American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tips to talk to patients in terms they'll understand

Patients with low 'health literacy'—and they're more common than you think—may need some extra help

From the February ACP-ASIM Observer, copyright 2003 by the American College of Physicians-American Society of Internal Medicine.

By Jason van Steenburgh

Ruth M. Parker, FACP, a general internist at Grady Memorial Hospital in Atlanta, treated an older man in a primary care clinic with a dirty wound on his injured leg. The patient had already seen several doctors and taken antibiotics, but his leg wasn't getting better.

When Dr. Parker asked the patient how he was caring for his injury, he claimed he was following the instructions he'd received in the ER a few weeks earlier: Keep the leg clean with warm salt water. "I take a glass, make sure the water is warm with my fingers," he explained, "then I put salt in it and drink it."

While the anecdote is an extreme example of medical advice gone awry, it illustrates how patients with low health literacy—individuals who have trouble understanding even the most basic medical information and instructions—can find health care incomprehensible.

Experts say that patients with low health literacy are at much greater risk for poor outcomes. In part because their doctors don't explain things in simple enough terms, patients with health literacy problems are hospitalized more often than other patients. One study estimated that the annual costs resulting from low health literacy approach $73 billion.

Due to concerns about both quality of care and cost, health literacy is receiving more attention from several organizations. Dr. Parker, for example, spoke on the topic at a recent conference on health care communications sponsored by the ACP-ASIM Foundation.

We asked several experts for advice on how residents can make sure they're getting through to all their patients. Here are some of their tips:

  • Look for patients who need help. Put simply, health literacy refers to patients' ability to understand their disease and how to manage their care. The problem does not exclusively affect completely illiterate and functionally illiterate patients who read at an elementary grade level. A patient can read and write with average skill and still not understand the language you use.

    Literacy experts point out that many patients have lower health literacy than you might expect. While average Americans read at an eighth-grade level, most doctors explain medical conditions and treatments at an 11th- or 12th-grade level. Patient literature and health Web sites can be even harder to comprehend.

    You can often spot patients who need special attention during check-in. "The intake form that patients fill out when they first arrive is a good place to start," said Terry Davis, PhD, a health literacy assessment researcher at the Louisiana State University Health Sciences Center in Shreveport, La.

    "Physicians sometimes conclude that an incomplete form means the patient just didn't care," she explained. "It usually doesn't dawn on doctors that patients may not be capable of completing it. Forms can be a major barrier for some patients."

    Ask receptionists or nurses to help patients with forms. That will give staff valuable insight into patients' literacy levels while tearing down a barrier to quality care.

  • Avoid jargon. It may be tough to avoid "physician-speak," but experts say you should assume that all your patients will be confused by most of what you say.

    Dean Schillinger, MD, a general internist at San Francisco General Hospital who has studied patient communication, said many well-intentioned physicians make the mistake of using technical terms, then trying to define them. "Don't say, 'I want to check your hemoglobin A1C; that's a blood test to check your sugar.' There may be no need for patients to know this fact, and it does not empower them," he explained. Instead, try saying, "I want to check how much sugar is in your blood."

    "You wouldn't use the Finnish word for something, because it's not relevant," Dr. Schillinger said. "So why use a technical term?"

    While you likely know to avoid words like "nephron" and "aneurysm," some words that you consider everyday English can confuse patients. Dr. Schillinger said that even a seemingly straightforward word like "stable" can trip up patients because its definitions range from "good" to "where horses live." He suggested saying "unchanged" or "the same" instead.

    And don't use medical terminology just because a patient has used it first. Mark V. Williams, FACP, director of the hospital medicine unit at the Emory University School of Medicine in Atlanta, recalled one patient who calmly explained that the admitting physician had told her she had a pelvic fracture. When he confirmed this by saying, "That's right, you have a broken bone in your pelvis," she gasped, "I have a broken bone?" She had no idea that "fracture" means "break."

    Louisiana's Dr. Davis has researched patient understanding of screening terminology. Patients consistently failed to recognize or understand the words colon, polyp, growth, tumor, screening, mammograms, cervix, vagina and bowel. They also confused the colon with the prostate gland.

    Many thought Pap tests screened for every kind of cancer. Of patients surveyed at one walk-in clinic, 25% who claimed they knew what a mammogram was didn't understand the procedure.

