A method to quantify and compare clinicians' assessments of patient understanding during counseling of standardized patients

Michael H. Farrell, Pramita Kuruvilla, Kerry L. Eskra, Stephanie A. Christopher, Rebecca S. Brienza

Research output: Contribution to journalArticlepeer-review

29 Scopus citations


Objective: To introduce a method for quantifying clinicians' use of assessment of understanding (AU) questions, and to examine medicine residents' AU usage during counseling of standardized patients about prostate or breast cancer screening. Methods: Explicit-criteria abstraction was done on 86 transcripts, using a data dictionary for 4 AU types. We also developed a procedure for estimating the "load" of informational content for which the clinician has not yet assessed understanding. Results: Duplicate abstraction revealed reliability κ = 0.96. Definite criteria for at least one AU were found in 68/86 transcripts (79%). Of these, 2 transcripts contained a request for a teach-back ("what is your understanding of this?"), 2 contained an open-ended AU, 46 (54%) contained only a close-ended AU, and 18 (21%) only contained an "OK?" question. The load calculation identified long stretches of conversation without an AU. Conclusion: Many residents' transcripts lacked AUs, and included AUs were often ineffectively phrased or inefficiently timed. Many patients may not understand clinicians, and many clinicians may be unaware of patients' confusion. Practice implications: Effective AU usage is important enough to be encouraged by training programs and targeted by population-scale quality improvement programs. This quantitative method should be useful in population-scale measurement of AU usage.

Original languageEnglish (US)
Pages (from-to)128-135
Number of pages8
JournalPatient Education and Counseling
Issue number1
StatePublished - Oct 2009
Externally publishedYes

Bibliographical note

Funding Information:
MF is supported in part by grants K01HL072530 and R01HL086691 from the National Heart, Lung, and Blood Institute. When the project was begun, PK was a medical student in the Yale University School of Medicine in New Haven, CT.


  • Communication
  • Health literacy
  • Mammography
  • Physician-patient relationship
  • Prostate-specific antigen


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