Does Your Patient Understand Their Treatment Plan? Factors Affecting Patient Understanding of Their Medical Care Treatment Plan in the Inpatient Setting

Abstract

The empathy and quality of communication between the physician and patient is believed to correlate with patient satisfaction and knowledge of the diagnoses and treatment plan. Examining patients’ understanding of their plan can allow providers to better aid patients upon their discharge from the hospital in the hopes of improving home care compliance. We sought to evaluate factors that we hypothesized to have an impact on a patient’s ability to understand their medical management plan in the inpatient setting. Over a 14-month period, patients were given a 10-question survey during their stay on the inpatient medical units at a safety-net tertiary care community hospital. The survey was given to patients to self-complete after our research team introduced it. A total of 366 patients were surveyed. Of the patients surveyed, more than two-thirds of participants had a clear idea of the management plan for their condition (68.5%), while 3.1% had no knowledge of their management plan. Significant associations between knowledge of the management plan and participants knowing their attending physician’s name ( P < .0005), participants having a primary care physician ( P < .0001), and educational background ( P < .0387) were found. These assessed factors can be addressed with quality communication and a strong patient–physician relationship. Accomplishing these 2 objectives with the gained knowledge of patient beliefs and perceptions from our study will likely lead to the patient having a much clearer idea of how their medical condition is being treated by his/her team and have overall positive health implications.

Full text

Research Article
Does Your Patient Understand Their
Treatment Plan? Factors Affecting
Patient Understanding of Their
Medical Care Treatment Plan
in the Inpatient Setting
Joseph Toole, DO
1
, Michelle Kohansieh, BA
2
,
Umer Khan, MD
3
, Sandor Romero, MD
4
, Mounir Ghali, MD
5
,
Roman Zeltser, MD
6,7
, and Amgad N Makaryus, MD
6,7
Abstract
The empathy and quality of communication between the physician and patient is believed to correlate with patient satisfaction
and knowledgeof the diagnoses and treatment plan. Examining patients’ understanding of their plan canallow providers to better
aid patients upon their discharge from the hospital in the hopes of improving home care compliance. We sought to evaluate
factors that we hypothesized to have an impact on a patient’s ability to understand their medical management plan in the
inpatient setting. Over a 14-month period, patients were given a 10-question survey during their stay on the inpatient medical
units at a safety-net tertiary care community hospital. The survey was given to patients to self-complete after our research team
introduced it. A total of 366 patients were surveyed. Of the patients surveyed, more than two-thirds of participants had a clear
idea of the management plan for their condition (68.5%), while 3.1% had no knowledge of their management plan. Significant
associations between knowledge of the management plan and participants knowing their attending physician’s name (P<.0005),
participants having a primary care physician (P< .0001), and educational background (P< .0387) were found. These assessed
factors can be addressed with quality communication and a strong patient–physician relationship. Accomplishing these 2
objectives with the gained knowledge of patient beliefs and perceptions from our study will likely lead to the patient having a
much clearer idea of how their medical condition is being treated by his/her team and have overall positive health implications.
Keywords
patient satisfaction, communication, patient-physician relationship, patient feedback
Introduction
Open and clear communication between the physician and
patient is paramount to the delivery of excellent health care.
The empathy and quality of this communication correlates
with patient satisfaction and knowledge of the diagnoses and
treatment plan (1,2). Patient understanding of their medical
management plan helps enhance outcomes by improving
compliance with treatment plans. Furthermore, the patient’s
knowledge of their plan helps open up a line of communi-
cation with their physician to better help tailor a plan that
best suits the patient’s physical, emotional, social, and eco-
nomic states (3). Examining patients’ understanding of their
plan can allow providers to better aid patients upon their
discharge in the hopes of improving home care compliance
and decreasing readmission rates.
