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Tajwar Taher

Mansoor

NSF

8 October 2018

How We Treat and How We Teach

The physician exits the room, sighing with exasperation and disappointment. “It’s just

never enough time,” she says later, as her eyes scroll down the chart listing the patient’s

seemingly insurmountable health conditions. It has become common knowledge that the current

healthcare system – with its disproportionately low ratio of physicians to patients, the

administrative tasks on top of clinical duties, and emphasis on cost-benefit efficiency – is one

which apparently prevents the patient from realizing the full potential of their health since they

are limited to twenty-minute appointments. Particularly in the setting of Primary Care, where so

much depends on the physician’s ability to educate patients on methods to best take care of

themselves, the system seems to hinder patient learning and – by extension – patient outcomes.

However, Benedict Carey’s How We Learn suggests these frustrated assumptions may be

misguided, for “The modern institution of education, which grew out of those vestigial ways of

learning, has produced generations of people with dazzling skills…Yet its language, customs,

and schedules – has come to define how we think the brain works, or should work…We all

‘know’ we need to…concentrate on our work…yet it’s an ideal, a mirage, a word that blurs the

reality of what the brain actually does while learning,” (215). For all we may assume about how

the patient’s brain works based on the “schedules” Carey cites, the exploration of efficient

learning styles and strategies presented in his book oppose the conventional sentiments regarding

stunted patient appointments. Indeed, the administrative or logistical limitations resulting in short

clinical encounters may enhance patient learning as it follows Carey’s concepts of interleaving,

spaced learning, learning through forgetting, and the “Teach Back” method. Carey’s
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investigation not only justifies the current clinic model but also provides insight on specific

quality improvement measures to best support patient education.

The primary complaint of physicians is that limited encounter time prevents them from

exploring all a patient’s problems fully, yet Carey’s discussion on interleaving provides evidence

that a cluster of topics may aid patient education. He writes “Interleaving is a way of building

into our daily practice not only a dose of review but also an element of surprise,” (171). For the

patient, discussing their lived experience is a review, but as the doctor jumps from issue to issue

while providing their insight, the patient may be minutely surprised each time the doctor

switches topic. Forcing the brain to be hyperaware allows the patient to be present during the

encounter, with the rapidity of assorted topics requiring the patient to develop an understanding

of how the parts fit the whole – the parts being each individual issue and the whole being their

entire health.

If interleaving is harnessed properly by the physician – in that many topics are targeted in

short bursts of time – it may facilitate the patient’s understanding of holistic medicine and the

importance of prevention. Understanding that the physician’s discussion of diet might be related

to the separate discussion of hypertension management may help the patient change their health

behavior overall rather than focusing on one single issue. Such a conceptualization could

ultimately prove very beneficial for their long-term health. Of course, interleaving must be

utilized appropriately by the physician. Without “setting an agenda” the patient will be confused,

preventing learning. Agenda setting does not, however, dissipate Carey’s element of surprise as

it is the short time spent on multiple topics that defines the method. Interleaving already has a

place in the flow of the short clinical encounter and may prove beneficial for the patient’s long-

term health through enhancing their education.

A necessity of such limited encounter time is that follow-up visits are scheduled to

address topics that did not get their due or to continue monitoring certain conditions. As it turns

out, even though scheduling patients to be seen months later might feel like the progress of their

health education will be lost in the interim, Carey shows that spaced learning is beneficial for
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retention when he writes “If you’re told – three times in succession - …you remember it for a

while; if you’re told it three times, at ten-minute intervals, you remember it for longer,” (69).

When relating this process to the current healthcare system – taking for example the way

diabetics are scheduled at 3-month intervals to check their A1C and continue counseling – it is

clear that giving patients time to sit and engage with the content between visits fosters a greater

understanding of the material. If patients were to see their provider every day, it would rob them

of the opportunity to make their own meaning with the knowledge: how to incorporate and apply

lifestyle changes to their lives. With spaced follow up visits, patients practice the knowledge

themselves in anticipation for the next refresher with their physician.

