Keywords
information - recall - comprehension - closed loop - reinforcement
Introduction
Information imparted to a patient during the course of a consultation is voluminous.
Diabetes mellitus (DM) is a multisystem disorder and greatly impacted by lifestyle.
Thus, during the course of a consultation for DM, the doctor not only provides information
about treatment options but also instructs the patient regarding diet and exercise.
The doctor also discusses about foot care, need for annual screening investigations,
instructions for follow-up, and so on
Overworked Informant
In resource-constrained settings, often the general practitioner or physician in a
busy outpatient clinic is the sole person responsible for this task of imparting information.
In some Southeast Asian countries, an average general practitioner or physician will
see almost 30 to 40 patients a day. Thus, the busy practitioner is unlikely to repeat
information. This is unlike many high-end centers who would have registered nurse
practitioners, diabetic educators, and nutritionists where same information may be
delivered by several people.
The Natural History of Forgetting
We usually remember information to which we turn our attention frequently and quickly
forget information that we hear only once or twice. The Curve of Forgetting Graph
or the Ebbinghuas curve[1] developed in 1885 demonstrates how quickly we forget newly acquired information.
When we talk to our patients, we often use words or terms they have never heard before.
Patients often hear the words HbA1c or glycosylated hemoglobin or diabetic retinopathy
or microalbuminuria for the first time when they visit a specialist. How likely are
the patients to remember these new terms is doubtful ([Fig. 1]).
Fig. 1 The curve of forgetting.
According to the Curve of Forgetting, if we learn 10 new terms on a given day (very
common situation in diabetic patients), we remember 100% at the time we first hear
them. However, if we do not repeatedly hear these terms again, 24 hours later we forget
40% of these new terms. If we do not review these terms for another 24 hours, we forget
60% of the new terms.
Patients with diabetes and limited health literacy or numeracy are more likely to
have poorer disease knowledge and symptom recognition,[2]
[3] poorer glycemic control,[4]
[5] greater difficulty interpreting food labels and estimating portion sizes,[6]
[7] lower self confidence in diabetes management, fewer self-management behaviors,[3]
[8] and poorer communication with their providers.[9]
Thus, poor recall due to the natural history of forgetting and poor comprehension
due to limited health literacy, confound patient education greatly.
Challenged Recipient
Now, if we apply this same principle to a diabetic patient seeing a specialist for
the first time, by the time the weekend is over, almost all of what information is
imparted to the patient is lost. How can this situation be remedied?
Improving Memory
These are simple tools employable in day to day practice to ensure that patients can
comprehend, recall, and act on information to achieve targets.
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Short-term reinforcement or closing the loop.
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Staggered information delivery.
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Long-term reinforcement.
1. Short-Term Reinforcement or Closing the Loop
Short-term reinforcement is the most important for immediate effect. This means that
at the end of the consultation, the doctor identifies three to four key messages that
need to be remembered by the patient. The doctor repeats them to ensure that the patient
has understood these messages and is able to carry out any instructions. After repeating
the message, he assesses patient comprehension and recall. He clarifies any doubts
and repeats the instructions.
For example, if after the consultation, the doctor wants to tell the patient that
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He needs to exercise 30 minutes a day.
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Be regular with his medications.
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Complete his annual diabetic screening investigations before the next visit.
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He needs the patient to bring HbA1c below 7%.
Doctor T–So, Mrs V, we need to bring your HbA1c to below 7% from the current value
of 7.6%. For this I need you to commit to 30 minutes of walking or cycling daily for
the next 3 months along with taking your medicines as instructed regularly. We also
need you to do the listed investigations to ensure you have not developed any complications
of diabetes. Is this clear?
Mrs.V–Yes Doctor.
Doctor T–Did you understand what I have said? Can you repeat for me what are the 4
things we need to accomplish before your next visit?
Mrs. V–Yes Doctor. Walk, take my meds, do my investigations before the next visit
and ….I forgot the last one doctor.
Doctor T–And ensure an HbA1c below 7% to prevent complications of diabetes. So, Mrs.
