Barriers to Patient Education a Clinic Can Control
Time is the barrier everyone names, and it is real.
A visit has a list of problems to cover, a schedule running behind, and a patient who has saved the real question for the moment the clinician stands up.
Studies of real visits point to five barriers to patient education. They are time, an agenda never asked for, patients who do not ask questions, written materials above the reader's level, and understanding that is never checked. Some barriers sit outside the clinic, such as cost and transportation. The ones inside the clinic depend on how a visit is run, and a clinic can change them.
Each of them has a study behind it.
Time is the barrier everyone names
Time is the barrier everyone names, and it is real.
Researchers who timed 392 videotaped primary care visits (opens in a new tab) of older patients found a median visit length of 15.7 minutes covering a median of six topics. The longest topic received about five minutes. Each of the others received about one minute. The visits were recorded between 1998 and 2000, but the authors' point still holds: "Many topics compete for visit time."
Another team modeled the time guideline care would take (opens in a new tab) for a panel of 2,500 primary care patients. Ten common chronic diseases alone needed 3.5 hours of physician time a day when stable, and 10.6 hours a day when not well controlled. That is an estimate of time required, not time spent. It shows why teaching is often the first thing cut.
Visit time will not grow. What a clinic can change is how much of the teaching depends on it.
The patient's agenda is often never asked for
Education aimed at the wrong question does not land.
In a study of 112 recorded clinical encounters (opens in a new tab), clinicians asked for the patient's agenda in 36 percent of visits: 49 percent in primary care and 20 percent in specialty care. When they did ask, they interrupted in 27 of 40 encounters, after a median of 11 seconds. Patients who were not interrupted took a median of six seconds to state their concern.
Six seconds is a small price for knowing what the patient came to learn.
Many patients do not ask questions
Silence at the end of a visit says little about understanding.
In 57 audiotaped primary care visits (opens in a new tab), patients with low literacy asked fewer questions about their medical care than other patients, a median of 4 against 6. They were more likely to ask the physician to repeat something, a sign the first explanation had not landed.
Reluctance is not limited to patients with low literacy. In six focus groups with 48 people (opens in a new tab) in the San Francisco Bay Area, even affluent and well educated participants described deferring to physicians. Some feared being seen as "difficult." The authors suggested that physicians "may not be aware of a need to create a safe environment for open communication."
A focus group cannot say how common that fear is. It does explain why waiting for questions is not a plan.
Written materials are often above the reader
A review of 24 systematic reviews (opens in a new tab), covering 29,424 materials, found that every review reported most materials above the recommended sixth to eighth grade reading level. A handout the patient cannot read teaches nothing at home.
Understanding is rarely checked
In one study of audiotaped visits (opens in a new tab) with patients who had diabetes and low health literacy, physicians checked recall or comprehension of a new concept in 12 of 61 visits. The teach back method shows how to ask without testing the patient.
What a clinic can change this month
Each change below answers one barrier. None needs a new system.
For time: teach the one or two actions that matter most in the room, and put the rest in a written plan the patient takes home, such as a plan for type 2 diabetes or hypertension.
For the agenda: open with "What would you like to cover today?" and let the patient finish.
For silence: say that questions are expected and welcome, then ask a specific one, such as what worries them about starting the new medication.
For materials: review the handouts in use against the steps for writing a usable handout, and test one with a patient.
For checking: before the patient leaves, ask what they will do first at home.
Some barriers stay outside the exam room. Cost, side effects and transportation are real, and the four pillars of better patient education name them. A clear plan does not remove them. It makes sure confusion is not added to the list.
Time will stay short. The teaching can still reach home.
Let's Complete the Care.