To think that they will forget some information along the way is not an invalid

assumption, yet Carey argues that this is “a common, self-defeating assumption: To forget is to

fail. …It seems like the enemy of learning,” (22).” On the contrary, Carey dedicates an entire

chapter to “The Power of Forgetting” in which he details that although memories can fade and

become hidden behind the demands of the present, their “storage” and “retrieval” capacities are

heightened each time those lessons are brought back to the surface. The spacing of clinical

encounters is therefore critical for patients to have enough time to apply the material, forget the

material, “incubate” it as Carey later describes, and then – most importantly – create novel and

stronger neuronal pathways to further entrench the lessons in their mind with each cycle.

Of course, the cycle of clinic visits is not flat; more of a spiral staircase, the patient

progresses along a journey with a beginning and an end. A narrative is a consequence of follow-

up visits and the continuity of care, and a narrative is integral in consolidating and retaining

memory in Carey’s book. Early on he details the power of retention in the context of narratives

(8), and then goes on to describe how in a study looking at whether learning and testing in the

same environment influences retention, it was found that “divers who took the test underwater

did better than those who took it on land…maybe the bubbles streaming past the diving mask

acted as a cue…Or the fact that those semantic memories became part of an episodic one

(learning while diving),” (49). The physician has a great opportunity to facilitate the patient’s
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grasp of semantic memories regarding their health by crafting the narrative which creates the

patient’s episodic memory. Looking back at past encounters and summarizing for the patient

their progress thus far will reinforce topics which have been discussed in the past; looking

forward to future encounters by scheduling follow-up visits and providing an After Visit

Summary will give the patient a focus to apply new information and continue progressing on

prior goals. The current system is already set up naturally to allow for episodic memory to

flourish, and the physician using the system to its full potential may find their patients better

internalizing and applying lessons from each encounter over the course of their care.

Assessing whether these lessons truly are being learned by the patient is done at OHSU

using the “Teach Back” method. Many physicians may find that running out of time in the

encounter or falling behind schedule for their next appointment prevents them from doing a

Teach Back; it might also seem like an added responsibility with low priority because it requires

time and may seem redundant if the AVS is deemed sufficiently robust. However, Carey asserts

that “you don’t really know a topic until you have to teach it, until you have to make it clear to

someone else…expose what you don’t know, where you’re confused, what you’ve forgotten –

and fast. That’s ignorance of the best kind,” (102). It is a detriment to the patient’s health and a

waste of the physician’s time if the patient leaves and is unable to implement the shared plan

because they did not understand it. The system’s requirement of a Teach Back, though it might

seem burdensome to the physician, is an effective method for preventing patient non-adherence

and ensuring better patient health outcomes; should there prove to be deficits in the patient’s

knowledge, then the physician can immediately correct it and further enhance the patient’s

understanding.

It is also all too easy to mistakenly think one has full grasp of the information, as Carey

writes “The fluency illusion is so strong that, once we feel we’ve nailed some topic or

assignment, we assume that further study won’t help…Repeating facts right after you’ve studied

them gives you nothing, no added memory benefit,” (82). Asking the patient “Did that all make

sense?” may be the wrong question to ask because it does not assess what the patient actually
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knows, only the extent to which the fluency illusion has worked upon them. Physicians are good

enough at explaining to patients on their level, so – especially when repeating the information to

them again – the patient feels confident they’ve understood everything. However, since they are

not actively engaging with the material themselves, only passively receiving it, this confidence

masks the fact that no lasting learning has taken place. One might argue that the Teach Back is

nothing more than the repetition right after studying that Carey calls out as ineffective, but since

the Teach Back requires patients to describe their understanding in their own words, pure

parroting is avoided, and the patient is forced to cortically manipulate the information they have

been presented and commit it to long-lasting memory. The Teach Back, as frustrating it may be

for the physician pressed for time, is an effective prompt built into the current system that

reinforces patient learning and influences better patient outcomes.

