ER Patients Don't Understand Doc's Orders

July 7, 2008— -- More than three in four emergency room patients do not fully understand the instructions that doctors give them after their visits, new research suggests.

Even worse, not only do the patients not understand the care instructions from their doctors, but the vast majority are also unaware that they have not fully understood what the doctor has told them.

The findings were published Monday in the journal Annals of Emergency Medicine.

"It is critical that emergency patients understand their diagnosis, their care and, perhaps most important, their discharge instructions," Dr. Kirsten Engel, one of the study's authors, at Northwestern University said in a news release issued Monday by the American College of Emergency Physicians.

"It is disturbing that so many patients do not understand their post-emergency department care, and that they do not even recognize where the gaps in understanding are."

Other experts agreed that these numbers, while high, are not surprising.

"This report confirms what I have long suspected," said Dr. Richard O'Brien, spokesman at the American College of Emergency Physicians. "Our nation's emergency departments are overburdened and overcrowded, and one of the consequences is a significant amount of difficulty communicating effectively with our patients.

"It is like trying to teach in an overcrowded classroom, with many distractions," O'Brien said. "The message will sometimes get lost."

But other experts said the study, which looked at 138 patients and two caretakers, could have resulted in such high numbers because it may have been too narrow or not comprehensive enough.

"Things like the kind of instructions patients were given and how complicated the patient problems were will play a role," said Dr. Alfred Sacchetti, chief of emergency services at Our Lady of Lourdes Medical Center in Camden, N.J. "For example, some instructions are simply overly complete, making it impossible for anyone to understand them."

Time and Training a Factor

The amount of time a doctor gets to spend with patients in a busy emergency department is a big factor in communication.

"The most important factor in having patients understand their instructions is time," said Dr. Jawad Arshad, senior staff physician in the department of emergency medicine at Henry Ford West Bloomfield Hospital in Michigan.

But because an emergency department doctor has to take care of emergencies, time is not always available after he or she takes care of the urgent need of one patient.

"Unfortunately, due to clinical burden, there are times when physicians literally go from room to room giving discharge diagnosis and instructions, and leave before the patient has had any time to digest the information given," Arshad said.

But there are ways to improve the system, Arshad added. "For example, at the Henry Ford Health System here, physicians go through periodic mandatory courses on active health care issues such as patient communication," he said.

In this course, health providers are taught a method of communication known as teach-back. In this approach, the health care provider will tell the patient what they should do to care for themselves, and then they ask the patient to repeat back the instructions that they are given.

By following this simple process, patients are better able to understand their diagnosis, treatment and follow up instructions, Arshad said.

Other experts said patients would do well to bear in mind the same kind of approach themselves.

"One of the easiest things a patient can do to make sure he or she is well informed is try to repeat to the nurse or doctor in their own words their understanding of what is being discussed, and ask, 'Have I got that right?'" O'Brien said.

Teamwork Important

But even though some patients may be assertive enough to take the reins in their health care, others may slip through the cracks, which means that health providers must work together to identify and educate these patients before they leave the emergency department.

"Nurses are essential," O'Brien said. "Emergency department nurses are there for critical care and critical communications as well."

Others agree that even if a doctor does not have time to spend with a patient, a nurse or technician reviewing detailed instructions with a patient fills the gap.

"Nurses sign off that the patients verbalized back to them that they understand their instructions before they leave the department," Camden's Sacchetti said. "If the patient has any questions, doctors can always go back."

And though being in the emergency department can be very scary for patients, they should not be afraid to ask questions.

"It is always helpful when patients have a list of questions written down instead of relying on memory," Arshad said. "Family members can be helpful in asking pertinent questions as well, and later can help a patient in remembering details of treatment and follow up.

"Medicine is half science and half art. Only by working together as a team can we really empower our patients."

Dr. Sami Bég is the associate medical director of U.S. Preventive Medicine