaction and recall. Med Educ. 2001;35(7):637-644. doi:10.1046/j.1365-2923.2001.00971.x
7. Paterick TE, Patel N, Tajik AJ, Chandrasekaran K. Improving health outcomes through patient education and partnerships with patients. Proc (Bayl Univ Med Cent). 2017;30(1):112-113. doi:10.1080/08998280.2017.11929552
8. About health literacy. Agency for Healthcare Research and Quality. Updated March 2023. Accessed July 19, 2023.
9. Parikh C, Ostrovsky AM. Analysis of trustworthiness and readability of English and Spanish hypo- and hyperthyroid-related online patient education information. J Patient Exp. 2023;10:23743735231179063. doi:10.1177/23743735231179063
10. AHRQ health literacy universal precautions toolkit, 2nd edition. Agency for Healthcare Research and Quality. Updated September 2020. Accessed July 19, 2023.
11. Health literacy: hidden barriers and practical strategies. Agency for Healthcare Research and Quality. Updated September 2020. Accessed July 19, 2023.
12. Communicate clearly: tool #4. Agency for Healthcare Research and Quality. Updated September 2020. Accessed July 19, 2023.
13. MedlinePlus. Choosing effective patient education materials. National Library of Medicine. Updated October 17, 2021. Accessed July 18, 2023.
14. Assess, select, and create easy-to-understand materials: tool #11. Agency for Healthcare Research and Quality. Updated September 2020. Accessed July 19, 2023.
15. Get patient feedback: tool #17. Agency for Healthcare Research and Quality. Updated September 2020. Accessed July 19, 2023.
16. Huang J, Ding S, Xiong S, Liu Z. Medication adherence and associated factors in patients with type 2 diabetes: a structural equation model. Front Public Health. 2021;9:730845. doi:10.3389/fpubh.2021.730845
17. Świątoniowska-Lonc N, Polański J, Tański W, Jankowska-Polańska B. Impact of satisfaction with physician-patient communication on self-care and adherence in patients with hypertension: cross-sectional study. BMC Health Serv Res. 2020;20(1):1046. doi:10.1186/s12913-020-05912-0