1
Department of Internal Medicine, Northwell Lenox Hill Hospital,
New York, NY, USA
2
Stern College for Women, Yeshiva University, New York, NY, USA
3
Lehigh Valley Health Network—Pocono, East Stroudsburg, PA, USA
4
Kendall Regional Medical Center, Miami, FL, USA
5
University of Michigan Health, Ann Arbor, MI, USA
6
Department of Cardiology, Nassau University Medical Center, East
Meadow, NY, USA
7
Department of Cardiology, Donald and Barbara Zucker School of
Medicine at Hofstra/Northwell Health, Manhasset, NY, USA
Corresponding Author:
Amgad N Makaryus, Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell Health, Department of Cardiology, Nassau University
Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA.
Email: amakaryu@numc.edu
Journal of Patient Experience
1-7
ªThe Author(s) 2020
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For the above reasons, we aimed to evaluate certain
factors that we hypothesized to have a correlation with a
patient’s understanding of their medical management plan.
These specific factors included patients knowing the name
of their physicians, utilization pattern of a primary care
physicians (PCP), and level of education. Something as
simple as the patient knowing their physician’s name is
often overlooked when it comes to physician interaction
with patients. Studies have shown that patients do not know
the name of their physician as well as physicians may think
(4,5). The revolving door of physicians that a patient may
encounter while admitted to the hospital can be quite inti-
midatingandconfusingforthepatient.Thiscanleadtothe
patient not knowing which doctor is from what service and
thus eroding their ability to understand their medical man-
agement plan. Our aim is to directly look at the impact of
the factors assessed in our survey upon patients’ under-
standing of the medical management plan, something that
has not been well studied in the past, with the anticipated
hypothesis that the understanding of these factors along
with their amelioration will improve patient understanding
of their medical management plan and thereby lead to pos-
itive outcomes.
Follow-up with a patient’s PCP can help augment a
patient’s understanding of their medical conditions and treat-
ment plans. Few recent studies have looked at the direct
correlation between medical understanding and the pattern
of PCP usage. We are looking to see whether increased use
of a PCP can lead to better patient understanding of their
inpatient medical management plan. The anticipated hypoth-
esis for further evaluation would lead to a positive correla-
tion between PCP usage and understanding of the
management plan. We believe repetition of discussion about
a patient’s health problems with a PCP will inevitably lead to
an improvement in that patient’s understanding of how their
problem is managed.
Primary care physician usage and educational level go
hand-in-hand when it comes to health literacy. There have
been a plethora of studies showing the impact that a lack of
health literacy has on poor understanding of counseling and
other instructions given by health care providers and the
negative outcomes associated with this (6,7). Improvement
in the delivery of the communicated plan to patients, espe-
cially those of limited health literacy, would likely lead to
improved outcomes.
Patients’ knowledge of the diagnosis and treatment
plan is a central component of patient education and is
a crucial part of the Patients’ Bill of Rights (8). For
patients to be active decision makers in their own man-
agement plans, patients should be aware of all essential
aspects of their plans, which can be achieved by having
quality communication with their physicians. We sought
to evaluate the above factors’ impact on a patient’s ability
to understand their medical management plan in the inpa-
tient setting.
Methods
Over a of 14-month period, patients were given a 10-
question paper survey during their stay on the inpatient
medical units at a 531-bed tertiary care community hospital
that is the safety-net hospital for the local area. The patients
were given paper surveys (Table 1) to self-complete. Our
institutional review board provided approval for this study
prior to survey administration. The survey’s answer choices
had an accompanying sentence to define what that choice
meant; this can be seen in Table 1. While many of our
questions assess basic patient characteristics, other ques-
tions aim to assess essential factors to the patient–physician
relationship such as recognition of name, understanding of
ways patients would like to be treated and cared for, and
overall understanding of patient perceptions of the health
care system. The surveys were administered at nonuniform
time periods during the patients’ care. The survey was
available in English and Spanish. For patients who were
unable to see or write, they were verbally administered the
survey by one of our researchers. Each patient was first
screened to see whether they were capable of answering
questions posed by our survey by establishing orientation
to person, place, and time. Patients who were unable to
satisfy the orientation requirements were excluded due to
possibility for inaccurate information skewing the results.
