Patient education encompasses a vast area. It is predominately the process of educating the patient regarding his or her medical condition and an appropriate treatment plan. It involves a discussion of the medications, possible adverse reactions and actions to take if they occur. It is a discussion about the importance of compliance with one’s treatment regimen.

This dialogue may emphasize the benefits of preventive services and lifestyle modifications. The conversation also involves helping the patient learn how to access the healthcare system and how to utilize his or her insurance. Patients may have questions about what insurance does and does not cover. They may have questions about what they should do if their condition becomes worse or what they can do if their condition gets worse after office hours, etc.

Patient education is a continuous process that takes place at each and every patient encounter. Preferably, patients should have supplemental materials to review in between visits. Depending upon the patient’s condition, educational level, support system and coping mechanisms, physician assistants and nurse practitioners have to judge what the appropriate amount of material is for each patient. Too much information cannot be processed by the patient or will overwhelm the patient, and too little information can be harmful.
Regardless, whenever you provide patient education regarding any topic, it is essential that the focus remains on the patient. Until you make it important for the patient to comply with the recommended treatment regimen, diagnostic procedures or lifestyle modifications, you are facing an uphill battle for patient adherence to your instructions. If it is not important to the patient, the message is not going to be received let alone acted upon.

According to the author, the patient cannot be expected to follow instructions if clinicians do not convey them in a manner that makes it easy for the patient to understand.

Putting this into a clinical perspective, I once worked with a nurse who claimed I could “sell ice cubes to Eskimos” because of my ability to convince patients, who had previously been labeled “noncompliant,” to follow all instructions. However, it had nothing to do with my salesmanship ability but my ability to listen and motivate.

Ascertaining And Addressing Patient Concerns
Good patient education involves hearing what the patients concerns are as well as their interests and values. What is important to you and what you value in life might not be all that important to your patient. Therefore, putting patient education in terms of these issues is not going to be effective. You have to be able to separate the illness experience from the disease process.

For example, Mrs. Osborne (not her real name) was a long-standing “noncompliant diabetic,” according to her extensive chart. The first day we met, I discussed what having diabetes meant to her. She replied, “I can’t stand to live if I am blind. Therefore, I am going to live life to its fullest while I can still see.” This perception, whether it is deemed correct or incorrect, is reality to Mrs. Osborne. This perception comes from the fact that the patient’s mother, aunts and grandmother lost their sight due to diabetes.

Once I elicited this information from the patient, I was able to see Mrs. Osborne as a middle-aged female with diabetes as opposed to a “non-compliant” diabetic.

However, I directly address this issue. I explain to the patient how tighter glucose control leads to less complications. I let her know that more medications are available to help control the disease today and that better treatments are available for early eye complications, etc. Accordingly, we have enabled the patient to make the decision to control her illness instead of having the illness take control of her.

Within three months, she had lost weight, started watching what she ate and walked daily. She was able to achieve normal fasting and postprandial blood glucose, hemoglobin A1C and lipid levels. She also was able to normalize her slightly elevated blood pressure. The patient also saw an ophthalmologist.

Essentially, she listened to me and my recommendations to control her diabetes because the recommendations became important and had value to her. Over 10 years later, all of the patient’s parameters are still in excellent shape and she has never felt better.

One has to take the illness experience into context when describing the disease process to the patient. In Mrs. Osborne’s case, the disease process with diabetes had to do with failing beta-cells in the pancreas; inadequate insulin secretion in response to elevated glucose; chronic elevated insulin levels; and increased glyconeogenesis in the liver.

The goal of treatment was prevention of short- and long-term complications. However, until Mrs. Osborne was able to adequately manage and move beyond her illness experience, she was unable (and unwilling) to treat her disease.

How To Secure The Patient’s Buy-In
The patient’s “buy-in” of the treatment regimen and the associated patient education is essential if the patient education is going to be effective or even desired. For example, Mr. Jones (also not his real name) is a 63-year-old male, who had a history of smoking over 200 packs of cigarettes a year. Despite showing him declining pulmonary function tests from year to year, emphysematous changes on his chest X-ray and progressive exertional dyspnea, the patient was certain that cigarette smoking had nothing to do with it.