Without the Teach Back too, the patient may not be forthcoming about their confusion.

Thus, this seemingly time-eating task not only prompts the patient to reveal what they know, but

also provides them a sense of empowerment. For the physician never utilizing Teach Back, their

patients may feel like Carey when he reflects “I remember longing or someone to tell me how to

proceed, sinking into a passive, tentative frame of mind, a fear of embarrassment trumping any

real curiosity or conviction. The result was that I rarely consulted the wisdom of the one thinker I

had easy access to: myself,” (144). Without the physician providing the patient an opportunity to

take part in their own learning through Teach Back, it may reinforce a paternalistic perception of

the physician. Robbing the patient of their own agency, the patient will find it far more difficult

to internalize health information and feel motivated to apply the knowledge for their own benefit.

As most physicians will agree, once the patient leaves the clinic it is on them to enact the plan

the physician has recommended. If the patient leaves “passive”, “tentative” and embarrassed then

there is less hope that that a good health outcome will be met. Of note too is the deficiency in

curiosity and conviction Carey describes, whose clinical correlate is the patient who becomes

non-adherent from lack of a driving spark to power them through. It is evident then, that the
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Teach Back method is a critical clinical tool to ensure a patient’s learning lasts and feels

empowered to apply that information, resulting in better patient outcomes.

Though the variety of structures like the Teach Back, short encounters, and spaced visits

already in place within clinics have demonstrated their utility in fostering patient learning, Carey

would agree that there is still much in design that could be improved to truly cater to patient

minds and maximize their learning. Already mentioned was Carey’s discussion on the

environmental impact on learning, about which he also states, “The more environments in which

you rehearse, the sharper and more lasting the memory of that material becomes – and less

strongly linked to one ‘comfort zone’” (224). While it is important to give patients a sense of

comfort while they seek healthcare since finding stability in setting can help balance the

instability of illness, with regards to their long-term health literacy or health goals it may be

more prudent to make changes to the clinic environment. Especially when thinking about

patients that have regular, frequent appointments but do not seem to be making advances in their

health goals, the fact that they come to a place that looks exactly the same each time may

reinforce the habits or mental frameworks that prevent them from progress.

Changing a visual cue – a new picture on the wall – or taking them to a different room

each time may be just the mental push needed to tip the patient out of a mental rut and towards

better understanding. Any challenge to the norm can push people to think deeper or differently,

as Carey writes “Each alteration of the routine further enriches the skills being rehearsed, making

them sharper and more accessible for a longer period of time,” (64). By implementing methods

like interleaving and Teach Back in a variety of settings or contexts, the provider avoids

presenting an encounter that the patient becomes familiar with. Once familiarity has been

established, the patient simply continues the same behavior; without a shift each time, without

something to prompt the patient to become hyperaware, they may not as actively engage with the

encounter’s content and therefore fail to create lasting and meaningful memories. In the interim

between clinic visits, it may be that one change in their environment or their routine that makes

the patient remember the new goal they set in clinic. While the current system has already
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incorporated many of the methods Carey cites as most effective for learning, there remains much

that can be improved to maximize patient education and ultimate outcomes.

Counterintuitive though it may seem, the logistical limitations or the additional cultural

ordinances physicians must implement in clinical encounters may have some beneficial influence

on patient outcomes. Short encounter times, spaced out visits, and the Teach Back method

parallel the ideas for efficient memory consolidation and retrieval that Carey describes in How

We Learn. If one theme emerges in the book, it is that humans learn best when assuming an

active role in their learning, a sentiment which pairs perfectly with the shift in healthcare to be

more patient centered. To be so, the healthcare system must not only ensure patients are

informed, but that they are being informed fully in the most efficient manner. Would it not be

better to make them captain of a ship with magnificent sails, than of one with nothing but oars?