Why Using Pictures In Practice Can Improve Patient Adherence

A recent study on healthcare notes that “Communication is 55 percent visual, 37 percent vocal, and 7 percent verbal or the actual message.”¹ This is certainly true in our practices.

I recently had a patient I was treating for a fifth metatarsal base avulsion fracture. After four weeks of fracture boot treatment, she wanted to go back into her regular sneakers. She pleaded with me for permission, saying that the foot did not hurt anymore and stated she had even been doing activities out of the controlled ankle motion (CAM) boot that I prescribed her in the preceding weeks.

I stressed to her that she needed to remain immobilized for another two to four weeks due to the insufficient amount of time elapsed for fracture healing but she didn’t seem too interested. Before she left, I told her we would look at the images together, a practice I try to do with as many of my patients as possible.

“Oh, that’s the fracture?!” she muttered before I was even able to point it out to her. The tone in her voice said it all. She knew she was not ready for increased activity based on this visual cue showing her the image provided. I also provided her with two handouts on fifth metatarsal avulsion fractures with weightbearing protocols, reinforcing the six to eight weeks of protected weightbearing required.

I am a visual person and wanting to carry this into practice, I have implemented multiple methods of using pictures in practice. This extends from aforementioned handouts explaining different pathology or rehab and treatment protocols, drawing pictures to explain pathology, or using a foot model that is always within arm’s reach. Furthermore, I take the opportunity to show as many patients as possible their imaging whether it as  an X-ray, magnetic resonance image (MRI) or computed tomography (CT).  

I love when patients say they tried to “read” their MRI before a visit. It means they want to be involved in their care. They may not completely understand the MRI but they want to. It is important to explain to your patients, using a language they understand, what their images show in order to better explain their pathology. Use analogies. I do not think there is a day where I do not use half a dozen analogies during my patient encounters, many stolen from my fellowship mentor. Public health literacy is low with approximately 33 to 68 percent of Americans lacking an adequate level of understanding.² Techniques such as analogies may seem childish but patients often go “I never thought about it that way” or “Now that makes sense” because they can relate to it, and therefore understand it.

If we use analogies and pictures, patients feel the doctor has truly taken the time to explain to why they hurt or why they must adhere to a treatment plan. Not uncommonly, patients will take the drawing home to show their family. Or patients will want a copy of their imaging to show family/friends what the problem is now that they not only understand it, but can see it or “read” it. This empowers the patient.

In a study by Delp and Jones, patients treated in the emergency room for lacerations received post-care written instructions that either had (a) just text or (b) the same text with illustrations depicting the text.³ Three days later, researchers called the patients to ask if they read the information handed out. In comparison to the patients with only text, the patients with the text and illustrations were more likely to have read the instructions (98 percent versus 79 percent) and more likely to be adherent with the instructions (77 percent versus 54 percent).

There are other, more recent studies in the literature that demonstrate increased understanding and adherence based on the quality of information received.^3,4 These concepts were recently reinforced in other articles discussing the importance of clinician-patient communication.^2,5  

Pictures have the potential to improve comprehension, recall and, most importantly, adherence to a protocol.^3,4 I believe by using these techniques, my own patients have a better understanding of their pathology and treatment plan, affording them the ability to take a proactive role in their recovery. Ultimately, this improves patient outcomes and satisfaction, two goals of utmost importance to the treating physician.

Dr. Hood is a fellowship-trained foot and ankle surgeon. Follow him on Twitter at @crhoodjrdpm.

References

1. Peregrin T. Picture this: visual cues enhance health education messages for people with low literacy skills. J Am Diet Assoc. 2010;110(5 Suppl.):500,502,503,504,505. doi:10.1016/j.jada.2010.03.005.

2. Rosenbaum AJ, Uhl RL, Rankin A, Mulligan MT. Social and cultural barriers: understanding musculoskeletal health literacy. J Bone Joint Surg Am. 2016;98-A(7):607-615.

3. Delp C, Jones J. Communicating information to patients: the use of cartoon illustrations to improve comprehension of instructions. Acad Emegency Med. 1966;3(3):264-270.

4. Houts PS, Doak CC, Doak LG, Loscalzo MJ. The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence. Patient Educ Couns. 2006;61(2):173-190.

5. Black H. Clinical-patient communication: how personal connections can improve outcomes. Low Extrem Rev. September 2016; 16-22.