The PENCIL Paradox: How Clearer Patient Education Could Improve Care and Practice Revenue

Consider a patient who leaves with a recommendation to return, repeat a test, or review a new treatment. The next step makes sense in the exam room. At home, the reason, timing, and details become less clear. The appointment never happens.

That missed follow-up can leave a clinical question unanswered and an opening in the clinic schedule. Helping patients complete recommended care has value for both the patient and the practice.

An idea from economics offers an interesting way to think about this.

In The Coal Question (opens in a new tab), first published in 1865, William Stanley Jevons argued that more efficient use of coal could increase total consumption. Efficiency made coal-powered work cheaper, encouraging broader use and greater demand. This became known as Jevons paradox: greater efficiency can lead to greater overall use.

I see a useful parallel in patient education.

If we make education easier for clinics to deliver and easier for patients to understand, we may see more education used, more patients prepared to act, and more recommended care completed.

I call this working hypothesis the PENCIL Paradox.

PENCIL Care Plans are built around four pillars: Relatable, Readable, Actionable, and Recognizable. A consistent format and plain language are intended to help patients understand their condition, medication, or procedure and know what to do next.

The possibility extends beyond handing out more plans. Better understanding could help patients return at the right time and arrive prepared for a more productive visit.

Published research gives us reasons to test that possibility.

An educational brochure and completed follow-up. In 1994, Stewart and colleagues reviewed the records of 108 women (opens in a new tab) who had participated in a randomized study involving educational brochures after abnormal Pap results. The brochures were provided when colposcopy was initially booked. At 18 to 24 months, 75.4% of women who received a brochure had completed recommended treatment and follow-up, compared with 45.8% without it, a difference of 29.6 percentage points. This small, older study provides a particularly relevant example of written education influencing completion of care.

Clearer materials for parents of premature infants. In 2023, McCahon and colleagues studied redesigned educational materials (opens in a new tab) about retinopathy of prematurity, an eye condition affecting premature infants. The materials followed health literacy guidelines, and parents also completed knowledge assessments. In the group receiving the redesigned materials, follow-up attendance was 80.0%, compared with a pre-study baseline of 68.2%. Parent knowledge also improved. The attendance difference was 11.8 percentage points, although the comparison with a prior baseline cannot isolate the materials’ effect.

A leaflet and reminder that reduced missed appointments. In a 2004 randomized trial (opens in a new tab), Tomlinson and colleagues studied 500 women referred for colposcopy after abnormal cervical screening. The intervention combined a detailed information leaflet with an appointment reminder letter sent 7 to 10 days before the visit. Missed appointments occurred in 18% of the intervention group versus 35% of the control group. Expressed as attendance, that is approximately 82% versus 65%. The study tested education and a reminder together.

Written reminders that brought patients back toward surveillance. In 2011, Leffler and colleagues tested a follow-up system (opens in a new tab) for patients due for surveillance colonoscopy. It included two patient letters, a letter to the primary care clinician, and a telephone call if the examination had not been scheduled by its due date. Within six months of that date, 44.7% had scheduled or completed colonoscopy, compared with 22.6% receiving usual care. This was a combined outcome of scheduling or completion, an important distinction when interpreting the result.

Education within a coordinated postpartum care program. In 2021, Suresh and colleagues reported a University of Chicago quality-improvement initiative (opens in a new tab) involving 926 patients. It combined patient and clinician education, a dedicated nurse educator, and protocols for managing hypertension after childbirth. Attendance at postpartum hypertension visits increased from 33.5% before implementation to 59.4% during full implementation. The program was also associated with better blood pressure control. These findings reflect the entire clinical program, which had several components.

These studies support the value of education and dependable follow-up systems. They provide a rationale for studying PENCIL; PENCIL’s own effect on follow-up, clinical outcomes, and practice finances remains to be measured.

The financial possibility follows from the care that patients complete.

In a practice paid for individual visits or procedures, improved follow-through may support revenue from care that was already clinically recommended. Fewer missed appointments may also make better use of available clinic capacity.

For a hypothetical illustration based on the abnormal Pap study, consider 100 women needing treatment and follow-up after an abnormal Pap result. If completion increased from 45.8% to 75.4%, roughly 30 additional women would complete their recommended care. Assuming one additional paid follow-up visit per patient and $150 in collections per visit, that would represent approximately $4,500 in additional collections.

Because these patients are already part of the practice, that additional visit volume could come without additional marketing expense. Patients receive recommended care, and the practice earns revenue from providing it: a win-win for patients and the clinic.

Those are illustrative assumptions, not a PENCIL forecast or a financial result reported by these studies. Actual benefit would depend on capacity, payment arrangements, and costs. In membership or capitated practices, additional visits may bring no additional payment; the financial question would center on workload and the cost of delivering care.

A clinic could test this opportunity by selecting one follow-up pathway, pairing an individualized PENCIL Care Plan with scheduling and reminders, and tracking:

• The percentage of eligible patients who leave with a written care plan.

• Whether patients can explain their next step in their own words.

• The percentage who complete follow-up within the recommended time.

• Missed appointments, staff time, program costs, and collections where applicable.

A more productive follow-up visit would be another useful outcome to measure: whether patients arrive knowing what to track, what to bring, and what needs discussion.

The PENCIL Paradox begins with a practical possibility: making patient education easier to use could increase its use and help more patients complete their care.

A clear written plan can carry the conversation from the exam room to the dinner table, keeping the next step visible when it is time to act.