  • Avoid unnecessary details. Limiting how much information you cover can reduce confusion.

    Many elderly patients have low health literacy and lack the education on health issues that has been more readily available to younger generations. Compounding that difficulty, many have multiple medical problems and may suffer some memory loss. These patients will understand and retain very little if you try to explain prevention and treatment options for diabetes, heart disease and colorectal cancer all in a single visit.

    For complex patients with low medical literacy, target one problem during each encounter. Make additional appointments to deal with separate health issues.

    Experts recommend making no more than two or three key points for each condition. When describing what's wrong, keep in mind that patients need to understand only their basic problems, drug side effects and how to take medicine to manage disease.

    As the case of the saltwater-drinking patient shows, you must be specific even if the details seem obvious. Don't worry that you'll irritate patients with simple explanations.

    Your tone of voice—not the content of your message—gives patients the impression that you are condescending. If they want more complex information, they'll ask.

  • Use the "teach-back" method. Avoid asking patients, "Do you understand?" Most will say they do even when they are confused. Instead, Joanne Schwartzberg, MD, director of the AMA's department of geriatric health, suggested saying, "I want to make sure I did a good job teaching you. Tell me how you are going to do this when you get home."

    Research consistently shows that this type of "teach-back" method improves recall and compliance.

    Instead of challenging patients' knowledge, ask them to repeat your instructions in their own words to help you gauge your teaching ability. Saying something like "In order to make sure I explained things well, can you tell me what we've decided to do?" puts the emphasis on your teaching expertise, which can ease patient anxiety.

    Regularly review critical points to make sure patients understand. Don't wait until the end of the visit when they could be completely lost.

    The teach-back method also helps establish rapport with patients who feel ignored by the system. It shows them you care that they understand.

    Keep in mind that the time you invest now will help in the long run by preventing recurring phone calls, errors and visits for the same problem, and may even improve patient health. A study by Dr. Schillinger and colleagues in the January 2003 Archives of Internal Medicine found that while physicians used the teach-back method with diabetes patients in only 12% of visits, those visits weren't any longer than when the method wasn't used. His research also found that patients whose physicians used the teaching strategy had better control of their diabetes.

  • Use pictures. Illustrations often convey instructions better than words. In a study published in the March 1996 Academic Emergency Medicine, physicians in the emergency department at Butterworth Hospital in Grand Rapids, Mich., randomly gave patients either illustrated or text-only instructions on wound care. In follow-up phone calls, 46% of those who received illustrated instructions correctly answered all questions about wound care, while only 6% of those with text-only instructions got them all right.

    Peter Houts, PhD, professor emeritus at Pennsylvania State University College of Medicine in State College, Pa., has also investigated the use of pictures in patient encounters. He found that physicians improved patient compliance by adding drawings to their instructions, even if they were only crude doodles.

    If patients are not supposed to drive while taking a medication, he said, draw a picture of a car and put an X over it. If a medication shouldn't be taken with dairy products, he suggested drawing a cow with a slash through it.

    "It doesn't have to be a work of art—four legs, ears and an udder," he said. "The picture doesn't stand by itself. It is there as a cue to aid recall of your oral instructions." Patients' amusement at watching you struggle to draw cars or cows might just be enough to jog their memory.

  • Talk to family members. Once you realize your patient has literacy troubles, enlist the aid of a family member or friend.

    Grady Memorial's Dr. Parker remembered a perplexed resident introducing her to a 43-year-old asthmatic who was still wheezing and suffering chest tightness after filling 14 prescriptions from six different hospital visits in seven weeks. The resident couldn't figure out why the treatments weren't working.

    When Dr. Parker asked the patient why she thought she wasn't getting better, the patient cried and admitted she couldn't read the labels on her medications, so she wasn't taking them. When Dr. Parker learned that the woman's fully literate son was in the waiting room, she invited him to join them.

    The son wrote down all of Dr. Parker's instructions, and they reviewed them together until the patient understood what she needed to do. A short time later, the patient's asthma improved.

    "Residents should always ask themselves if low literacy could be contributing to the clinical scenario in front of them," Dr. Parker said, "especially if the patient has had recurrent visits for manageable problems."

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