Teach Back as an Effective Patient Education Tool

by Edward Leigh, MA

A patient tells you they understand everything you said about their treatment plan.  You feel good about this patient visit and are ready to close the meeting.  The patient stated they understood, but did they really?

Problem with “Do you understand?” question

There are serious issues associated with the question, “Do you understand?”  Just because the patient says, “Yes,” does not mean they truly understand.  How can you be sure they understand? Use the powerful “teach back” method.

Teach back is a powerful communication tool to assess a patient’s understanding. After the professional shares new medical information with the patient, the patient is asked to “teach back” what they just heard, verbally or in the form of a demonstration. This allows the professional to correct misunderstandings and provide additional information, if necessary. (In some cases, the patient’s caregiver may be the person “teaching back” the information.)

Factors to consider

If the teach back strategy is not properly set up it could actually backfire leading to a worse patient experience.

Patients may feel you are questioning their intellectual abilities. I have interviewed thousands of patients regarding their experiences with healthcare professionals.  For example, I asked one patient if she was familiar with teach back. She stated she was not familiar with the strategy. She also asked, “Is that for people with learning disabilities?” Upon further discussion, she said if a healthcare professional asked her to repeat back what she heard, she would feel that they think of her as dumb. This example illustrates that the set up to the discussion is critical.  It is vital that patients know the strategy is useful for everyone.

This strategy is not a like a pop quiz you had in school. Don’t simply tell a patient, “Repeat back what I just said!”  This comment will put them on the spot and cause anxiety.  They will feel like a school kid who was just told to clear their desk for an unannounced pop quiz.

To avoid these potential issues, ask the patient certain types of questions. View sample questions in the next section.

Sample of open-ended questions to assess understanding

There are many ways to assess patient understanding via teach back. The questions below provide a friendly and comfortable manner to assess understanding.

Focus on “I” Language. It is important to remember teach back is a way to test our abilities at explaining. In other words, we are actually testing ourselves, not the patients. Using “I” language takes the stress off the patient.

• “I want to be sure I explained everything clearly. Can you explain it back to me so I can be sure I did?”
• “Please show me how you will use the device, so I can be sure I have given you clear instructions.”

Focus on how they would tell other people in their lives.

• “How would you describe your health condition to a friend?”
• “When you get home and your spouse asks about your treatment plan – what will say?”

Possible reasons for patients not being able to teach back

If the patient is not able to repeat back their medical situation this may be an indication the professional needs to rework their teaching approaches. There could be several factors reducing the ability of a patient to teach back.

Excessive use of medical jargon. If patients do not understand what professionals are saying, they will not be able to repeat back what was said to them. Use everyday language.  For example, do not say, “NPO after midnight.” Rather, state, “Do not eat or drink anything after midnight.”

Too much information presented too quickly.  The “chunk & check” strategy is a tool to avoid this scenario. Provide a “chunk” of information and then “check” with the patient for understanding.

Patient anxiety.  Regardless of how skilled the professional is at explaining to the patient their medical situation, if the patient is very tense, the material will not be absorbed.  In this case, use empathy. Mention that you understand their feelings of anxiety.  You may want to engage in brief deep breathing exercises with the patient to help them feel calmer so they are better able to take in the information.  The exhale should be longer to achieve maximum relaxation. For example, inhale on a count of four and exhale on a count of six. A few deep breathes goes a long way!

If the patient was not able to repeat back, do not repeat – re-phrase.

Benefits of teach back

Improves outcomes. According to the Joint Commission, research indicates that the teach back technique is effective, not just for improving patients’ understanding, but also for improving outcomes. For example, patients with diabetes whose physicians assess their comprehension and recall with the teach back technique have significantly better diabetes control than patients whose physicians do not use the technique. (Schillinger D, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83-90.)

Can ultimately save time. Professionals often feel they have no time for the teach back method.  It actually does not take very long to assess a patient’s understanding.  Think of how much time it will take if the patient has to call back or visit again.

Enhances patient safety. If a patient does not understand their medical issue, they are at risk. A patient’s medical situation is not nice-to-know information, it is need-to-know information!

