Take note

Patients at University of Michigan's University Hospital are given bedside notepads to encourage discussions about care.

Where: University of Michigan's University Hospital, a 610-bed academic medical center in Ann Arbor, Mich.

The issue: Improving patient-physician communication.


During medical school, Aaron S. Farberg, MD, took a class that changed his perspective on communication between physicians and patients. “Every med student [got] paired up with a chronically ill patient and [saw] them over a series of months,” explained Dr. Farberg, who is now a surgical resident at the University of Michigan. In his interactions with his patient, he noticed that “chronically ill patients, they develop techniques to deal with the health care system and one of them is taking notes. The problem is that they don't figure out to do that until two, three years into it.”

Working together with a classmate, Andrew M. Lin, MD, Dr. Farberg came up with a method to nudge more inpatients to take notes regarding their health care earlier on in their treatment.

How it works

The Michigan team designed notepads titled “Dear Doctor” at the top, with sections below labeled for diagnosis and treatment, tests and procedures, and medications. “We had [the notepad] placed by the janitorial staff in the hospital when they would clean up the room,” said Dr. Farberg.

Neither clinicians nor patients were given any specific instructions on the use of the bedside notepads. “The patient could use it however they wanted to, if they wanted to take notes on their diseases, write down their medications, or I remember one patient used it to play tic-tac-toe with their kid,” said Dr. Farberg.

The design of the notepad, with an example question in each section, encouraged patients to use it for communicating about their care, and some clinicians may have instructed their patients to do so. “We did mention to the nurses and the residents on the units that we were trialing these on, that these notepads are there, use them as you may,” said Dr. Farberg.


In that trial, about half (47%) of the 440 patients who received notepads used them. Compared to a control group of patients, they were more likely to take notes during their hospital stay and to feel that they had their questions answered by their physicians, according to results published online on Aug. 28 by the Journal of Hospital Medicine.

The intervention didn't change overall patient satisfaction ratings of communication during the hospital stay, but in a survey about the notepads, all of the patients who used them said that their communication with physicians had been enhanced.

“Just having this notepad here, they thought they had a better experience or had more of their questions answered,” said Dr. Farberg. “The fact that it was able to improve people's perception of their health care was quite surprising to us.” It was not surprising that overall patient satisfaction numbers didn't budge, considering that study was small and the ratings were already high, he added.

How others benefit

Another sign of the project's success was the notepads' unplanned spread across the hospital. “Other nurses would steal them and take them to their floors and give them to their patients,” said Dr. Farberg.

An anecdotal report helped explain the phenomenon. “One of the nurses said that this saved her paging the doctor team a dozen times throughout the day because if it was a nonurgent question, rather than paging the MD, they would tell the patient to write down the question,” he said.

Next steps

After the trial was complete, the notepad concept spread through the health system by more official channels. “The cardiovascular center here has now purchased a notepad for every patient that's admitted,” said Dr. Farberg. “There are lots of different variations. Our ICU now has an entire journal book. Our children's hospital has their own notepad that they created.”

The project has even made an unofficial move into the outpatient setting, where Dr. Farberg also sees it having potential benefits. “My mom got a couple of these and she brought [one of] them to her doctor's office every time she would go,” he said.