He did not believe he was at risk for lung cancer, chronic obstructive respiratory disease or any other associated complication. The patient followed this assertion with an extensive listing of the names of several relatives and friends who “smoked until the day they died.” Even when his dyspnea started preventing him from participating in and enjoying many of his favorite activities and hobbies, the patient would just say, “What do you expect? I am getting old.”

The patient’s “buy-in” of the treatment regimen and the associated patient education is essential if the patient education is going to be effective or even desired.

Remembering that the patient’s granddaughter was pregnant with his first great-grandchild, I asked him about it. His chest swelled up and he talked happily for a good five minutes. I then started showing him the results of his PFTs for the past few years and the changes in his chest X-rays. I then pointed out his symptoms and their rate of progression. I provided estimates of functional capacities based on current rate of deterioration.

Then I advised him he would be fortunate to see his unborn great-grandchild’s second birthday let alone be able to play with him in any meaningful capacity. Mr. Jones stopped smoking “cold turkey” right then and there. Five years later, he is still tobacco-free, has better pulmonary function and enjoys not one but two great-grandsons daily.

Checking The Personal Baggage And Demonstrating Cultural Sensitivity
In addition to making patients partners in their health care by getting them to “buy into” the treatment plan, you also have to ensure that your recommendations are culturally sensitive for the particular population.
For example, when I first began working in rural West Virginia, one of the programs I took responsibility for was our family planning program. I was doing presentations in the schools for community groups, etc. The goal was encouraging teens not to become sexually active or to make responsible choices if they did become sexually active. We would follow this with a discussion of the various methods of birth control available and how they could obtain it without parental consent, etc. However, the adolescent pregnancy rates remained stable.

Why? The message I was promoting was that a teenage pregnancy would make it extremely difficult, if not impossible, to attend college to study for a wonderful career. The problem with this argument was the fact that it was irrelevant to them from their point of view. Of the female adolescents in the area who did graduate high school, fewer than 10 percent had any plans on attending college. For the adolescent females in the area, their goals for life were to finish high school, get married, have babies and become housewives. The only thing an unplanned pregnancy did was alter the order of these events and possibly force them to skip the graduation part.

Accordingly, I started focusing on the increased health problems to the mothers and the babies; the increased incidence of low birth weight infants and their associated complications; and the possibility of these children having a learning disability.

This example once again illustrates the importance of having the ability to listen to our patients, empathize with them, and accept their value and beliefs while checking our “baggage” at the doorway.
Ensuring Easy Understanding

Just as important as being able to “walk in his shoes” is being able to “talk” in his shoes. The patient cannot be expected to follow our instruction if we do not convey them in a manner that makes it easy for he or she to understand. Current estimates show that individuals can only retain three pieces of new information per patient encounter. This can be reduced even further by the stress experienced by those in the “patient role.”

Therefore, it is often necessary to provide these patients with written materials to supplement or reinforce the information they need. However, if they cannot understand what your have said or comprehend what is written due to poor health literacy, then they are not going to adhere to the recommendations nor are they going to benefit from them. Accordingly, it is essential that you communicate with each patient on a level consistent with his or her current emotional and educational levels. This should include some type of feedback mechanism in which the patient repeats the information back to you to ensure that he or she has it correct.

Final Notes
By following these simple steps, you can make patient education a significantly more enjoyable and rewarding experience for yourself and for your patients. At the same time, you have enhanced their compliance, made them active partners in their health care, and prevented often severe and/or fatal complications. Additionally, this should help reduce the estimates that 11 percent of all hospital admissions, 40 percent of all nursing home admissions, and approximately 125,000 deaths occur in this country annually due to noncompliance with the treatment regime.1

Therefore, in order to effectively provide patient education to our patients, we have to remember that the first and most important word is “patient.”