Do you hear me now? Do you understand me?

Patients don't always process instructions correctly

Fact sheets on the procedure are produced and distributed through the surgeon's office, brochures about your outpatient surgery program are in the packet the patient receives when surgery is scheduled, a nurse talks to the patient in a pre-admission telephone call, and a comprehensive instruction sheet is given to the patient upon discharge.

So, why is the patient making frantic calls in the middle of the night to report pain? Why didn't the patient call the surgeon's office two days postoperatively to report increasing redness at the incision site? Why is the patient calling the surgery program staff to ask about when to change the bandage?

There are a number of reasons that all of the information that the surgeon and the nurses provided was not heard or understood, says Ilene Corina, president of the Wantagh, NY-based Persons United Limiting Substandards and Errors in Healthcare (PULSE) and a member of the Joint Commission on the Accreditation of Healthcare Organizations' Board of Commissioners. "Low health literacy is a problem for many people, regardless of their income, education, or language," she says.

Health literacy is defined as the degree to which an individual can obtain, process, and understand basic health information needed to make health decisions, but the degree of literacy differs between provider and patient, Corina says. Information about a surgical procedure might be well written and well presented from the surgeon's or the nurse's point of view, but a patient with no medical experience doesn't understand some of the words used on a regular basis, she explains. "I don't know if instructions to take a medication three times a day means at mealtimes, or every eight hours because I don't know how the medicine works," Corina says. "It's the same as not knowing the difference between 'business class' and 'more leg room' when I fly, but when I fly, the employees are not wearing white coats, I am not naked, and no one is looking at their watch, so I feel comfortable asking questions."

The day that a patient learns that he or she will need surgery is not the day to give them all of the details of the procedure, says Corina. Anxiety and fear about surgery will make even the most intelligent patient stop listening to the surgeon once the words "you need surgery" are spoken, she explains. There are two ways to address this problem, she suggests. "If the surgery is elective, as most outpatient procedures are, then offer the patient a chance to come in at another time with a list of questions," Corina says. "You can also suggest that the patient bring a friend, family member, or other person who can be a health advocate."

Larry E. Gellman, MD, FACS, a surgeon in Great Neck, NY, encourages his patients to have someone with them to take notes, ask questions, and obtain clarification on information. "Doctors and surgery nurses present this information every day, so we don't always know how it sounds to someone who is experiencing a visit to a surgeon and discussing surgery for the first time," he admits. Patients will disconnect during the conversation, or they latch on to information they want to hear and stop listening to other information, he says. "A friend or family member can listen to the same information and remind the patient later about what was discussed," Gellman adds.

Advocate for procedures important

An advocate is especially helpful if the procedure is an outpatient procedure, says Gellman.

"People tend to think of an outpatient procedure as not very serious, but the reality is that they will be taking care of themselves as soon as they leave the surgery center, Gellman says, "so they need to understand care instructions more than an inpatient surgery patient does." Even before the surgery, a pre-admission visit to the surgery center with an advocate is very helpful so that the patient and the advocate know where it is located, what will happen on the day of surgery, and who will take care of the patient, he says.

While privacy concerns related to physician-patient confidentiality or Health Insurance Portability and Accountability Act (HIPAA) requirements might appear to discourage the use of advocates, Gellman points out that when the patient brings the advocate to the appointment, there are no problems. "I remind the patient that we will be discussing private information and ask them if they want the friend, family member, or advocate present," he says. "If they agree to the other person's presence, I proceed," he adds.

"I make a point of telling patients the process by simply explaining that they will go to the surgery center, a nurse will review their information, an IV will be inserted, an anesthesiologist will talk with them, and they'll go into the operating room," Gellman says. "When I describe each step, I know that they will not be anxious that they haven't met the anesthesiologist before they talk with a nurse because they know that meeting the anesthesiologist is not the first step." This type of simple description of the process should be repeated throughout the day of surgery to let patients know that everything is happening as it should, he suggests.

Another key to making sure patients understand discharge instructions is to keep the instructions simple, suggests Corina. Put basic wording on instruction sheets and make them easy to read, using bullet points and clear headings, she says. "I also don't think aftercare instructions should only be given at the time of discharge," she says. "If the patient is undergoing a common procedure, have the discharge instructions given at the time the patient is scheduled for surgery."

Discharge instructions should be given not only to the patient, but also to a family member or other advocate as well, points out Gellman. "The patient is still feeling the after effects of anesthesia and will not remember instructions or be able to ask questions about printed instructions," he says.

Be sure that your instructions address the most common aftereffects of surgery, suggests Corina. "Be specific about what the signs of infection are and when a patient should call with concerns," she says. "Also, be specific about who to call. Sometimes the surgery program staff can answer questions; other times, the surgeon must talk to the patient." The most common concerns usually are signs of infection and level or duration of pain, Corina adds.

"When I first started practicing and performing laparoscopic hernia repairs, I would hear from 80% of my patients who were complaining about not feeling well and being bloated," says Gellman. "As a new surgeon, I would have them come into the office to be seen, only to discover that they had not moved their bowels in four days." His calls decreased when he added more information for patients as they were discharged. "My discharge instructions now include directions to drink plenty of liquids and take milk of magnesia or prune juice to stimulate bowel movement after surgery to prevent this discomfort," Gellman says.


For more information about improving communication with patients, contact:

  • Ilene Corina, President, Persons United Limiting Substandards and Errors in Healthcare (PULSE) of New York, P.O. Box 353, Wantagh, NY 11793-0353. Telephone: (516) 579-4711. Fax: (516) 520-8105. E-mail:
  • Larry E. Gellman MD, FACS, North Shore Surgical Specialists, 310 E. Shore Road, Great Neck, NY 11023. Telephone: (516) 482-8657. E-mail:
  • The American College Of Physicians Foundation sponsored a conference "Practical Solutions to the Problem of Low Health Literacy" in November 2005. To access copies of presentations and links to other resources, go to
  • Persons United Limiting Substandards and Errors in Healthcare (PULSE) offers a patient safety brochure review service that gives health care organizations an evaluation of the clarity of their information from the perspective of nonmedical readers. For more information about this and other services offered by PULSE, go to Choose "About Us" on the left navigational bar, then choose "services." Scroll down to "To learn more about our Patient Safety Brochure reviewing capabilities, click here."