Teach back

Doves & cherubim are not strictly required for successful teach back.
[L'Annonciation de 1644 via wikimedia]

I love the "teach back" technique. Teach back is a way to verify shared understanding by asking someone to explain their understanding of the instructions and/or event.

Done well, this can keep patients from skating out the door just by smiling and nodding at the provider, even though they didn't understand anything the provider said. When I am asked to do teach back, I find it often prompts me to ask questions I didn't have when asked "do you have any questions?" I might realize I zoned out during the encounter. It forces me to pay closer attention. It also lets the provider know if I've truly understood key details, like how many times to take a medicine per day, what the next step in my diagnosis is, or what will keep the rash from returning.

However, the two most common way most learners employ teach back is  at the end of the encounter:

1. "I just want to make sure you understand everything correctly, so will you please tell me what I've just told you?" 

2. "So, sometimes I am unclear and use big words when I am talking to patients. To make sure I was clear, will you please tell me what you understand of our conversation today?"

Both of these framings are incredibly awkward. As one student told me in feedback, "It's like I have to choose between calling the patient stupid or calling myself incompetent."

So here's the best way I know how to use teach back with patients:

• Start with a summary of the history and physical exam findings. Summaries are awesome in general because they give both the learner and me a last chance to verify/update inaccurate information. But a summary also primes me for teach back because it helps me focus on the things the learner finds important, making it more likely I will recall and retain that information.

• "What questions do you have?" after the summary helps make sure that all questions are resolved before moving to teach back. No new info should be introduced during teach back. Resummarize after all questions have been answered if possible.

• Identify the patient's most relevant support network. Sometimes that information has already been obtained through the social history, but if not, questions like "Who brought you in today?" or "Who are you going to call when you get home?" or "Are you going to need to contact work?" et cetera can be helpful. The student-doctor can ask more than one question to help identify the person I am most likely to discuss my condition with. These questions should be approached with a transitionary tone rather than come across as a complete non-sequiter.

• Now do teach back! "What are you going to tell [person identified in Step 3] about [the next step/your medicines/what we talked about today]? The learner can continue to prompt me in this way about any of the key details they want to ensure I understand. 

For example:

Student-doctor: So let me sum up: You’ve had a rash for a week, and when I looked at your leg I saw circular black dots. So I'm going to prescribe some cream you'll use twice a day. How does all that sound to you? 

SP: Yeah, great. 

Student-doctor: OK. What questions do you have? 

SP: I can't think of any. 

Student-doctor: OK, then we're good. So who brought you into the clinic today? 

SP: My husband. 

Student-doctor: Great, so on the way home, what are you going to tell him about your condition?

There can be lots of nuance here depending on how the patient answers. But this basic structure makes me feel as if the learner is preparing me for a conversation I'm going to have rather than giving me a pop quiz. And because the learner seems like s/he is interested in my life and support network, it enhances our rapport.

Discussion question:

Does your school practice the teach back method? I'd love to see more examples of how to introduce teach back well, or other resources that talk about the concept. Everything I've found doesn't explain it as well as I'd like, hence the generic Wikipedia link.