Patient education: Simple solutions are the best solutions

In another entry for the communication category, here’s a little play I wrote:

Scene: Pre-op area.  Patient arrives for surgery exactly at the scheduled start time, that is, 90-minutes late.

Anesthesiologist (me): Good morning Mrs. Jones.  I’m Dr. so-and-so.  How are you this morning?

Patient: Oh, doctor, I have the most terrible headache.  They told me my surgery was at 11 so here I am at 11, and now they tell me I’m late.

Me:  It’s OK, Mrs. Jones.  It’s a common mistake.  Now, did you have anything to eat this morning?

Patient: Oh, no, doctor.  Just a little toast and coffee.

Pause, as the anesthesiologist takes in this little statement.

Me: I see you have some arthritis.  Do you take anything for pain?

Patient: Oh no, doctor.  I don’t like to take pills.  Just a little Motrin and aspirin.

Me (bracing for impact): How much aspirin?

Patient: Not more than three or four a day.  As I said, I don’t like to take pills.

Preoperative instructions for patients almost always include scheduled surgery time, when and where to arrive, instructions not to eat before surgery, and to stop taking any blood thinners, including aspirin.  And yet people show up late having had bacon and eggs, practically swimming in dysfunctional platelets.  I did it myself.  With my cat.  And I of all people should know better.  I took her in for her little kitty-hysterectomy and the receptionist asked me if I had taken her food away the night before.  Oops.

Hospitals have various ways to impart preoperative instructions.  Some have everyone come in the week before to the pre-anesthesia clinic.  Some use nurses making phone calls.  Some give written instructions.  These things have only middling success.

A study in Anesthesiology suggests that as many as 40% of patients forget some portion of their pre-operative instructions.  Some anesthesiologists at the University of Alabama decided to study whether a simple intervention could lower this percentage.  They created a one-page, illustrated, color-coded instruction sheet.  So patients would have received a sheet that had “don’t eat breakfast” in big letters, with a picture of bacon and eggs with a line through it, the whole thing with a background of red.  Her blood pressure medications would be illustrated with a picture of a pill and a blood pressure cuff, highlighted in green.  I’m not sure how you would indicate that aspirin is a no-no, but you get the idea.  It sounds simplistic and even a little infantile, but the folks in Alabama got a 14% bump in patient compliance preoperatively.  Why?

Well, for one thing, we sometimes assume people can read when they can’t.  Health care professionals can easily forget that, and an illiterate patient may not want to tell you.  Beware of the “nod and smile” patients.  Secondly,  patients don’t read what they’re given, or they posse the piece of paper, or their kid throws up on it.  A third reason is that people are less likely to remember what to do when they don’t know the reason for the instructions.  Many people don’t know that the reason to stop taking aspirin before surgery has to do with blood clotting properly. Lastly, no one remembers things when you just tell them.  Just ask my poor cat.

Maybe the biggest reason the University of Alabama folks might have seen the results they did is that humans are very visual and habitual.  Anesthesiologists know this very well.  There’s a reason why anesthetic drugs are packaged with colored tops.  When one of us reaches for a drug one of the cues that tells us we have the right one, besides reading the label, is habituation to the colors and shapes.  Red tops mean paralytics, purple is saline, a small vial in orange is for benzodiazepines.

Medical errors in routine cases occur when either the color has changed or even, sometimes, the shape of the vial.  In real life the same thing occurs.  Red, yellow, and green are powerful indicators of action. The shape of a stop sign indicates stop, even if you can’t read the word.  Signs in blue on the freeway mean a hospital is nearby.  In the UK a white circle with a red line through it means subway.  We take in these kinds of visual cues all the time.  They are immediate and unmistakable forms of communication. Bravo, University of Alabama.  Simple solutions are sometimes the best solutions.

Of course, people will still lose the color-coded paper.

Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine for real.

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  • Patient Kit

    I find, more than anything else, people remember things if they know WHY. Aspirin thins your blood so you might bleed too much in surgery. Eating too close to surgery means there will be food in your digestive system that could get in the way (especially if it’s abdominal surgery) and you don’t want to vomit while unconscious on the table. And you need to get there early so you have time to get changed out of your street clothes and into your cute OR outfit and discuss whether you ate a big breakfast with aspirin. WHY, WHY, WHY!

    • guest

      Although this is probably true for some people it is also true for others that lengthy instructions that include explanations will appear too long, and will not be read.

      • Patient Kit

        I’m sure you’re right — that if it’s too long, people won’t read it. But for me, the key is WHY. If it’s short but I have no idea WHY I should do it, there’s a better chance that I might forget. I tend, however, to be exceptionally good at following pre and post operative instructions though. I’ve also had four major surgeries with zero complications and excellent outcomes.

        Sometimes you’d think the WHY would be obvious. When I had my first colonoscopy, another woman in the waiting room for the same procedure had followed instructions — to a point. She stopped eating and drinking at midnight the night before. She drank the two prescribed bottles of yuck and purged her bowels. Then she stopped at a diner on her way to the doctor and ate a huge breakfast. WHY, you might wonder? She said she was starving from all that fasting and purging the night before and didn’t want to be hungry during the procedure. I guess sometimes there is just a disconnect in the logic.

        I am surprised that the rate of failing to follow instructions is so high. I’m always very motivated by wanting surgeries to be successful and by not wanting to have to “do over” any procedures. It’s also why I’m able to be perfectly still during MRIs. I do not want to have to start over.

  • Patient Kit

    I was being a little facetious about getting there early to change into your cute OR outfit, even though that is among the things that must be done before being whisked into the OR, not the least of which is assessing to make sure there is no compelling reason to not bring the patient into the OR that day.

    But you’re right — if there is a last minute cancellation, the OR schedule may change. That’s also why we usually don’t find out what time to come in until the night before a scheduled surgery.

    My last surgery was scheduled for 7:30am on a Tues morning. I arrived at the hospital before some staff that morning. Other than middle of the night emergencies, I was the first surgery scheduled that day, so there was no chance that a last minute cancellation would have moved mine up. But I can see how that could become a factor as the day goes on.

  • Edward Leigh, MA

    Excellent post. In healthcare, many professionals are under the illusion that patients actually read educational information and instructions. We give patients piles of information — most never gets read. I am a huge proponent of the “one sheet” that clearly has everything listed in big bold letters and various colors. Of course, we still must give them the “big piles” of info, but the one-page summaries are essential. I got the “one sheet” idea from my vet!

    • Patient Kit

      Same concept as writing a well-documented in-depth report and a very concise one-page executive summary of that detailed report because those top executives are never going to actually read that report they requested. Me? I’m that strange patient who reads those doctors’ instructions. But then, I also wrote many of those in-depth investigative reports that I also had to summarize. I’m used to reading the footnotes and between the lines. ;-)

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