Patient-centered approach to education maximizes treatment success

San Francisco - Even if a dermatologist has only a few minutes per visit to devote to patient education, taking a practical approach can boost the impact of these efforts, says Judith Hong, M.D., a third-year dermatology resident at the University of California, San Francisco.

Effective patient education requires using a simple, straightforward approach designed around each individual patient’s needs, Dr. Hong says.

A dermatologist’s ability to explain medical information to patients significantly and independently impacts patient satisfaction (Renzi C, Abeni D, Picardi A, et al. Br J Dermatol. 2001;145(4):617-623), Dr. Hong says. “Patient education also can potentially improve patient compliance and outcomes,” she adds.

A systematic review of 10 studies that addressed patient education regarding chronic diseases showed that in five of the studies, such education resulted in improved quality of life (de Bes J, Legierse CM, Prinsen CA, de Korte J. Acta Derm Venereol. 2011;91(1):12-17).

Personalized approach

To bridge the gap between what patients know and what physicians want them to know, “I’m proposing that we move toward the patient and focus on patient-centered education,” Dr. Hong says. “This is where we consider each person’s needs and goals and try to develop an educational approach that’s best for each individual.”

Patients’ needs and goals depend largely on what the patients believe and understand, Dr. Hong says. In these areas, “It’s important to understand your patients’ health beliefs.” To that end, “You can ask patients, ‘What do you think is going on with your condition?’ or ‘What are you worried about?’ Checking in with patients about their concerns lets you focus in on a discussion.”

A patient with psoriasis may complain that his or her topical steroids aren’t working.

“If you delve deeper, you may find out that the patient’s friend told them that topical steroids are terrible because they thin the skin,” and this belief could explain why the patient is not using the drugs as instructed, she says.

In such cases, “Our educational efforts must focus on the safety of topical steroids, hopefully to affect compliance.” In this regard, one study showed that medical beliefs more accurately predict adherence than any other variable examined, including age, gender and educational experience (Horne R, Weinman J. J Psychosom Res. 1999;47(6):555-567).

Measuring understanding

To gauge what a patient understands, Dr. Hong recommends asking the patient to tell you what he or she knows about his or her condition. “This way, you can tailor your education to build on existing knowledge rather than repeating things they’ve already heard.”

Dermatologists also must consider patients’ level of health literacy, she says. Research has shown that one-third of Americans have only a basic or lesser ability to comprehend written medical information (Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. 2006. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483).

“A patient with basic to below-basic health literacy cannot read an over-the-counter drug label and distinguish what substances may interact with it,” or what time he or she should take the medication, Dr. Hong says. “We need to keep our information simple, and we need to make sure our patient understands it.”

In the former area, she recommends using simple words such as “cancer” instead of “malignant.” Rather than characterizing blood test results as “negative,” she adds, “Say blood test results were normal. Patients may think negative is a bad thing.”

To complete each visit, Dr. Hong recommends asking, “What questions do you have for me?” Some experts propose that this is a more effective question than one that can be answered yes or no, such as “Do you have any questions?”

“Most importantly, we should finish with what we call the teach-back method,” she says. “Ask the patient, ‘Can you repeat the (treatment) plan?’ It’s a simple, fast way to assess how effective you were at communicating with your patient. And having patients explain the information in their own words helps them to consolidate and remember it.”

Highlighting handouts

To maximize the effectiveness of teaching aids such as printed handouts, Dr. Hong says that much evidence indicates that combining them with verbal education works better than either method alone. She recommends that handouts use specific principles for layouts and information presentation. Using headers to break up text and leaving blank space around page edges and elsewhere makes handouts easier on the eyes, for example. Additionally, “You can use arrows, color or bold text to draw attention,” she says.

Moreover, chunking, or grouping, similar pieces of information together helps patients to remember them. As in verbal explanations, using the active voice makes for easier reading than passive verbs.

For instance, rather than writing, “The elbows, knees and scalp are often the areas affected by psoriasis,” she says, “It’s better to say psoriasis often affects the elbows, knees and scalp. Write handouts as you would talk,” and keep in mind that the average American reader has an eighth-grade reading level.

“Actually, 20 percent of people in the United States read below the sixth-grade level. A good guideline is that handouts should aim to be between the fifth and sixth-grade reading level,” which is approximately the level at which the “Harry Potter” novels are written, she says.

With content and style, “A good rule of thumb is to keep it simple.” For medication instructions in particular, “Lists are better than paragraphs. And patients remember more if information is presented in this order: the name and purpose, how to take the medication, and possible outcomes, such as side effects,” Dr. Hong says.

As for visual aids, “Patients prefer pictures to text-based information. They can help improve comprehension, recall and adherence to medication instructions (Katz MG, Kripalani S, Weiss BD. Am J Health Syst Pharm. 2006;63(23):2391-2397). But it’s still very important to use written or oral instructions to avoid misinterpretation of pictures,” she says.

Other teaching tools

In keeping with the above guidelines, Dr. Hong says her practice sometimes gives a grid-like “Eczema Action Plan” to parents of pediatric patients. Across the top of the page, it lists three states of disease severity - flare, mild-moderate and normal-mild, for example - with corresponding body areas such as the scalp or face written down the left margin. With medications and doses for each clinical situation filled into the appropriate boxes, it provides a handy take-home tool that helps parents make sense of the many medications their children may require, she explains.

“Many patients come in with previous prescriptions. I’ll tell them to bring them in, and I fill in the form with them,” Dr. Hong says.

Moreover, she says that studies have shown that informational videos are more effective than written information for topics such as sunscreens, atopic dermatitis and melanoma. A recent study involving skin biopsies also showed that patients gained more knowledge from videos than from oral education regarding informed consent and post-procedure instructions (Armstrong AW, Alikhan A, Cheng LS, et al. Br J Dermatol. 2010 Nov;163(5):1014-9).

However, “Videos do not replace doctors,” Dr. Hong says. “You want to be able to say, ‘Now that you’ve seen the video, let’s discuss any questions or concerns you have.’” In this regard, she says, a melanoma study showed that a video can impart information, “But it was the clinic visit that decreased patients’ anxiety (Orringer JS, Fendrick AM, Trask PC, et al. J Am Acad Dermatol. 2005;53(2):224-229).”

Online education

As for the Internet, Dr. Hong says patients can find the amount of information presented there to be overwhelming. For every study that shows reputable Internet sites to be accurate and easy to find, she adds, “There’s a lot of incorrect and conflicting information out there, too.”

One study found that 68 percent of tanning-related videos on YouTube portrayed a pro-tanning message (Hossler EW, Conroy MP. Arch Dermatol. 2008;144(10):1395-1396). Therefore, “It’s very important for us to be able to counsel patients regarding what they might find on the Internet,” and to create and direct patients to reliable online sources, she explains.

Finally, Dr. Hong says it’s important to continue measuring the impact of educational efforts in dermatology, and in medicine as a whole.

“Do these patient education techniques take more time than conventional visits? That’s always our worry. But maybe these techniques will save time in future visits” and ultimately improve patient outcomes, she says.DT

Disclosures: Dr. Hong reports no relevant financial interests.