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PATIENTS quickly forget most of their doctors’ instructions and much of what they do remember is incorrect, according to neuropsychology researcher Roy Kessels PhD. Dr Kessels’ research interest is human memory, specifically focusing on neuropsychological impairments of memory in clinical groups. He recently surveyed a wide variety of studies, dating from 1975 to 2002, on patient compliance with physicians’ instructions, problems with memory function and ways to improve recall. "Several studies have been done and I think it is safe to say that approximately two-thirds of the information doctors give to patients is forgotten immediately. In addition, almost half the information patients do seem to remember is actually recalled incorrectly," he told EuroTimes. Factors like age, stress, perceived importance and whether information provided to the patient is in verbal, written or visual formats all have an impact on recall. For example, Dr Kessels advises doctors to leave little time between providing information to the older patients and getting a decision on treatment because older patients forget faster. Similarly, preconceptions are often an obstacle to memory. It is more difficult for patients to recall information that contradicts their personal theories. "Currently, medical doctors are often unaware that incompatible information is poorly recalled. If doctors recognise that patients might have their own ideas about a given illness or disorder, it might then be easier to correct these 'false beliefs'. This could be done, for example, by explicitly explaining what is incorrect and why this is so, though this is my personal opinion, and little research is available," Dr Kessels said. He noted that stress impairs patient recall through both attentional narrowing and state dependency. Attentional narrowing refers to a patient's tendency to focus on stressful information - 'you may go blind', rather than treatment, 'use these drops twice a day'. With state dependency, recall is more accurate when the patient is in the same emotional and physical state when the information was memorised. "The fact that advice on treatment is commonly given in the stressful environment of a clinic, yet is applicable in the more relaxed home environment, may partly explain why patients forget how many pills to take or the date of their next appointment," Dr Kessels said. He added that providing a video or audiotape can help overcome these problems. Perceived importance also plays a key role. Patients often focus on what they consider important; again 'you may go blind' will have more importance than 'take these drops'. Dr Kessels advises clinicians to put the important information first and be specific. For example, 'you need to take two weeks off' will be recalled better than 'you need some rest'. Simple phrases will be better recalled than complicated ones. He emphasised that recall is also improved if doctors spell out explicitly the information they are going to provide. This means telling them exactly what information you will provide. A standard five-category set begins by telling the patient what is wrong, then what tests will be performed, then what is expected to happen, then which treatment will be needed and finally what the patient can do to help herself or himself. How instructions are communicated has a major influence on patient recall. Spoken instructions are poorly recalled, while written ones are better remembered. Cartoons or pictographs are examples of non-verbal communication that can produce dramatic improvements in patient recall. In some studies, recall jumped from 14% with spoken instructions to 80% with the pictographs "Of course, patient recall is also affected by factors related to the physician, for example, the communication skills of the doctor and the patient's satisfaction with the doctor, which I didn’t address in the paper. "Memory for medical information is a necessary component for good therapy adherence or compliance. That is, if a patient cannot remember the advice the doctor gave him (or her), he (or she) is unlikely to follow these guidelines," Dr Kessels said. Ophthalmologists, for their part, are not formally aware of the problems memories pose for patient compliance, commented Eve Higginbotham MD, Professor and Chair of the Department of Ophthalmology, University of Maryland School of Medicine, US. "Dr Kessels nicely puts together, in a more formal fashion, the problems of memory for treatment. Compliance is a big issue in ophthalmology, not only in terms of just the memory, but patients frequently have to acquire new skills. "We have to teach patients to put drops in their eyes. Michael Distlehorst MD in Germany has a very nice video where one of his patients, who is a physician, tries to put drops in and misses his eye. It just indicates how hard a skill it can be," she said. She noted that even something as apparently straightforward as instilling eyedrops requires careful instruction by the doctor and memory retention by the patient. Patients have to learn how to put the drops in, then they have to remember to pace the drops and then they have to remember to put in the drops in the first place.
Dr Kessels’ research appears in the Journal of the Royal Society for Medicine (Vol 96, May 2003, 219-222). |
