“OK, so we think you have pleurisy. Your D-dimer was negative. You should take ibuprofen, rest and stay hydrated, then follow-up with your primary care physician. Any questions?”
My daughter reached for her discharge papers as she slid off the exam table and we thanked the staff as we made our way out of the urgent care part of a local emergency department.
She was eighteen at the time, a college freshman studying sociology. She called me to tell me she had been experiencing two days of pleuritic chest pain and felt a little short of breath. Because our logical, medical brains turn into parent brains when our child is sick, I dropped everything I was doing to go and see her. She looked fine, the pain was probably just musculoskeletal; she is a ballet dancer and these minor aches and pains are common. But, I thought, “What about a pulmonary embolism?” “Not likely” I thought, “but I’m here so let’s go get it checked out”.
We were lucky, it was a slow day and we were seen right away. We were seen by a Physician Assistant (PA) who also said this is probably pleurisy and gave a plan of rest and ibuprofen. Then I became “that guy,” the family member who is in medicine and “has some questions.” I could see the displeasure of the PA as I uttered “D-dimer.” This is a test commonly used to evaluate for the presence of a blood clot in the vessels of the lung, called a pulmonary embolism. A D-dimer test is a very sensitive test, meaning that if a blood clot is present, the test is almost always positive. The downside is that it is not very specific, meaning that it can be positive for reasons other than a blood clot. Inflammation from arthritis, cancer, recent surgery, and even pregnancy can result in a positive D-dimer. A positive test often means getting a CT scan, which means exposing the patient to radiation and additional medical costs, which is the downside of a low specificity test. After a discussion of pros and cons, my daughter had her blood drawn for a D-dimer test. Thankfully it was negative, and we were handed our discharge instructions just like that.
I was fine with the diagnosis, although I did not really suspect viral pleurisy. Pleurisy is caused by inflammation between the two linings of the lungs or pleura. It often follows an illness like pneumonia or even a cold, which my daughter did not have. The discharge instructions were from a commercial electronic medical record (EMR) and read to us by a medical assistant. I had already developed my own ideas about my daughter’s pleuritic plan and what I was going to recommend. This was a standard minor visit with a simple diagnosis and her symptoms would likely resolve regardless of what we did.
Thinking back now, had I not had that knowledge, was that discharge “teaching moment” really adequate? Did my daughter understand these directions? Would my Mom? Would an elderly patient with mild cognitive dysfunction? I work as a nurse practitioner in a busy suburban emergency department. I know that my own discharge instructions, also from an EMR, also not often performed by me, are handled in very much the same way.
I am fortunate to be a scholar at the Harvard Macy Institute Program for Educators in the Health Professions, and have learned how different methods of teaching engage learners and improve comprehension. As a nurse practitioner who engages with students in the clinical setting, I apply these principles to bedside teaching. As an instructor in nursing at a nearby university, I have “flipped” my classroom, integrated art into the science, and use a lot of reflection in my teaching. Why then was I not applying these same principles to a very important clinical teaching opportunity, the patient’s discharge instructions?
I know the answer. I am too busy. It is easier to hand them a pre-scripted packet of papers that “explains it all” in common every day and simple language. Most patients are fine with this. But even simple discharge instructions can be complex. We are providing a diagnosis, offering our thoughts on an appropriate care plan, recommending follow-up, and identifying reasons they should return to a healthcare provider. That is a lot of information, even for a simple diagnosis. Use of medical jargon and lack of patient understanding is common and contributes to the dysfunction of this process.
A lot of work has already been done in this area and there has been an array of recommendations from using pictures, to simplifying language, as well as involving family members to help reinforce the instructions. These are all great. I think, however, that there are some very simple things that can be done to enhance this process even more. I again looked to a session at the Harvard Macy Institute Program for Educators in the Health Professions, focused on teaching a skill called Peyton’s Four-Step Approach. This session offered some great principles that apply not only to skills, but also to processes.
The process involves an instructor demonstrating a skill without narration, then demonstrating a skill with narration. After these two iterations, the teaching was in the learner’s hand, as they had to walk the instructor step-by-step through the skill. Finally, the learner demonstrates their understanding of the skill by doing it on their own. It is a great way to ensure understanding and enhance retention. I still recall how to make a proper cup of English tea, the skill I learned that day at the course.
This same principle can be applied to what can be considered the “skill” of understanding the care plan set forth at discharge. It draws from the principle of exercise, providing simple bullet points, repeating teaching points at spaced out intervals and then having the patient “learner” demonstrate their understanding. Instead of now handing a pile of papers to the nurse who normally manages the discharge, as a nurse practitioner, I am trying to do most of the discharge myself. I type up the most important bullet points, review them twice and then ask the patient or family member to go over them with me. We then can clarify things and the patient can ask questions. The patient has time to hear my instructions, but allowing them to explain everything back, step by step, ensures clarity and understanding.
I have also started to incorporate videos, mostly from YouTube® on how to perform skills like self-administer an epinephrine auto injector or exercises to help relieve back pain. Directing patients towards legitimate internet resources is also incorporated, so that any information they get is from a reliable resource. It is also an opportunity to link them to our hospital website, which has an array of valuable resources and patient tools.
Discharge instructions are an important aspect of patient care. We have a history of doing them poorly. It is important then, to practice what we preach and make sure the patients understand them using some of the pedagogical methods that enhance learning. Using media like video helps to ensure patients have the right tools to take care of themselves when they go home. My next step? Integrating Twitter® as a social media platform for patients to access important and common post-care practices. Developing a tool to evaluate this method is something we are endeavoring for the future. Now sign here and you are free to go!
Did you know that the Harvard Macy Institute Community Blog has had more than 150 posts? Previous blog posts have explored topics including the role of formal training in medical education, creating new models for academic publishing, and well-being in health care.
Stephen P Wood
Stephen P. Wood, MS, ACNP-BC (Educators, ’19) is a nurse practitioner, working in the field of emergency medicine as well as an instructor at Northeastern University in the Bouvé College of Health Sciences Graduate School of Nursing. He is a fellow at the Harvard Medical School Center for Bioethics and a regular blogger for the Harvard Law School’s Petrie-Flom Center “Bill of Health”. His areas of interest include the flipped classroom, experiential learning and simulation. Stephen can be followed on Twitter or contacted via email.