The following were also excluded: patients diagnosed with
a terminal condition, patients diagnosed with a psychiatric
condition, patients diagnosed with a continuing substance
abuse problem including alcohol, those who are “do not
resucitate” (DNR), those under the care of the researchers,
or those with a recorded pain score of 4 or greater as per
current progress notes. These were the chosen exclusion
criteria as each factor could alter the perception of how a
patient viewed his/her management plan as well as alter
their emotional state. All patients on non-intensive care
unit medical floors that did not fall into the exclusion cri-
teria above were evaluated.
Descriptive statistics (frequency, percentage, mean,
standard deviation, median, quartiles) were used to
describe the sample of patients and their survey responses.
For categorical demographic factors, the w
2
test or the
Fisher exact test, as appropriate, was used to examine the
association between demographic factors and (binary or
nominal) survey questions. The Mann-Whitney Utest or
the Kruskal-Wallis test (for more than 2 groups) was used
to compare ordinal survey questions (ie, medication com-
pliance) between demographic factors. For continuous
demographic factors (ie, age and day of hospital stay),
logistic regression was used to model binary survey ques-
tions as a function of each demographic factor. Nominal
survey questions with more than 2 categories were modeled
using multinomial logistic regression as a function of each
demographic factor. Spearman correlation coefficient was
used to examine the relationship between ordinal survey
questions and continuous demographic factors. The w
2
test
2Journal of Patient Experience

Table 1. Survey Questionnaire Presented to the Patients.
Question 1 – How best would you describe your knowledge of HOW your medical team is handling your medical problem?
cI have a clear idea of the management plan for my condition. I understand my diagnosis/possible diagnosis, planned tests and what the
medical team is doing to treat it
cI have some idea of the management for my condition. I have some understanding of my diagnosis/possible diagnosis, planned tests and
what the medical team is doing to treat it
cI have no knowledge of what my diagnosis/possible diagnosis is, the planned tests and what is being done to treat it
Question 2 – Nassau University Medical Center is a teaching hospital. Medical students and residents accompany the attending physician in
patient rooms forming a large group entering your room. What best describes your HONEST VIEW on this:
cIt is ok for residents and students to accompany attending doctors forming a large team. I am comfortable with this.
cI am uncomfortable with a large team entering my room
cIt is not ok for large groups to enter my room
Question 3 – How much information do you want to know about your management at the hospital? Please select what best describes your
requirement:
cI want to know all details available to the doctors. This includes essential and nonessential lab results and other investigations (all test
results)
cI want to know information that is essential about my condition and care
cAs long as I am getting better, I don’t really care
Question 4 – Do you have a primary care physician (general medical doctor)?
cYes I do and I see my doctor regularly
cYes I do but I do not go to every appointment
cYes I do but I only go when I am sick
cNo I do not have a primary care doctor
Question 5 – Do you take your medications as prescribed at home? What percentage BEST describes your compliance with your
medication:
c100%
c90%
c60%-80%
c50%
c20%-40%
c10%
c0%
Question 6 –
cMost likely reason/reasons why I may not take my medications as prescribed. Check all that apply:
cI always take my medication. This question does is not apply for me.
cMedicines that cost too much
cNo reason in particular, I am just lazy
cWhen I just forget to take my medication
cWhen I am worried about side affects
cWhen I don’t think I need the medicine even if the doctor wants me to take it
cI start to take my medication as prescribed, and then I lose interest
cWhen I forget to refill my prescription
cWhen I run out of refills
cWhen I don’t feel my medications are working/treating my condition
cWhen I don’t know/cannot understand instructions on how frequently or how much I should take
cWhen I have to take medications many times a day
cWhen I feel like being my own doctor and change the amount or frequency of medicines myself
cWhen I don’t like the doctor who prescribed the medication
Question 7 – Do you know the name of your attending physician involved with your care?
cYes
cNo
Question 8 – Do you know the name of the resident doctor (junior physician) involved with your care?
cYes
cNo
Question 9 – Do your primary team of physicians introduce themselves by?
cTheir name
cTheir name and business card
cThey have not told their name
Question 10 – How much medical terminology does your doctor use that you are not able to understand?
c1 - My doctor explains everything in plain language and whenever the doctor uses medical terminology, it is followed up with a clear
explanation. I hardly ever have to ask for a clarification.
c2 - My doctor explains most things in plain language and explains medical terminology most of the time. I sometimes have to ask for an
explanation.
c3 - My doctor does not explain in plain language and uses medical terminology a lot without explaining. I frequently have to ask for an
explanation.
