Communication studyImproving patient recall of information: Harnessing the power of structure
Introduction
Communication in health care often means the exchange of medical information. This is true for ward rounds in internal medicine [1], outpatients in internal medicine [2], and oncological consultations (e.g. [3], [4]). Findings indicate that many patients and their relatives want to be fully informed about their condition [5], [6], [7], [8]. For instance, questionnaire data indicate that 87% of patients “want to be told all information” and only 9% “want the doctor to choose how much information to give” [9] (see also [5], [6]). Similarly, qualitative data show that both patients and parents expect physicians to inform them about diagnosis, therapy, and prognosis [10], [11], [12].
Patient–physician communication goes beyond the filling of knowledge gaps, however. It is also the basis for patients’ inferences about the health practitioner. For instance, recent qualitative studies on communication in oncology have demonstrated that patients’ trust is based primarily on the impression of clinical competence that emerges from their communication with oncological surgeons and haematologists [13]. Furthermore, Parker et al. [14] and Hagerty et al. [15] have reported that patients’ hope depends largely on the impression that their physician is competent and “knows all there is to know about the disease”. Physicians may not be aware of the importance that patients attribute to receiving information, however: In their studies of patient centeredness and consultation skills in primary care, Ogden et al. [7] and Robinson et al. [8] found that patients ranked items relating to patient information and the structure of consultations significantly higher than physicians did.
However, other findings suggest that the exchange of information may be an ephemeral phenomenon. Specifically, several studies have found that patient comprehension and recall of information is limited [16], [17]. Three examples from surgery illustrate these limitations: On average, only 2 out of 5 complications were recalled in the context of elective plastic surgery [18]; 5 out of 32 pieces of information were correctly remembered 2 h after the preoperative discussion prior to brain surgery and 4 out of 25 pieces of information prior to spinal surgery [19] (for a recent review, see [20]). Questionnaire data from patients with advanced metastatic cancer revealed how little patients understood of their clinical situation. Although they had been informed by their doctors about the advanced stage of their disease and the clinical consequences, they largely overestimated the chance of recovery and failed to understand the palliative rather than curative goal of their treatment [21].
These insights raise the following questions: How can patient recall and understanding of medical information be improved? One of the first authors to address these questions was Ley (e.g. [22]). Ley recommended using explicit categorisation, with the clinician presenting “information in categories, which he has announced in advance”. Several review articles have since investigated whether patient understanding and recall of information can be improved by the use of additional communicative aids. Although results have been mixed and the evidence is not always convincing, the general picture to emerge is that patients recall slightly more information when they are given written or otherwise designed information material. For example, Ciciriello et al. [23] found weak evidence that the addition of multimedia material to standard instructions improved patient knowledge about medication (see also [24], [25], [26]). To our knowledge, however, none of the interventions evaluated in these review articles have focused on the explicit structuring of verbal information.
Although the provision of generic written information improves patient knowledge to some extent, it is associated with two major problems: First, information leaflets on diagnostic interventions usually cover the standard procedure in common diagnoses. However, the typical patient presents with a more complex combination of symptoms, diagnoses, and treatment options – a complexity that cannot be accommodated in standardised materials. Second, even when provided with the most sophisticated information material, patients show much lower recall capacity than physicians evidently assume: Physicians asked which information was essential for patients discharged from the emergency department after presenting with acute chest pain on average chose 36 out of 81 pre-defined items [27] – far beyond the typical recall capacity reported in the literature (e.g. [20]). Both problems are related. Tailoring information to more complex real-world cases is likely to involve the provision of even more information.
In principle, there are two ways out of this dilemma: less information or better communication. By better communication, we mean communication in ways that increase the likelihood that patients will later be able to retrieve the information. Here, we investigate whether structuring medical information improves recall. Specifically, information appears easier to retain when it is structured in a way that helps the recipient to organise it [28], [29]. In written material, structure is reflected in the way content is ordered sequentially. For instance, in newspapers, headlines precede the main text and are easy to identify; they announce the topic elaborated on in the text. Books use even more sophisticated structural elements to guide readers through content: title, table of contents, chapter headings, text, reference list, etc. In our communication skills training for medical students, we have used the term “book metaphor” to help participants understand, appreciate and remember the value and function of “structuring information” [30], [31].
In this pilot study, we investigated whether first-year psychology students serving as surrogate patients recalled more information when discharge information was presented in structured form, in accordance with the book metaphor, than they did when exactly the same information was presented in nonstructured form.
Section snippets
Participants
First-year psychology students were invited to participate in a trial measuring recall of medical information. Of the 167 students approached, 105 agreed to participate and provided informed consent. Sixteen of these students were male; mean age was 21.5 ± 3.8 years. Ninety-eight students returned completed recall protocols. The study was approved by the local ethics committee (protocol number: 362/11). Participants received no compensation for their participation.
Study design
On their arrival, students were
Results
One student in the nonstructured and 6 students in the structured condition returned empty recall protocols. Students in both groups reported a similar sense of well-being on the day of the study (6.5 ± 1.8 in both groups; n.s.). Students in the structured group felt better able to concentrate (6.5 ± 1.8 vs. 5.6 ± 2.0; p = 0.03). Students in the structured group answered 3.20 ± 1.3 items correctly in the medical knowledge assessment, slightly but not significantly more than their counterparts in the
Discussion
Our findings show that the number of items of information that experts considered essential for patients being discharged from the emergency department by far exceeded participants’ recall capacity [18]. This finding could have major consequences for clinical practice and teaching. Assuming that medical information has one primary goal, namely to enable the patient to make informed choices, the elements of information provided need to be limited to a number that patients can retain in memory
Acknowledgements
Many thanks to Claudia Steiner and Susannah Goss for editing the manuscript and to the students who volunteered as participants. The research was supported by the Scientific Fundof the Emergency Department, University Hospital Basel.
References (40)
- et al.
Communication during ward rounds in internal medicine. An analysis of patient–nurse–physician interactions using RIAS
Patient Educ Couns
(2007) - et al.
From patient talk to physician notes—comparing the content of medical interviews with medical records in a sample of outpatients in internal medicine
Patient Educ Couns
(2009) - et al.
A questionnaire study of GPs’ and patients’ beliefs about the different components of patient centredness
Patient Educ Couns
(2002) - et al.
Information needs and experiences: an audit of UK cancer patients
Eur J Oncol Nurs
(2006) - et al.
Examining the validity of the unitary theory of clinical relationships: comparison of observed and experienced parent–doctor interaction
Patient Educ Couns
(2011) - et al.
Integrative qualitative communication analysis of consultation and patient and practitioner perspectives: towards a theory of authentic caring in clinical relationships
Patient Educ Couns
(2011) - et al.
Breast cancer patients’ trust in physicians: the impact of patients’ perception of physicians’ communication behaviors and hospital organizational climate
Patient Educ Couns
(2009) - et al.
Beyond consent—improving understanding in surgical patients
Am J Surg
(2012) - et al.
Templates in chess memory: a mechanism for recalling several boards
Cognit Psychol
(1996) - et al.
Chunking mechanisms in human learning
Trends Cogn Sci
(2001)