Teaching clinicians the teach-back for patient education

I’m a big fan of the teach-back. To my knowledge, it is the only way to confirm that my patient understands my message. I don’t believe avoiding jargon or creating written materials at a favorable readability level can ensure understanding. So, I’m always left with uncertainty until my patient teaches it back to me.

I’ve been teaching clinicians to do the teach-back for about a decade now. For the same amount of time, I’ve been trying to master this technique in my own practice. Why do I have to work on integrating teach-back into my own practice? Because being taught how to do the teach-back method does not mean I use it when I should. In fact, I was embarrassed the first few times I taught teach-back because I knew in my heart that I didn’t use it very often. Many clinicians are like me and have difficulty changing their routines and integrating new strategies. Many studies have shown that giving lectures to clinicians doesn’t lead to much behavior change in practice.

So how do we help clinicians integrate a strategy that we think will help them and their patients?

I’ll be the first to say that I don’t know the perfect answer. But, let me tell you what I’ve been doing.

For the past 4 years I’ve taught a faculty development course on health literacy and aging. This course includes faculty with diverse backgrounds including physicians, nurses, social workers, dental school faculty, pharmacists, librarians, and allied health. I tell them that everyone who takes my course will want to teach people to do teach-back, and I don’t want anyone to teach the teach-back, unless they have done the teach-back. So, all students in my course, even if they don’t regularly take care of patients, have to figure out a way to try the teach-back method.

The Teach-back Method: Teach-back is a way for practitioners to confirm that what they explain to the patient was clear and understood. Patient understanding is confirmed when the patient explains it back to the practitioner or does a return demonstration (instead of just saying, “Yes, I understand.”)

My favorite example is of a nursing professor who is now mostly in administration. She decided to teach her daughter the proper way to dispose of unused medicine. (Did you know you are not supposed to just throw it in the trash or flush it down the toilet?) She did some research, boiled down the lesson to a quick 3 step process, and taught it to her daughter—followed by a teach-back. She then tried with a couple other friends. I thought this was a creative approach to learn how it feels to do the teach-back when it isn’t a normal part of information exchange.

For all of my students, I have them keep a log of their teach-back experiences. For clinicians, we start with one patient a day. Try the teach-back. Write down the reflection.

  • How did it go?
  • What would you do differently?
  • Did the patient seem to mind?
  • Did the teach-back uncover any miscommunication?

After doing it with one person a day, we increase to 2 a day. By the next course session, all students have tried the teach-back and submitted their log books. Invariably, the clinicians report that they may have never tried to implement the teach-back without knowledge that they had to for the course. It is really a change from usual clinical care.

First, having non-clinicians find a way to try the teach-back gives them an appreciation for the complexity of fitting this strategy into usual communication. I think they will be more empathic teachers as they engage clinician students.

Second, an expectation of implementation with achievable goals and accountability helps to push clinicians into the practice stage.

I cannot say this led to sustained use in clinical practice, but I do know that many clinicians actually tried the teach-back method with several patients and are one step closer to regular use.

Darren A. DeWalt is an internal medicine-pediatrics physician who blogs at Engaging The Patient.com.

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  • Anonymous

    This is an absolutely fabulous teaching concept that should be required reading for ALL physicians, Dr. DeWalt!  I’m a heart attack survivor who frequently does presentations about women and heart disease. I’ve been utterly gobsmacked by the apparent lack of awareness demonstrated by so many of the heart patients in my audiences.  Last week, for example, one very well-dressed, elegant-looking, articulate woman in her 70s put up her hand and asked: “My doctor says I have a ‘heart rhythm problem’ – what does that mean?”  I almost fell over.  This is a person who had likely sat there nodding and smiling politely in her cardiologist’s office while he reviewed her test results, procedures and prognosis with her – and she had then left his office completely ignorant of what he had just explained to her.  Meanwhile, her doc puts away her file and moves on to the next patient, confident that she “gets it”.  SHE DOESN’T – and until doctors start using this very practical teach-back method, patients will continue to sit there just  smiling and nodding as if they do.

