The following two clinical scenarios demonstrate how the lack of culturally competent communication can lead to inappropriate use of medication and bad clinical outcomes.

Clinical Scenario 1: Never underestimate the value of communication and demonstration when prescribing medicines.

A nine-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to have otitis media and was prescribed amoxicillin. The doctor gave the first dose to the infant in the office, demonstrating step-by-step how to deliver the medicine via syringe. At home, the father drew up the next dose without removing the syringe cap. He gave the dose to the child who suddenly had difficulty breathing and collapsed. When emergency medical services arrived, the child was intubated and transported to a children's hospital. At bronchoscopy, the syringe cap was found lodged in the trachea. Evaluation in the subsequent days revealed brain death. The infant was removed from life support and died shortly thereafter.

This case of misunderstanding of instructions for administration of medication raises two questions.

• How common are provider-patient misunderstandings regarding medication instructions?
• Could the pediatrician have done anything to prevent this unanticipated outcome?

First, clinician-patient miscommunication is common among all patient subgroups, but patients at greatest risk of not understanding medication instructions are those who do not speak English or have only limited fluency in English. These patients will struggle with written documents, but they will also have difficulty with oral communication in the clinical encounter.

It is probably a good idea not to assume that traditional instruction is uniformly successful and to develop a repertoire of teaching techniques to systematically reduce the likelihood of miscommunication and subsequent errors.

One of the simplest and most efficient means to enhance communication and reduce errors is the "teach-back" method (also known as the "show-me" approach or "closing the loop"). This method involves taking the extra step of asking the parent or patient to demonstrate how he/she would be drawing up and administering the medication. When using the teach-back method, you can phrase the request as "Can you show me how you're going to do this when you get home? I want to make sure I did a good job explaining this to you." Although physicians employ this method for only 13% of new medications, physicians who employ the teach-back method do not have longer visits than those who do not (Schillinger 2004).

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