Studies over several decades have consistently found that patients do not correctly recall much of the recommendations and information given by their physicians. Typically, about half of items are found to be accurately recalled. While some studies have assessed patient recall of important information from ambulatory care visits, none has done so recently. Furthermore, little is known about features of clinical interactions which are associated with patient understanding and recall, without which shared decision making, a widely shared ideal for patient care, cannot occur.
[Photo: Dr. Michael Barton Laws, assistant professor of health services, policy and practice and lead author of the study]
The objective of this Brown University School of Public Health study was to evaluate characteristics of patients and outpatient encounters associated with patient recall of information after one week, along with observation of elements of shared decision making. This was an observational study based on coded transcripts of 189 outpatient encounters, and post-visit interviews with patients one week later. Coding used three previously validated systems, adopted for this study. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36 percent recalled with a prompt; 15 percent recalled erroneously or not at all. Provider behaviors hypothesized to be associated with patient recall, such as open-questioning and “teach back,” were rare. Patients with less than high school education recalled 38 percent of items freely and accurately, while patients with a college degree recalled 65 percent (p < .0001). In a multivariate model, the total number of items to be recalled per visit, and percentage of utterances in decision-making processes by the provider (“verbal dominance”), were significant predictors of poorer recall. The item count was associated with poorer recall for lower, but not higher, educated patients.
This study has demonstrated the utility of a structured approach to assessing recall quality, combined with the CASES method to support assessment and analysis of multiple decision making processes within an encounter. For the investigators, these tools were novel in the information they can generate about interaction processes in clinical decision making.
Findings suggest that patient recall could be enhanced if providers were to use more of the techniques to encourage patient engagement, such as open questioning, agenda setting, and teach-back; and limit the amount of information to be remembered in a single visit based on an assessment of patients’ ability to recall.
The investigators are not the first to observe that there has been surprisingly little change in physician-patient interaction over the decades. While Brown’s study does not provide any particular insight into why this is true, it serves as confirmation. It also points to the greater challenge of achieving a consistently high level of patient understanding and recall with less educated patients.
This article was published in PLoS One in February.