22 year old woman, first pregnancy, 13 weeks along. There's a lot to accomplish at this visit! I'm shadowing about ten minutes in, and the doctor is on a roll. She has great advice for ways our patient can keep herself healthy and get the care she needs, and the advice keeps on coming and coming. The patient looks completely zoned out. She won't remember any of it.

I've never been the kind of person who gets much out of a lecture, so I was sympathetic to this young woman being talked at. The resident wasn't wasting words, but there was too much being said to absorb. So I wrote down the important points for the patient, line by line, and hopefully she can interpret my scrawls well enough to remember to get her EKG.

After the visit, I was in the team room, and the resident and intern were talking about how much they have to counsel their patients. After the previous visit, I was surprised to hear that they wanted more time to talk at their patients. "There's so much to teach, and so little time!"

I couldn't help myself. "But how much of that actually sticks?" (A professor of mine taught me to ask this question. She said, "I want you to understand x and y from this lecture. The rest are details to understand, not to memorize." Two years later, I understand x and y and remember nothing more. From countless other lectures that did not emphasize what was important, I remember nothing.)

The resident's reply surprised me even more. "Not much probably, but I can put it in the chart and, if there's a problem later, know it's been said." I was taken aback. On one hand, she is hemmed in by a legal system that has her checking boxes at each visit. On the other hand, if something won't be remembered, why say it? Yes, the patient can access her notes in the patient portal, and yes, there are handouts that may jog her memory. But there has to be a better way.

Patient counseling is analogous to student teaching. I've had a lot of professors over these past few years -- over 300, probably -- and I've seen a lot of different styles. You know what doesn't work? Shouting facts at people. One braggadocious physician said at the beginning of his lecture, "Y'all are gonna learn today!" then proceeded to talk quickly and loudly for two hours straight. I didn't learn much that day. Another guy (why is it always men?!) gave eight hours of hematology lectures in one day. From hour five, my brain was effectively off.

Just because something is said does not mean it is understood. Maybe those professors can go home proud of all the correct things they said that day, but what good is a teacher if the learners don't learn? Same goes for the doctor. Do our words really count if they are meant only to pad the chart?

Yes and no. I'm not saying the patient must remember every single word, and it's important to avoid being sued, but there's an element of teaching in doctoring which seems to be largely ignored. Saying words doesn't make them heard!

So what's the solution? Here are some ideas which I'll channel in the coming days:

- speak concisely and summatively, and say what's most important. Watch out for the weeds!

- first, ask what they know, e.g. "You may have heard that you shouldn't eat certain foods while pregnant. Do you know which ones those are?"

- provide handouts reviewing and maybe building on what's been said

- if there are specific things that a patient needs to do, write down a simple bullet point reminder for each

- check for comprehension (probably only enough time to do this for very important topics, like consent for a procedure)

- consider saving less-urgent complaints for a future visit

Of course these ideas will be complicated by language, reading comprehension, and potential future adherence. But I think being cognizant of how our patients or students are receiving our words is a great place to start.

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