If you’ve got to explain something to a patient, how do you do it?
If you have important information or complex ideas to share, how do you get it all across?
This is another in my series on patient education. I’ve talked about getting clear on what you’re teaching and how you’re assessing; on patient knowledge and misconceptions; and on how to shift gears when you can tell things just aren’t going well.
Multitasking, plus increasing EHR documentations requirements, often means less time with patients. And yet, how you spend this short time educating your patient has been shown to have an impact on numerous health outcomes, patient satisfaction, and patient engagement.
This is about having different ways to get your message across. Because people learn differently.
Quick planning for lasting impact
There are topics you explain frequently, some less frequently. This includes information and concepts, as well as ways of thinking, being, doing and acting.
We can call this your content. It’s what you’re trying to get across.
So here are 10 different ways to organize your content. Read through them, picking out the ones you lean on most frequently.
Then do yourself and your patients a favor, pick another (or two). Try using a different organizational structure for the same content. Because, I’ll repeat, people learn differently.
These are organizational structures that are common in everyday experience – in our conversations, in arts and media, in popular culture, in logic and argument, and more. You will recognize all of them. But I also throw in some twists, to expand your options.
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Cause-effect
Medicine relies on cause and effect relationships. Fortunately, we often think in cause and effect patterns in everyday life. Here’s an example from one study where a physician is explaining a metaphor he uses to illustrate the concept of inflammation–and the effect of a medication–using cause-and-effect:
“I explain that airways are like a plumbing system. Swelling of the tubes (inflammation) is like when the plumbing system gets obstructed, and prednisone cleans the tubing system.”
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Conditional
This is about probability, and reasonable expectation. Sometimes the conditional is phrased as an if/then statement, as it was by a physician in this study:
“If the cancer is still resistant to the cancer-fighting tools, other weapons are injected to attack the disease or to boost the body’s own defenses.”
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Parts to whole – whole to parts
A nurse was describing to me a topic she addresses often. After surgery, she explained, there is often a small part of an incision that is “left open without a drain if possible.”
Apparently, “patients can be worried about ‘the hole.’”
Therefore, she frequently was explaining to patients how wounds healed. She did this in a part-to-whole structure, where the ‘parts’ were the multiple layers of skin. “It’s the bottom layer that’s first to heal. I tell them, the last to heal is the surface [layer].”
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Temporally
There are many ways time enters our thinking. For purposes of organization, here’s a few: things may happen
- chronologically
- sequentially
- cumulatively
Chronologically is easy enough. But consider that events occurring over time also includes over our individual and collective history.
Such a framing might look like ‘we used to x, but then this happened, so now we y.’
In Atul Gawande’s Better, he uses temporal organization to explain an innovation made by a friend of his:
“…an experiment he had done as a young obstetrician at the University of Colorado in 1975. At that time, babies born two months prematurely or more were considered to have almost no chance to survive. Little, therefore, was done for them. For one year, however, he decided to treat those babies as if they would live…and they discovered that the vast majority of these premature babies, babies only two or three pounds in size, could survive to be normal and healthy” when the doctors “simply did everything they would normally do for a full-term baby” (p. 159-160).
For an example of a cumulative organization, we can turn to another physician in another book.
In the autoethnography After a Fall, author Laurel Richardson writes about the two-week inpatient rehabilitation period after she had broken her foot. When she asks how soon she can put weight on her healing foot, once it is in a walking cast, her surgeon answers her with a ‘cumulative’ kind of reply:
“Twenty-five percent weight—then fifty percent—then 100 percent weight…gradual increments as pain permits.” (p. 138)
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Compare/contrast
You know that comparing involves two like items or ideas. Obviously metaphor, simile, and analogy are helpful here. Contrasting takes up the ancient practice of illustrating what something is by showing what it is not. Venn diagrams are possible here as well, when there are both similarities and differences in two target groups.
Here’s an example from a physician, taken from a study on the use of metaphors and analogies in difficult conversations, that uses both compare and contrast:
“You know you can live with [ovarian cancer] for a long time. I mean, you can live with diabetes for 50 years. There’s a lot of diseases that we don’t cure, we just manage. Hypertension, right? We don’t cure it, we just give you a pill to take every day that keeps it under control.”
This physician compares ovarian cancer to diabetes, and then to hypertension. The contrast is between diseases that can be ‘cured’ and diseases that can be ‘managed.’
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General to particular
This may sound familiar, in terms of assessing or diagnosing. It’s common in everyday language as well.
The pyramid (or inverted pyramid) is often used to indicate hierarchical relationships. But it can also be used to show that a specific case is (or isn’t) a reasonable or plausible example of a general phenomenon.
That was the case when I spoke with an exasperated nurse who was ‘on phones’ at a physician practice, during flu season. She told me:
“People say they got the flu. When I ask their symptoms – Do you have fever? ‘No.’ Do you have a headache? ‘No. But I’ve been throwing up all weekend.’ That’s not flu.”
The particular conditions of individual patients did not plausibly represent the general condition of ‘the flu.’
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Spatially
Another common organizational scheme. Spatial arrangements can be from top to bottom, back to front, left to right. But don’t forget near to far.
This is a physician’s response using a spatial orientation across the knee and down the leg. It concerns a symptom cause in a palliative care consultation study,
“Down that pattern sort of across the knee and down towards the ankle is the L4 distribution and I think you’ve got pressure on the nerve and it’s making it numb.”
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Average
Sure, you use this already.
As an OB-GYN told me, part of her talk to moms in their 3rd trimester is:
“Most people have healthy babies. This is why I have you coming in all the time at 36 weeks. We’re checking you, and if we can get good care at this time, we can pretty much ensure all will go well at time of birth.”
Averages can indicate most common/least common relationships, as well as typical/atypical relationships, and “rules and exceptions.” It’s sometimes possible to talk about statistical significance. (Don’t forget those outliers.)
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Narrative
Tell a story – because narrative works! Researchers have long proved that as humans, we are hard-wired for story.
Narrative medicine is a robust field. Providers’ narratives of practice are being published in medical journals. Patients’ narratives are increasingly recognized for the insights they offer.
If your storytelling skills need a refresher, it can be quite simple.
Who’s your protagonist? It could be
- your patient (or a family member)
- a part of the body
- the disease/injury
- some aspect of the treatment
- you
You set the stage, there is some complication, a climax, and a resolution.
But this is just one possible narrative frame.
Sometimes, stories start in the middle of things. Oftentimes, there is not a straightforward narrative, but a looping back or a digression. There can be a loss of ground, a surprise twist, or an unintended consequence. And it’s ok to resist the pressure for a happy ending, every time.
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Chunking
This refers to organizing material in categories or chunks that hang together conceptually. Sometimes you know the categories ahead of time (a priori); sometimes you discover them as you go.
It’s the organizing structure I use in this article. (Bet you figured that out already.)
An important caveat here: I am not advocating a simple to complex arrangement. Despite its common sense appeal.
The notion that ‘you have to walk before you can run’ simply does not account for many of the ways people learn.
Such a breaking down can be helpful, after someone is familiar with a concept, to deepen their understanding. Like what I’m doing here. I’m showing you the simple (organizational structures) because you already know about the complex (teaching/learning).
Organizing your thoughts to share
At its most basic, this is about organizing your thoughts so that you can present them to someone else. You could think of these as examples of sense-making structures, or common patterns of thought.
Which ones do you tend to lean on? Which ones will you try as a backup?
And just a reminder – if at all possible also have a graphic, image, website, video. If not, have a pen in your pocket. Because multimodality helps.
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