Unity Point Health, Des Moines University and other organizations collaborated to develop an excellent Teach Back Toolkit.  Click on the link for more information on this very helpful toolkit.

http://www.teachbacktraining.org/

After giving it – be sure they get it!

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication. The Center focuses on increasing patient satisfaction, improving compliance and decreasing the risk of medical errors. The Center offers high-impact training, consulting and one-on-one coaching. Edward Leigh’s new book, Engaging Your Patients, is due out in late 2014.  http://www.CommunicatingWithPatients.com or 1-800-677-3256

Effective Use of PowerPoint in Medical Presentations

by Edward Leigh, MA

During the morning break from an all-day physician workshop, a participant approached me (while smiling) and stated, “I’m angry at you!”  He then went on to say, “I come to these seminars and always sit in the back. I open up my laptop to get work done, but you made me listen. You made me work. This is the best seminar I have attended in I don’t know how long.”  I am not sharing this story so I could simply tell you how wonderful I am at presenting programs. Rather, I am sharing the story to reveal a significant problem in medical education. The red flag here is the dependence on PowerPoint as a teaching tool. Effective learning must be an active engaging process that stimulates the learners’ minds, not a passive process of simply looking at slides.

Before you create your first slide – answer this question.  What’s your point?  What are the goals of your session?  When I coach people on their presentation skills, I always ask this question, “A month from now, what  two to three points do you want people remember from your presentation?  I am talking about the big picture take home points.” People struggle with this question often telling me they have dozens of points.  Think about your big overall goals and build your slides from that information.

PowerPoint is ONE component of a dynamic presentation. In addition to the slides, we must have a great opening, powerful close, audience involvement and THE key attribute – enthusiasm! This is your subject and you must show your passion! PowerPoint is an aide to us, we are not an aide to it. The slides are part of our program, but they should never become THE program. You and your knowledge base are the stars of the show.  In the very unexpected event of the PowerPoint not working, could you still present your program and engage the audience?

Avoid all-text slide presentations. This scenario creates an uninspiring presentation that leads to audience boredom.  Incorporate photos and charts to make the program come alive.  Periodically, add graphic elements between text slides to keep the audience interested in your presentation. A medical student told me he attended a presentation by a visiting professor, who spoke in a monotone voice and had text-only slides. When the professor was done speaking, the audience didn’t clap at first because they didn’t realize he completed his presentation! When an audience is so tuned out they don’t realize a presentation is over, that’s really bad news!

6 x 6 rule.  No more than six lines per slide.  No more than six words per line.  It is important to think in terms of “less is more.”  Each slide should contain ONE main idea.  I have attended medical presentations in which the slides were so busy and complicated most audience members were completely baffled, which led to a lot of frustration.  When coaching people on their presentation skills, the biggest issue I find is information overload.

No one learns when they are sleeping. Providing the slides to audience members and then simply reading the slides verbatim is not only a poor educational tool, it is also incredibly tedious. While attending typical medical programs, I often look around at the audience. I see few people truly engaged. Many people looking are at their smart phones, reading something else, quietly talking to a neighbor, or worse, sleeping. Since the audience can read, the presenter is not necessary. The audience members could read the slides on their own. To be truly effective, speakers must bring something more to the presentation.

Moving from passive to active audience members.  Yes, you can engage audience members with PowerPoint!  This can be done in a variety of ways. Put a question on a slide and ask the audience to briefly discuss the question with a neighbor. Then ask for responses. Show a picture and ask the audience, “What is going on here?”  These very quick engagement tools perk up the audience! Go from dull to dazzling! When I incorporate questions in my slides, I do not put the answer in the written slides. They have to attend the session and listen to get the answer!

Be consistent with fonts, colors and backgrounds.  You want the audience to focus on your content, not your ever-changing visuals.  Also, the addition of animation and sound adds variety, but should not be used excessively. They key to an excellent presentation is balance. Also, be sure there is a significant contrast between the text color and the background color. For example, dark text on a dark background is very hard to read.

