Interest In Health Literacy Grows
Two major newspaper stories in the past month addressed health literacy, one of the major causes of patient-clinician miscommunication, which in turn often leads to inadequate treatment plan execution, a phenomenon typically included under the aegis of patient compliance.
Sources:
‘Doctor-ese’ often stumps patients Jane E. Brody New York Times 4 Feb 2007
A Silent Epidemic Sandra G. Boodman Washington Post 20 Feb 2007
The Points Made In These Articles Are Straightforward
1. Impaired Health literacy is a national healthcare problem of huge proportions. According to the Institute of Medicine, more than 90 million Americans of all ages, races, and income and education levels, are unable to adequately understand basic health information.1
2. Poor health literacy results in poor adherence to prescription instructions, infrequent use of preventive medical services, increased hospitalizations and visits to the emergency room, and worse control of chronic diseases. The consequences are poorer health and greater medical costs.
3. Doctors fail to speak to patients in plain English (or Spanish or Chinese or any other language) and fail to make sure that patients understand what they are told and what they are supposed to do and why.
The disconnect between the offerings from healthcare and the capacity of patients is noted in a 1999 report by the American Medical Association which found that consent forms and medical information are typically written at the graduate school level while the average American adult reads at the eighth-grade level. Worse, a 2003 survey completed by the U.S. Department of Education found that over 40% percent of adults read at a fifth-grade level or lower, and 5 percent are not literate in English (in some cases because it is not their first language). Math skills are similarly lacking.
The Impact Of Low Health Literacy Is Equally Clear-Cut
These excerpts are characteristic:
Another study in the Journal among 175 adult asthma patients treated by Cornell University doctors found that “less health literacy was associated with worse quality of life, worse physical function and more emergency department utilization for asthma over two years.”
Among the many problems resulting from limited health literacy are misinterpretations of warning labels on prescription drugs. For example, among 251 adults attending a primary care clinic in Shreveport, La., those with low literacy were three times more likely to misunderstand warnings than the more literate.
Despite major reports on the need to improve health literacy issued in the last decade by organizations including the American Medical Association and the National Academy’s Institute of Medicine, little improvement has been noted in how much patients understand and remember about encounters with health care practitioners.
Primary Problems
A second hurdle is the embarrassment that patients with limited health literacy experience when they do not understand what the doctor has said. And, of course, asking for clarification is seriously impeded by the imbalance in power between the white-coated physician and the paper-wrapped patient. Even when conversations are conducted in the doctor’s office with a fully clothed patient, patients are often reluctant to ask questions.
Fixes
These newspaper reports included several specific recommendations for clinicians as well as patients to improve communications, many of which come with the imprimatur of the Joint Commission which recently presented 35 recommendations to address this problem, along with the implication that such suggestions might become future Joint Commission requirements for healthcare facility accreditation. Examples follow:
Doctors should use plain language, not medical jargon, vague terms and words that may have different meanings to a lay person. They should say “chest pain” instead of “angina,” “hamburger” instead of “red meat” and “You don’t have HIV” instead of “Your HIV test was negative.”
Experts on health literacy also encourage doctors to assess patients’ health literacy by asking them to read aloud a list of 66 medical terms, each within five seconds. Patients are scored on how many words they pronounce correctly.
The advice for the patients is clear – be proactive or risk poor healthcare.
Insist that conversations about serious medical matters take place when you are dressed and in the doctor’s office. Take notes or take along an advocate who can take notes for you. Better yet, tape-record the conversation to replay it at home for you and your family or another doctor.
Also mentioned is a Pfizer-sponsored program called Ask Me 3 that was designed by the Partnership for Clear Health Communication, a coalition of national health and literacy groups. The program encourages patients to ask three simple questions and to be sure they understand the answers: What is my main problem? What do I need to do? Why is that important?
Commentary
I’ve summarized and excerpted material from these articles at length to point out (1) the importance of the problem, (2) the growing urgency demonstrated in the press, professional organizations, and regulatory agencies for a solution, and (3) the solution being promoted.
While the severity of the problem and the mounting pressure for a solution are, it seems to me, clear cut, the only solutions offered are incomplete.
Doctors, for example, are unlikely to find that “none of this [i.e., the suggested improvements in communication techniques] should take more than a few minutes,” as the experts quoted approvingly in the New York Times article declare, to be reassuring. By simple arithmetic, “a few minutes” added onto each appointment in a busy day, assuming the estimate is accurate, accumulates into “a few hours” added every week.
Even more problematic is the contention that every patient has, within himself or herself, the capacities to be a “patient expert” on his or her disorders and a self- advocate with the interpersonal skills to assure that the right information (whatever that might be) is provided and understood without being so confrontational that the relationship with the clinician is jeopardized. Neither clinical experience or personality studies would seem to support this hypothesis.
What is to be done for those individuals who cannot, especially in the sick role, assume this proactive stance?
The current Patient Literacy campaigns do not seem to take this issue into consideration, let alone provide pragmatic answers. I believe, however, that there are potentially useful responses, some of which I will be addressing in forthcoming posts.
Footnotes
- The Journal of General Internal Medicine August 2006↩