Toole et al 3

or Fisher exact test, as appropriate, was used to examine the
association between survey questions of interest. All anal-
yses were conducted using SAS
®
version 9.4.
Results
A total of 366 patients were surveyed and responses to select
questions are noted in Table 2. Approximately half of the
patients (184) were women. Detail on the study population
education level and ethnicity is noted in Tables 3 and 4,
respectively. Of the patients surveyed, more than two-
thirds of participants had a clear idea of the management
plan for their condition (68.5%); meaning that patients
understood their diagnosis, planned tests and the medical
team’s treatment plan. Another 28.4%had some idea of their
management plan. However, only 3.1%had no knowledge of
their management plan (question 1).
Approximately two-thirds of participants had a PCP and
saw them regularly (64.4%). A smaller percentage of the
participants (6.4%) had a PCP but did not go to every
appointment, and 11.1%had a PCP but only went when they
were sick. The remaining 18.1%did not have a PCP at all
(question 4).
Almost half of the participants (48.6%) knew the name of
the attending physician involved with their care, the other
51.4%did not know the name of their attending physician
(question 7). A large majority of participants did not know
the name of the resident doctor involved with their care
(70.2%); while the minority (29.8%) knew the name of the
resident physician (question 8). Percentage breakdown of
select answer results is presented in Table 2.
There was a significant association between participants
having a PCP and the participants’ knowledge of how the
medical team is handling their medical problem (P< .0001).
Specifically, participants who only saw their PCP when sick
were less likely to have a clear idea of their management
plan (37.5%) as compared to participants who saw their PCP
regularly (76.4%). The definition of regularity is influenced
by diagnoses and comorbidities. For healthy patients with no
risk factors or diagnosed diseases, regularly could mean once
a year. For patients diagnosed with hypertension, regularly
could mean every 2 months. There was also a significant
association between age and PCP usage (P< .0006).
Table 2. Select Percentage Breakdown of Answers to the Survey Questionnaire.
Question 1 – How best would you describe your knowledge of HOW your medical team is handling your medical problem?
cI have a clear idea of the management plan for my condition. I understand my diagnosis/possible diagnosis, planned tests and what the
medical team is doing to treat it – (68.5%)
cI have some idea of the management for my condition. I have some understanding of my diagnosis/possible diagnosis, planned tests and
what the medical team is doing to treat it – (28.4%)
cI have no knowledge of what my diagnosis/possible diagnosis is, the planned tests and what is being done to treat it – (3.1%)
Question 4 – Do you have a primary care physician (general medical doctor)?
cYes I do and I see my doctor regularly – (64.4%)
cYes I do but I do not go to every appointment – (6.4%)
cYes I do but I only go when I am sick – (11.1%)
cNo I do not have a primary care doctor – (18.1%)
Question 7 – Do you know the name of your attending physician involved with your care?
cYes – (48.6%)
cNo – (51.4%)
Question 8 – Do you know the name of the resident doctor (junior physician) involved with your care?
cYes – (70.2%)
cNo – (29.8%)
Table 3. Education Level of Patients Responding to the Survey
Questionnaire.
Education
Education Frequency Percent
Cumulative
frequency
Cumulative
percent
College degree 116 32.04 116 32.04
High school 199 54.97 315 87.02
Middle school 21 5.80 336 92.82
Elementary 20 5.52 356 98.34
No formal
schooling
6 1.66 362 100.00
Frequency missing ¼4
Table 4. Ethnicity of Patients Responding to the Survey
Questionnaire.
