Sunday, August 15, 2010

Leaving the Hospital with Inadequate Information

Have you ever discharged a patient from the hospital and had a gnawing feeling that maybe you could have done more to educate the patient about their disease, medications, and plan of care?  Probably so.  A recent survey published in the Archives of Internal Medicine tells us that this feeling is based in reality (I'm guessing that you already knew this) and that you are not alone.

The survey was conducted at a not-for-profit teaching hospital affiliated with Yale University School of Medicine and included 89 patients and 43 physicians of various levels of training (intern, resident, and attending).  Patients were interviewed on the day of discharge using the Picker Patient Experience Questionnaire and the Consumer Assessment of Healthcare Providers and Systems Hospital Survey.  Physicians were interviewed towards the end of their inpatient month.

Key results:

  1. Only 18% of patients knew the name of the physician in charge of their care (most physicians assumed the patient knew)
  2. 43% of patients could not state their reason for admission (most physicians assumed the patient understood diagnosis at least somewhat well)
  3. 90% of patients reported not being told about adverse effects of new medications
  4. Physicians were more likely to report that they occasionally spoke in front of patients without including them in the conversation 
  5. 58% of patients described physician explanations as always comprehensible compared to only 9% of physicians
  6. Half of patients reported having anxiety or fears while hospitalized and of those half, 54% indicated that a physician never discussed these fears (while only 2% of physicians, ie one physician, reported never discussing fears)
Many of the results are subject to recall bias, perhaps especially physician responses.  However, the results are not surprising by any means and while the physicians seemed to have blind spots in some areas (especially in responding to emotion), some of the results suggest that the physicians know there areas in which they might improve (such as always explaining things comprehensibly).  Other questions could have been asked of patients, such as, "who will you call if you have questions regarding your care when you get home" or "has your follow-up plan been explained to you?" How often can patients correctly identify this information?

In the commentary, the authors suggest that providing visual/written materials may help improve matters, and there is research to support this.  Another obvious solution would be to dedicate more time to patient education.  The study was not conducted in a palliative care context but one might expect that in a palliative care population, the risk of leaving the hospital relatively uninformed is higher (controlling for communication effectiveness) due to the complexity of disease, greater risk of cognitive impairment, etc.  When seeing these patients, palliative care clinicians can do their other colleagues and learners a favor by teaching communications skills that we use every day, which can then be applied to all patient encounters.  For instance:
  • The Teach-Back Method:  All clinicians should use this routinely to make sure patients understand key information.  In a general medicine context, here's some evidence that this method actually improves outcomes (not just comprehension) in diabetes management.
  • Family Meetings:  Get the patient's family involved early and often.  I hypothesize that family education not only improves patient understanding (because families can reiterate what doctors have said to the bewildered and perhaps mildly delirious patient) but also once again may improve outcomes because who is going to help the patient with their care after discharge?  
  • Address Emotion:  This study is more evidence that we are missing empathic opportunities.  Fearful patients don't listen well.  Addressing emotions in care can reduce fear (sometimes), build trust, and make it more likely that the patient will hear the physician's message.  
It's a chronic pet peeve of mine that patients don't know their physician names and commonly don't always understand the role of all individuals on the healthcare team (or at least the main players).  It's by no fault of their own and I'm not sure what the solution is- I've thought about requesting pictures of members of the primary team to place in the patient's room so that at least they are identifiable.  Maybe someone out there has done a QI project on this and can enlighten me.

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