“Seeks to confirm patient’s understanding”

1. “Seeks to confirm patient’s understanding” Kate Culley ST3 Lighthouse medical Practice

2. What? un·der·stand·ing   "http://dictionary.reference.com/audio.html/lunaWAV/U00/U0064800" noun 1. mental process of a person who comprehends; comprehension; personal interpretation: My understanding of the word does not agree with yours. 2. intellectual faculties; intelligence; mind: a quick understanding. 3. superior power of discernment; enlightened intelligence: With her keen understanding she should have become a leader. 4. knowledge of or familiarity with a particular thing; skill in dealing with or handling something: an understanding of accounting practice. 5. a state of cooperative or mutually tolerant relations between people: To him, understanding and goodwill were the supreme virtues.

3. Why? • 1 in 6 in UK have literacy below that expected of 11yr old • Important part of health literacy is acting on information, not just reading and understanding it • Many studies show that about half of all patients do not correctly follow medical instructions. • Around 1/3rd to 1/2th of medicines are not taken as prescribed

4. Do Patients Understand? • Doctor : “I see you are taking birth control pills. Tell me how you are taking them.” • Patient : “Well, some days I take one; some days I don’t take any. On weekends I usually take more.” • Doctor : “How did your doctor tell you to take them?” • Patient : “He said these pills were to keep me from getting pregnant when I have sex, so I take them anytime I have sex.”

5. Why? • Patient understanding and involvement are central to treatment selection and active patient role in treatment and recovery. • Informed consent requires informing patient about the condition and its likely course, treatment options, expected benefits and risks. • Key to assessment of Capacity... • Safety • Maximizes patient benefit and minimizes unrealistic expectations – key area claims • CSA and COT marking scheme!

7. COT marking scheme

8. How? • The only way to know for sure whether patients understand is by asking

9. http://www.youtube.com/watch?v=cYdQRuHEoWk http://www.youtube.com/watch?v=l8Z09pfr9ZE&feature=related http://www.youtube.com/watch?v=g0P64KahcRA&feature=related

10. MPS guidance on assessing capacity ‘frame questions in such a way that the patient will need to give a full response in order to assess their understanding, eg, “tell me what you understand by...” rather than “do you understand?” which may only require a yes or no answer.’ MPS GP registrar autumn 2011

11. How? • Statements such as, “I want to make sure I explained this clearly. When you go home today, what will you tell your [friend or family member] about [key point just discussed]?” • So do you want to summarise what I've said in your own words? • I've just said a lot of things and I want to make sure I explained things clearly. Can you explain things back to me, so I know you understand?

12. Checking understanding Cambridge Calgary style EXPLANATION AND PLANNING Providing the correct amount and type of information • 33. Chunks and checks: gives information in manageable chunks, checks for understanding, uses patient’s response as a guide to how to proceed • 34. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information, discovers extent of patient’s wish for information • 35. Asks patients what other information would be helpful e.g. aetiology, prognosis • 36. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely

13. Aiding accurate recall and understanding • 37. Organises explanation: divides into discrete sections, develops a logical sequence • 38. Uses explicit categorisation or signposting (e.g. “There are three important things that I would like to discuss. 1st...” “Now, shall we move on to.”) • 39. Uses repetition and summarising to reinforce information • 40. Uses concise, easily understood language, avoids or explains jargon • 41. Uses visual methods of conveying information: diagrams, models, written information and instructions • 42. Checks patient’s understanding of information given (or plans made): e.g. By asking patient to restate in own words; clarifies as necessary

14. Achieving a shared understanding: Incorporating the patient’s perspective • 43. Relates explanations to patient’s illness framework: to previously elicited ideas, concerns and expectations • 44. Provides opportunities and encourages patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately • 45. Picks up verbal and non-verbal cues e.g. patient’s need to contribute information or ask questions, information overload, distress • 46. Elicits patient's beliefs, reactions and feelings re information given, terms used; acknowledges and addresses where necessary

15. Planning: shared decision making • 47. Shares own thinking as appropriate: ideas, thought processes, dilemmas • 48. Involves patient by making suggestions rather than directives • 49. Encourages patient to contribute their thoughts: ideas, suggestions and preferences • 50. Negotiates a mutually acceptable plan • 51. Offers choices: encourages patient to make choices and decisions to the level that they wish • 52. Checks with patient if accepts plans, if concerns have been addressed

16. Something to reflect on? ‘ A patient’s understanding depends not only on the material he or she receives but also on the way the patient assimilates that information and translates into actionable beliefs, based upon cultural and individual values and beliefs as well as past experiences.’ http://www.aaos.org/news/aaosnow/mar09/managing6.asp

17. “So... If you had to go home and tell someone what you learnt today....” Thank you! Any questions?