Now Reading: “Tell Back- Collaborative Inquiry” to Assess Understanding of Medical Information

One of my patient centered health-care mentors, David Sobel, MD, from Kaiser Permanente passed this study on to me in the context of work we are exploring in the area of self management. Since I haven’t mentioned David on this blog before, I’ll point out that his impact in my career and many other health care professionals has been significant. David is the physician that taught me that the primary care giver is the patient (and their family, community). Because of this, when I think of “medical home,” I don’t think of the primary care provider’s office. I think of the true medical home, the place where the patient lives, works, and plays (with their family and community).

I digress, but back to the article, it puts together the call to action to involve patients and families in their care, before they leave the exam room.

First, the paper starts with a very helpful literature review of the “elephant in the exam room,” as I call it, the fact that patients don’t remember most of what doctors tell them during visits. When they are tested afterward, they typically don’t remember things correctly (correct treatment was relayed back by patients to researchers in only 49% of cases after immediately leaving the emergency room). I use this data to support the idea of a written summary of every visit that patients can use by themselves, and with their families and communities. As colleagues of mine have pointed out, the written summary is not the product, the process of preparing it is.

The study itself examines three different ways of inquiring about patient understanding, in a specific and potentially scary situation, a deep blood clot in the leg. The approaches are “Yes-No” (Which most physicians will relate to as the “hand on the door knob to leave the exam room), “Tell back-collaborative,” and “Tell back-directive.”

Here’s the content of the “Tell back-collaborative” approach:

I imagine you’re really worried about this clot. I’ve given you a lot of information. It would be helpful to me to hear your understanding about your clot and its treatment.

In testing the three approaches using standardized video clips, this approach was significantly more preferable by patients, and there’s a nice discussion of what this means.

The study brings up a lot of compelling issues for me at the same time:

  1. This collaborative approach could easily be worked into the after visit summary process: “I’ve given you a lot of information. Let’s compose the summary of what we talked about, together, so that your treatment is successful.”
  2. In the era of secure e-mail between patients and providers, what a wonderful tool to support an approach like this and provide continuity of care. Imagine saying (in addition to the above): “I would like you to e-mail me your understanding of the condition tomorrow in the event any questions have come up, and also let me know how you’re doing.” The days of depending on the visit to ensure understanding are hopefully over.
  3. As a practitioner of LEAN (Toyota Management System), this approach also speaks to the value of “getting inside” the clinical encounter, to standardize things that should be standardized (but not things that shouldn’t be standardized, like personal preferences). In health care systems, we have been anxious about scripting parts of the physician visit. I think we should move past that and use approaches that work, for every patient, every time. If every patient in a care system could expect the same approach to confirming understanding, it could change interaction during the visit, to something like, “I know she/he is going to ask me my understanding of things, so I should ask questions now, or note which areas need more explaining.”

The study does not measure whether patients were able to understand the treatment regimen from the various approaches, just which they preferred. It’s possible that their preference for an approach at the very least would have an impact on their satisfaction on the visit, and in turn on the satisfaction of the provider in helping patients understand (the “happy providers come from happy patients, not the other way around” hypothesis). At the most, a return visit, or a devastating complication could be prevented.

Our profession has incredible and incredibly complex therapies at our disposal – this is about making sure they actually help the people that we ask to use them to achieve their life goals through optimal health.

To the patients out there (all of us) – what approaches have you seen used at the end of the visit? To the providers out there – what are you willing to try during your next patient visit?


I have been doing something similar for several years, but this post and the article it references will lead me to make some adjustments.

What I have been doing: I do my notes in real time during the visit in order to be able to print and provide a copy of our (hopefully collaborative) process when they leave. Depending on the circumstances, I may do the discussion of assessment and negotiation of a plan first, and then move to documentation mode, or I may do the discussion/negotiation and documentation as a single process. In both cases, the documentation happens in ‘chunks’ that allow me to check in with the patient. (“Does that make sense?” “Is that your understanding of what we decided?”).

The change: I will work in the introductory of something like “We’ve covered a lot today. Let’s record it together to make sure we are on the same page.”

I’d love to add the post-visit email piece, but my institution has yet to provide us with any tools.

Hi Peter,

Thanks for your thoughtful comment. I can tell from the above and from your writings on your own blog (which is very engaging, by the way) that you pay attention to the relationship which in my opinion is 90 % of the necessary behavior. From there, a few specific techniques are only going to make you better. Post a reply on how it goes if you get the chance,


Ted Eytan, MD