Ethnicity
Ethnicity Frequency Percent
Cumulative
frequency
Cumulative
percent
Caucasian 149 40.71 149 40.71
Hispanic 73 19.95 222 60.66
African American 98 26.78 320 87.43
Asian 8 2.19 328 89.62
Haitian/Caribbean 12 3.28 340 92.90
Native American 10 2.73 350 95.63
Arab 2 0.55 352 96.17
Other 6 1.64 358 97.81
Indian 3 0.82 361 98.63
Multi 5 1.37 366 100.00
4Journal of Patient Experience

Specifically, with each 10-year increase in age, the odds of
having a PCP seen regularly as compared to not having a
PCP increased by 36%(odds ratio: 1.36, 95%CI: 1.15-1.60;
P< .0003). In addition, a significant association between
gender and having a PCP (P< .0286) was noted. Specifi-
cally, males were more likely to not have a PCP (23.89%)as
compared to females (12.22%)
There was also a significant association between educa-
tional background (Table 3) and the participants’ knowledge
of how the medical team was handling their medical problem
(P< .0387). Specifically, participants with less than a high
school degree were less likely to have a clear idea of their
management plan (54.6%) as compared to those with a high
school degree (70.0%) and those with a college degree
(73.0%).
There was a strong correlation (P< .0005) between par-
ticipants knowing their attending physician’s name and their
knowledge of how the medical team’s treatment plan. Spe-
cifically, participants who knew the name of the attending
physician were more likely to have a clear idea of their
management plan (78.5%) as compared to participants who
did not know the name of the attending physician (59.6%). A
similar significant association between participants knowing
their resident physician’s name and the participants’ knowl-
edge of how the medical team was handling their medical
problem was found (P< .0114).
Our data also showed some interesting nonsignificant
correlations when it came to patients’ understanding of their
medical management plan. We found that there was no sig-
nificant correlation between age, gender, ethnicity, English
language proficiency, or days in the hospital with patients’
understanding of their care plan.
Discussion
Although more than two-thirds of our patients (68.5%) had a
clear idea of the management plan for their condition, we
wanted to see which factors influenced these data. Having
patients aware of their medical plan helps foster a better
patient–physician relationship, which leads to improved
patient outcomes (9). The main factors that we found to have
the most significant impact on the patient’s knowledge of
their medical plan were the pattern in which these patients
utilized their PCP, the patient’s level of education, and
knowledge of their attending and resident physician’s name.
We did find that ethnicity (Table 4) played a significant
role in the pattern of PCP utilization. Specifically, Caucasian
participants were most likely to have a PCP who they see
regularly (74.5%) as compared to African Americans
(64.3%), Hispanics (52.1%), and others (52.3%), while the
Hispanic participants were most likely to not have a PCP. A
study by Shi (10) found paralleling results showing that
American minorities were more likely to have their first-
contact aspect in a hospital setting rather than a private clinic
compared to Caucasian Americans. Our results also found
that 18.1%of our participants did not have a PCP. This
statistic is similar to what the Henry J. Kaiser Family Foun-
dation (11) found during their 2016 national survey. In that
survey, they found that 17.3%of American adults did not
have a place of usual medical care.
The relationship between PCP utilization and the
patient’s knowledge of their medical plan points to the
development of a knowledge base via the frequency of expo-
sure. The patients who visit their PCP on a regular basis, as
per their medical conditions, risk factors, and comorbidities,
are exposed more frequently to their medical problems and
the ways by which their problems are managed. Theoreti-
cally, this knowledge base is what allows the patients, who
visit their PCP regularly, to better understand the plan set
forth by the hospital’s treatment team. This statistical rela-
tionship only strengthens the importance of patients having
regular access to PCPs.
As anticipated, there was a significant positive correlation
between the patient’s level of education and their knowledge
of the treatment team’s plan for their medical problem. This
emphasizes the need for increased communication and time
clarifying the plan to patients with lower levels of education.
Effective and quality communication between the physician
and patient has been shown to positively influence emotional
and physical health statuses of patients (3,12,13). A study by
Bartlett et al (14) found that quality patient–physician com-
munication influenced patient outcomes and satisfaction
more than quantity of teaching and instruction. The practice
of quality communication ties into the last two significant
factors in our study, which are the patient knowing the name
of their attending and resident physicians.
