Saba Shahab is a third year medical student at Western University.
How many patients remember every advice shared by their physician at a clinic visit? How often do patients know exactly what disease they take each medication for? As a medical student, I have had the unique opportunity of following a few patients through their encounter with several health care providers. During my physical medicine and rehabilitation rotation, I saw an 86 year old man who had suffered a stroke and had come in for a follow up visit after receiving rehabilitation therapy at the hospital. At the end of the visit, the doctor had multiple recommendations for the patient that included another follow up visit, medication changes, continued therapy at the outpatient rehab unit, community resources for stroke patients, a referral to another specialist for an unrelated problem, and counselling for prevention of future strokes.
Three days later, I was following an occupational therapist at the outpatient rehab unit and saw the same patient come in for their first day of therapy. The patient asked the therapist why the physician recommended that he seek therapy in the community instead of outpatient rehab at the hospital. The occupational therapist was confused as he felt that the program at the hospital was ideal for this patient at this time. I remembered the doctor’s recommendations and clarified that the physician wanted the patient to seek resources in the community after completing the outpatient rehab program if he needed more therapy.
This instance made me wonder how often patients are able to accurately remember physician recommendations. I have come across several patients who don’t clearly remember the medical advice they receive from their physicians. Many patients don’t know what pills they are taking and don’t know why they are taking the pills they have. This may be partly explained by a lack of clear communication between the physician and the patient and a result of patients relying on memory alone. Humans have a limited capacity for storing information in short term memory with research showing that we can store four chunks of information at a time. Additionally, people see physicians during stressful periods of their life and life stressors seem to worsen working memory capacity.
A possible solution to this problem would be for physicians to provide patients with written instructions. Of course, if the instructions are simple and few, this step may be unnecessary. Physicians could take out a few extra seconds to write down a list of recommendations and names of new medications with the reason for taking those medications. This will reduce instances of miscommunication and ensure that patients know what their physician recommended for them. During my emergency medicine rotation, I saw a patient who brought a sheet of paper with him with three columns: name of medication, reason why medication is taken, and additional notes. This patient knew his medications very well and undoubtedly was compliant with all his medications.
CMPA encourages physicians to provide patients with written instructions to supplement personal interaction during informed discharge of admitted patients. Adopting this practice not only at discharge but also during clinic visits will result in more patient compliance and better communication as the written instructions will help patients remember the information provided to them. A research study showed that written instructions provided to parents of children being discharged from acute care resulted in improved satisfaction and knowledge. This approach could be applied to adult populations as well. Providing written instructions has shown to result in improved recall of medical advice.
Of course, written instructions will not solve the problem fully. Some patients may lose the paper handed to them or may forget to bring it at their next appointment. As medical students, we learn about the importance of CanMEDS roles, qualities that physicians should acquire to be able to meet the needs of our patients. Communication is one of those CanMEDS roles. Providing written instructions is one way for us to become better at communicating with our patients.
Jibran Changi
Brilliant article. Stumbled upon it while reading up on memory loss in mental health patients.
What about having an app with voice recorded memos in an online database accessible to those specific patients only? Granted it might not be suitable for an 86 year old but a vast majority might benefit from it.
Robert MacLachlan
The idea of written instructions for patients regarding their present and future care is long overdue. I recall the remark of a colleague, a urologist, that, as soon as surgery (in particular) was mentioned, the patient’s ability to hear any more information was disrupted and another appointment became necessary for re-presentation. And that was about 50 years ago.
Saba Shahab
Thank you for sharing your thoughts and apologies for the late reply. I agree that it is difficult to absorb information under stressful situations, especially after receiving unexpected or bad news. Written instructions could certainly supplement that second or third appointment that a patient might want to attend to fully comprehend the situation and have their remaining questions answered by the physician. In such a case, written communication could work both ways. A patient could come back with a list of written questions that their physician can then answer one-by-one.
Hillel M. Finestone
I agree that patients should likely not leave the medical office without some type of written document that tells them what happened, what needs to be done, what physical, psychological, social and/or other measures need to happen in order for there to be improvement or recovery. I wrote an article in the CMAJ a few years back which discussed providing patients with a “lifestyle prescription“. I also try to provide my patients with chronic pain with a document called a ”pain explanation and treatment diagram”. Giving patients something to hold onto also allows them to better explain their condition to other non-physician healthcare professionals.
Saba Shahab
Thank you for your note and apologies for the late reply. I just read your post on the lifestyle prescription and it wonderfully captures the idea that I have tried to convey in this blogpost. I recently read an article surveying family medicine residents about their perception of exercise prescriptions (Solmundson, Koehle, and McKenzie, 2016). I am hoping that medical schools and residency programs will start recognizing the importance of written communication, including information on lifestyle changes, and will train students to implement this in their future medical practice.
For anyone else reading these comments, this is the CMAJ post referred above: Finestone, H. M., & Sohmer, J. (2011). The lifestyle (LSx) prescription: another use for the pad. CMAJ, 183(17), 2068-2068.