Use a text size of at least 24 point.  I prefer a font size of 28 to 32 for text and 36 to 44 for titles. Try this readability test; put your slides on the screen and stand in the back of the room in which you will be presenting. Can you read the slides? I have been to many presentations in which the speakers say, “I know you can’t read this, but …” If the audience can’t read it, don’t show it.

Arrive at the program venue early to check the slides.  It is important to arrive to a presentation location early for many reasons, including checking the AV equipment. Before the audience members arrive, check to be sure your slides are working properly.  Unfortunately, I have seen many presentations start with this statement, “Does anyone know how to work this?” As a backup, even if I email my slides to the meeting planner, I always carry the slides with me on a flash drive. It is also a good idea to arrive early to meet audience members; this is helpful to gain insight as to their needs / questions.  Through my pre-program chats, I have also received excellent ideas that I incorporated into the session. Audience members love this recognition! For example, I have stated, “Just before the program, I spoke to Steve who mentioned a great idea to help patients …” I have Steve waive his hand so the audience could acknowledge his great idea.

Separation of handout from slides. I speak at hundreds of medical conferences, and I am usually the only presenter that separates the slides from the handout. The handout is given to participants; the handout has all the information well organized into sections. The slides are highlights of key points, including graphics.  There are also surprise questions and mini quizzes. The audience is constantly engaged.  Granted, it takes more work to present in this manner.  However, it is time well spent since I know people are engaged and learning. We do what’s best for our audiences, not what’s easiest for us.

Make PowerPoint work for you to create memorable presentations. You are brilliant, you are the expert – that is the reason you are making the presentation. The spotlight should be on you and your vast knowledge, not the slides.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication. The Center focuses on increasing patient satisfaction, improving compliance and decreasing the risk of medical errors. The Center offers high-impact training, consulting and one-on-one coaching. Edward Leigh’s new book, Engaging Your Patients, is due out in the Spring of 2014. http://www.CommunicatingWithPatients.com or 1-800-677-3256

Opening a Patient Interview: Part II, Your Powerful First Few Questions

by Edward Leigh, MA

After you have greeted the patient / guest(s) and introduced yourself, now it is time for your opening questions / statements.

Start with a general question. The literature suggests that even if you know the exact reason for the patient’s visit (e.g., “upset stomach”), it best to still keep the opening question general, such as, “Tell me what brought you here.”  The initially stated chief compliant may not be the underlying reason for the visit.  This is especially true if the underlying reason for the visit is of a sensitive nature (e.g., substance abuse or sexuality issue).

BEFORE asking any details of the first issue, ask the patient, “What else?”  There may be no other issues, however asking this question in the beginning will reveal all the issues to avoid the dreaded late-occurring “Oh by the way” issues.  Excellent article on the subject:

“Two words to improve physician-patient communication: what else?” Link below http://www.meddean.luc.edu/lumen/meded/ipm/IPM1/TwoWordsBarrierArticle.pdf

Example

Clinician: “Tell me what brings you here?”

Patient: “I have been having stomach pains.”

Clinician: “What else?”

Patient: “Well, sometimes, my toes feel numb.”

(If the patient has no other issues, then ask about the stomach pains.)

Too many issues and not enough time. If the patient has multiple issues and there is not sufficient time to discuss everything, this situation has to be handled delicately to retain an excellent patient experience. Do not say, “I don’t have time to discuss all those items.”  Instead, use an “I wish” statement, such as by stating, “I wish we had time to discuss everything that is going on.  How about if we discuss two issues and schedule an appointment to discuss the other items? How does that sound?”

Mute Yourself.  Once you begin the information-gathering phase, DO NOT interrupt. MUTE YOURSELF! Give the patient 1-2 minutes to fully tell you their story and then ask for details. In the classic study by Beckman and Frankel, they found that physicians prevented patients from completing an opening statement 77% of the time and interrupted their patients in a mean time of 18 seconds. (Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101:692–6.)

Start your patient interview with impact through the use of powerful questions!

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication. The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. The Center offers high-impact training, consulting and one-on-one coaching. Edward Leigh’s new book, Engaging Your Patients, is due out in the Spring of 2013. http://www.CommunicatingWithPatients.com or 1-800-677-3256