    • http://pulse.yahoo.com/_GJCNF5QLKW7ROYAZZGB7HFH57Y jamesp

      For Pete’s sake, why won’t  such patients be HONEST and say, they don’t understand???

      • Anonymous

        I don’t know, James – it’s maddening!  I’m thinking now of my own mother, part of an elderly demographic who – perhaps because they don’t want to appear stupid – are notably reluctant to interrupt or ask clarifying questions of their physicians.  So when they get home and the rest of the family asks: “What did the doctor say?” – they are often unable to report accurately.  On the other hand, I personally have experienced specialists who used medical jargon, did not maintain eye contact, rushed through complicated explanations and then appeared clearly exasperated when I stopped them in mid-monologue for further clarification. 

        As this essay confirms, many doctors simply have no clue if “what they explain to the patient was clear and understood”.

        • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

          Well, I’ll say this about my recent cardiologist experience. I was referred via a pulmonary doc b/c I kept telling my PCP office (the NP or whoever I saw) for 3 visits over 6 months that I couldn’t breath even to vacuum and I’m nauseated all the time. My PFT’s were fine. The stress echo shows a reduced EF and by the way has anyone told you blah, blah, blah – b/c I was still about to pass out from that stupid treadmill….  All I knew was that I was to stop the migraine BP med and start this BP med. And I’m a pharmacist in my 40′s! I could perfectly well check my BP at work, but made an appt to go back just to find out my diagnosis and get some more info with a clearer head!
           
          I went with a short list of questions based on the few things I remembered him saying. He was a nice enough doctor as the “doc of the day for this test”. But it was a short visit all told when you factor in all the stressful stuff going on and a pretty shocking, unexpected outcome. Unfortunately, I didn’t get to see him on the second visit but when I talked to “Mike”, the nurse, who was amazingly intelligent about hearts, I had to ask him to repeat all the words he said were my diagnosis just so I could write them down. They were vague things - long myopathies and dyfunctions and prolapses and such. His explanation was so far over my head I just decided I’d go home and do my own research because I’m that type of person. And essentially, I’m being treated for heart failure.
           
          So I can really see where any person who is not used to medical language (honestly, it’s probably amazing they get the basic diagnosis right after my experience!) would be so intimidated as to just walk out in a daze. I also find it pretty amusing as I read book after book that says you should find a great cardiologist (really ANY doctor!) for yourself b/c this will be your partner…. And in some of these books, folks really do go to many docs before they settle. I have my first “real” appt in about 6 weeks so we’ll see if he passes my list of questions. Mike says I’m not that bad. So be it. It’s my life, my health, my kid’s kids I want to live to see. And maybe their kids too…

  • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

    We use a family practice doc and I LOVE him as do my kids. I have considered switching b/c he now has a 2 month wait time for appts and I have found it frustrating the past couple summers when I have had to see various people for my immediate needs and seem to bounce from provider to provider. I recently took the boys for their 12 yr old “physical/med refill/etc”. One has asthma, which we thought he was outgrowing but in fact was actually a bit worse and the other has migraines and has recently revealed that since starting middle school, he gets daily headaches. As a mom/pharmacist/person with both of those health problems, I try to work through and help the kids with solutions for their issues. But also as a mom, my advice sometimes falls on deaf ears.

    But watching him coach both kids at their level was just amazing. He says the same thing I do and whether they do it or not in the long run, they “got it” that day. He just has those magical words – the same ones he used with me when we first started using him when our previous doc left the practice and we warily switched. He asked me why in the world I would let myself suffer so badly with migraines and headaches. He took me under his wing, worked with me for several years and truly helped me the best he could until his knowledge base was exhausted. We actually educated each other as time went on and I learned more about my problems.

    So there are those folks out there. I never questioned going to a family practice doctor with my kids after our first doctor told me all the same stuff the ped did (except he didn’t expect me to keep a log of feedings and diapers with twins good grief!) since I figured I could always learn anything I needed to medically and teach my kids. How naive I was way back then. Who knew kids wouldn’t always listen to their parents, even about the most common sense stuff – like take your medicine in the morning and you’ll feel better?