Procedures

A digital audio recorder was placed in the examination room and started by a trained research assistant, who then left the room. After the visit ended and the provider left the room for the last time, the research assistant retrieved the recorder. The research assistant administered baseline measures to the parent/child dyad before and after the clinician-patient encounter as feasible in the context of the visit. Visit recordings were stripped of patient identifiers and tagged with a unique identifier for coding with the Roter interaction analysis system (RIAS).¹¹ At the end of the study, parents who had participated in the audio-taped encounters were invited to participate in focus groups to discuss their experience of doctor-patient communication. An expert in qualitative methods used a structured guide to facilitate two 60-minute focus groups with parents and one focus group with the four participating clinicians.

To enable analysis of encounters with and without Teach-back, we waited until midpoint through study recruitment to engage clinicians in a three-week series of one-hour interactive trainings in health literacy and use of Teach-back. During the first session, the principal investigator (IS) presented information about health literacy and methods used to improve communication, including principles of “living-room language”, “chunk and check,” and Teach-back. The video, “In Plain Language”⁹ was shown. Community-specific demographic data and known associations with health literacy were discussed. For reinforcement, participants were given a copy of “Help Patients Understand: A Manual for Clinicians.”² The second session focused on Teach-back. To demonstrate the technique and increase clinician’s skill without the bias of excessive content knowledge, interactive role plays were conducted where clinicians tried to teach each other a new instruction (e.g. “How to kill hair follicle fungus with sea salt). For reinforcement, a Teach-back prompt was added to the electronic medical record template in the “Plan” section for all patient visits, and a poster reminding clinicians to use Teach-back was placed in front of the provider desk in each exam room. During the third session, the group discussed their experience with using Teach-back over the preceding week, and discussed strategies they used to incorporate the technique in practice. For reinforcement, providers were reminded to review Teach-back with trainees and to include Teach-back as a measure during structured observations of resident visits.

After all audio-taped visits were completed (September 2010), focus groups were conducted with parents and clinicians regarding their perceptions of Teach-back. The study was reviewed and approved by the Institutional Review Board of Nemours; informed consent was obtained from clinicians and parents, and assent was obtained from children seven years and older. We report on a cross-sectional analysis of all audio-taped encounters completed over the course of the study. Then, we report on the qualitative analysis of the focus group data.