V–Walk, take your meds daily, please complete all investigations before the next visit
so that we can ensure your HbA1c is below 7%.
Mrs. V–Ok, Doctor T. I will see you in 3 months with my reports and hopefully with
an HbA1c below 7.
Doctor T–If you walk daily and take your meds as you have promised Mrs. V, I am confident
we will be able to achieve a target HbA1c below 7%.
This is called closing the loop in business parlance. Closed loop communication is
a communication technique used to avoid misunderstandings. When the sender gives a
message, the receiver repeats this back. The sender then confirms the message by using
the word “yes.”
Schillinger et al[10] conducted a study which observed the extent to which primary care physicians working
in a public hospital assess patient recall and comprehension of new concepts during
outpatient encounter. They used audiotapes of visits between 38 physicians and 74
English-speaking patients with DM and low functional health literacy. They examined
whether there was an association between physician's application of interactive communication
strategy and patients’ glycemic control using information from clinical and administrative
databases.
Physicians assessed recall and comprehension of any new concept in 20% of visits and
for only 12% of new concepts. Patients whose physicians assessed recall or comprehension
were more likely to have HbA1c below mean (≤ 8.6%) versus patients whose physicians
did not (odds ratio [OR] = 8.96, 95% confidence interval [CI]: 1.1–74.9; p = 0.02). After multivariate logistic regression, the two variables that independently
associated with good glycemic control were higher health literacy levels (OR = 3.97,
95% CI: 1.09–14.47; p = 0.04) and physicians’ application of the interactive communication strategy (OR
= 15.15, 95% CI: 2.07–11.78; p < 0.01).
2. Staggered Information Delivery
Delivering information in a staggered fashion is an effective way of imparting information.
At each visit, one question is answered giving the patient time to digest the information,
think about it, and come back next visit for a short review of previous sessions before
new information is added. Thus, gradually building on information with a chance for
doctor or educator to assess comprehension and recall. This helps to reinforce memory
of the patient and retain the information.
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1st visit—What is DM? Why does it happen?
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2nd visit—Why do I need to control my blood sugars?
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3rd visit—Medications for diabetes.
In a study on 170 subjects with type 2 DM[11] who were randomly assigned to group (n = 87) or individual (n = 83) educational setting, group information delivery was as good or slightly more
effective at providing equivalent or slightly greater improvements in glycemic control.
Thus, in resource-constrained settings, group information delivery based on a consistent,
curriculum based but staggered way can be used to achieve better quality care.
3. Long-Term Reinforcement
In this age of social media and easy access to smart phones, long-term reinforcement
is easy, provided the patient has access to accurate information from an expert instead
of being diverted or confused with misinformation.
This can be done by follow-up telephone calls especially to new patients asking if
instructions regarding medicine and lifestyle prescription are clear. This can usually
be done in the week after the visit. Reminder telephonic messages with tips and tricks
to manage DM help reinforce information. These can be disseminated in weekly or fortnightly
fashion.
Lastly, applications that patients can download which have patient information videos
and text can help the patient to clarify information at their leisure in a relaxed
environment which is often not possible in the doctor's clinic. Reviewing information
in a relaxed environment will also ensure better recall.
Diabetes self-management education (DSME) delivered via the internet is effective
at improving measures of glycemic control and diabetes knowledge compared with usual
care.[12] Studies demonstrate that improved eating habits and increased attendance at clinic
appointments occur after online DSME although engagement and usage of internet materials
waned over time. Interactions that involve an element of interaction with healthcare
providers were seen as attractive to participants.
Conclusion
Patient recall and comprehension are vital to ensure that patients achieve their glycemic
goals. We forget 60% of new information by 48 hours. Thus, reinforcement of information
is the key to information retention. Short-term reinforcement by “closing the loop”
of the conversation, staggering of information with reassessment of recall at each
step and using social media/smart phones for long-term reinforcement are simple tools
we can employ to achieve treatment goals. This way, we can create a curve of remembering
during the diabetes care dialogue.
