We have argued in other articles that the persistent use of jargon is one of the most important reasons for the existence of the knowledge gap between the voice of medicine and patients. It prevents the layperson from accessing, processing and acting upon treatment instructions. This inhibits patient empowerment, disables shared decision-making and blows wide open any claim to elevate the Patient Voice.

However, there are occasions where written patient information contains instructions that seem simple and easy to understand on a surface level. Yet, these can mask deeper doubts and confusion. So, an instruction such as ‘take one tablet three times a day’ is simple enough. A typical response in a comprehension test of a Package Leaflet or a Medication Guide would be something like ‘it’s telling me that I need to take a tablet three times during the day’. In lots of tests, the investigator may accept this as a correctly explained response and then move swiftly onto the next question. On a surface level, they would perhaps be right to do so. It is just a test of comprehension after all and this fictional answer would provide sufficient criteria for proof of understanding in, for example, a US comprehension or EU readability test.

But what does this instruction really mean? Dig a little deeper and it can be understood in a number of different ways. Each interpretation presents potential for harm to patients. This article examines the hidden interpretations of four simple written instructions around the dosing of medications. The examples used are real (anonymised) instructions taken from written patient information in the USA, Canada, UK, Ireland, Australia and New Zealand.

Instruction 1: "Take Three Times a Day"

This instruction is commonly used but is vague and ambiguous. It can lead to multiple potential interpretations and dosing errors. This instruction lacks specific detail about:

-            Timing: When exactly are you expected to take each dose? Morning, afternoon, night, or evenly spaced every 8 hours? Only during waking hours?

-            Intervals: What is supposed to be the gap between each dose? Should it be every 8 hours for three times a day, even if this means taking it during the night?

-            Do you take the tablet with or without food?  Should the doses be taken with meals or on an empty stomach? If it is with main meals, such as breakfast, lunch and dinner, then this leads to uneven intervals: 8 am, 1pm, 7 pm and then nothing for another 13 hours.

The implication for misinterpreting this instruction is that there is a risk of under-dosing or overdosing. If doses are too close together, it can lead to overdosing or increasing the risk of side effects. If doses are too far apart, it could lead to under-dosing, which means the medicine will not be effective. Alternatively, the user of the medicine can experience confusion and non-adherence due to unclear instructions.

A solution could be to state clearer alternatives. If the ‘3 times a day’ should be equally spaced doses, for example, the medicine may require the user to have consistent blood levels:

-            “Take one tablet every 8 hours (e.g., at 6:00 am, 2:00 pm, and 10:00 pm).”

If the medication should be taken with food:

-            “Take one tablet with breakfast, lunch, and dinner.”

For people who prefer a fixed schedule:

-            “Take one tablet at 8:00 am, 2:00 pm, and 8:00 pm.”

For people who prefer not to wake up at night:

-            “Take one tablet during waking hours at evenly spaced intervals (e.g., at 8:00 am, 2:00 pm, and 8:00 pm).”

There could also be additional guidance that includes contextual advice, such as

-            “If this schedule is difficult, speak with your doctor, nurse or pharmacist about an alternative timing.”, or:

-            “Take consistently at the same times each day for best results.”

Instruction 2: “Take as Needed”

The problem with this instruction is that it lacks details about frequency, intervals, and maximum daily dosage. This can cause a misunderstanding where patients might take doses too frequently or they may interpret "need" subjectively. This could risk overdose or dependency.

One solution to making this clearer could be to provide more explicit detail, such as: “Take one tablet when you feel pain, but do not take more than four tablets in 24 hours, with at least 4 hours between doses.”

Instruction 3: “Take Before Bedtime”

This instruction does not specify how long before sleep the medication has to be taken. Patients can misunderstand it as taking it just before lying down, potentially delaying onset of sleep or causing morning grogginess.

The solution could be to write it as:  “Take 30 minutes before you plan to go to sleep to allow the medication to take effect.”

Instruction 4: “Continue Until Symptoms Subside”

The problem is that a person’s symptoms may fluctuate and this can lead to inconsistent dosing, taking it for too long (risking side effects) or stopping the course of medication prematurely (risking relapse).

One way to communicate this better is to provide more detail and an actionable instruction, such as: “Continue taking the medication for at least 7 days, even if symptoms improve. If symptoms persist, contact your healthcare provider.”

These four examples demonstrate that seemingly simple medication instructions can be deceptively complex, leading to confusion, non-adherence, and even potential harm. While medical jargon is often blamed for communication gaps, this analysis reveals that even plain language can be ambiguous when contextual details are overlooked. To empower patients and enhance shared decision-making, healthcare providers must recognise the nuanced interpretations of common dosing instructions such as these. Clearer, more detailed alternatives tailored to individual lifestyles and needs can bridge this gap, ensuring that patients not only understand their medication regimens but also feel confident in their ability to follow them safely and effectively.

Thank you for reading!

Mark Gibson

Leeds, United Kingdom, February 2025