Attending and Resident physician names were chosen, as
they were the ones leading the medical management deci-
sions for patients. Patients who knew the names of their
physicians had a higher chance of having a clear idea of their
management plan. Our data indicate that a patient knowing
the names of the professionals treating them does assist in
the understanding of their medical care plan. A patient
knowing their physician’s name is just the first step in cre-
ating that quality relationship. A way to improve this area is
to have physicians provide their name in writing, for exam-
ple, on a business card, to patients; that way patients can
refer back to it as needed. This solution is supported by
Makaryus and Friedman (5) where they found that 14.7%
of patients were unable to correctly recite their physician’s
name. However, after they made a specific effort to have a
smaller group of patients remember their physician’s name,
more than 75%of the patients were able to do so, compared
to our study’s 29.8%. Physicians at a teaching hospital have
to do a better job at also identifying what level physician
they are (Santen et al [15]). In that study, as many as 93%of
resident physicians failed to identify their level of training
and 94%of attending physicians failed to do the same (15).
Especially in a teaching facility, this lack of introduction
makes it tough for patients to know who is actually in charge
of their treatment, thus eroding the crucial patient–physician
relationship. Furthermore, emphasizing to patients the
Toole et al 5

importance of knowing the physician’s name can also help
improve this area (4).
We recognize a limitation of our study is that there are
more factors not touched upon in our survey which play a
critical role in a patient’s understanding of their care.
Follow-up data postdischarge would need to be collected
in order to better illuminate the degree of home care com-
pliance in our patients and further long-term follow-up
would delineate actual influences of our survey findings on
outcomes.
Conclusion
The factors that significantly impacted a patient’s knowl-
edge of their medical treatment plan in our study revolve
around quality communication between the patient and their
physicians. This includes even the simple physician name
recognition by the patient. Even though the level of educa-
tion does not rely upon the communication in a patient–
physician relationship directly, the physician must take the
patient’s level of education into account when attempting to
develop a quality rapport with the patient. With quality com-
munication and a good patient–physician relationship in
place, the patient will likely have a much clearer idea of how
their medical problem is being treated by his/her team. Fur-
ther research is necessary to examine whether, with this
improved knowledge of their condition, a patient may be
able to improve their own self-care and improve health out-
comes after discharge from the hospital. We believe if steps
are taken to improve the patient’s PCP usage and name
recognition of their physicians, then we could see improve-
ment in home health care compliance and possibly a
decrease in readmission rates leading to improved medical
treatment outcomes.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Joseph Toole, DO https://orcid.org/0000-0001-6802-9983
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Author Biographies
Joseph Toole is a second year Internal Medicine resident in New
York City. He is planning on pursuing a Cardiology fellowship
after his residency.
Michelle Kohansieh is a third year MD candidate at Albert Ein-
stein College of Medicine. She completed her BA in biology at
Stern College for Women at Yeshiva University. She has previ-
ously conducted and published research in cardiac imaging and the
effects of sleep on heart health.
6Journal of Patient Experience

Umer Khan is an internal medicine specialist in East Stroudsburg,
PA. He is affiliated with the medical facilities at Lehigh Valley
Hospital-Pocono and Wilkes-Barre General Hospital.
Sandor Romero is an internal medicine specialist in Homestead,
Florida. He is affiliated with Kendall Regional Medical Center.
Mounir Ghali is the director of the Interventional Pulmonology
Division at Metro Health University of Michigan Health. He com-
pleted his Interventional Pulmonary fellowship at Cooper Univer-
sity Hospital.
Roman Zeltser is the associate Chair of the Department of
Cardiology and the cardiovascular fellowship program director
at Nassau University Medical Center in East Meadow, NY. He
is also an associate professor of Cardiology at the Donald and
Barbara Zucker School of Medicine at Hofstra/Northwell. His
interests include medical education, non-invasive imaging and
clinical research.
Amgad N Makaryus is the Chair of the Department of Cardiology
and the associate cardiovascular fellowship program director at
Nassau University Medical Center in East Meadow, NY. He is also
a professor of Cardiology at the Donald and Barbara Zucker School
of Medicine at Hofstra/Northwell. His interests include medical
education and clinical research for the ideal application and inte-
gration of multimodality cardiovascular imaging into the appropri-
ate diagnosis and management of patients with and at risk for
cardiovascular disease.
Toole et al 7