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Make Sure Your Patient Gets It

Janet Brown and Catherine Baker

It happens all too often: A clinician treats a patient, prescribes medication, or provides nutritional or other self-management education, but when he or she returns, nothing has changed, or the patient has become even sicker.

Patients face challenges at many levels, including comprehending and applying information. Problems with health literacy—the ability to obtain, process, and understand basic health information to make appropriate health decisions¹—occur in both spoken and written communication.

"So many of the patients that we talk to are figuring things out by trial and error," says Terry C. Davis, PhD, professor of medicine and pediatrics at Louisiana State University Health Sciences Center in Shreveport. "Patients tell us what they need is a way to get practical help to get through a day. We need to teach people what they need to know and do."

For those who suffer from a chronic illness such as diabetes, poor health literacy can compound the challenges of making lifestyle changes and performing a variety of self-care tasks to avoid adverse reactions and complications. Research shows type 2 diabetes patients with poor health literacy have worse glycemic control and higher rates of complications such as retinopathy than those with adequate health literacy.²

A lack of math or numeracy skills (e.g., counting carbohydrates and reading labels) can cause added difficulty, as can the need to negotiate and understand how to apply information in diverse settings such as a doctor's office or hospital, home, work, and the grocery store.

In its 2004 report, Health Literacy: A Prescription to End Confusion, the Institute of Medicine (IOM) estimates that health literacy is an issue for 90 million people in the U.S. at all education levels.³ It is particularly prevalent among those who are elderly, have a low income, or are undereducated, the IOM reports, and among immigrants or members of minority or ethnic groups who face additional language and cultural barriers.

"Some of my older patients have lower literacy skills through no fault of their own," says internist Joseph Okafor, MD, of Providence Hospital in Washington, D.C. "Education was not available to them 60 years ago. I explain things to them in layman's terms, without using medical jargon. Then they get it."

For people who speak little or no English, a family member, friend, or hospital or clinic worker may be able to help the patient read health-related materials. Having an independent translator available also is useful because family members may not be able to translate what the clinician says because of not understanding or not being impartial.

Also, providers should try to recognize that the health beliefs and customs of other cultures may be different from their own.

MAKING YOUR MESSAGE CLEAR

Clear health communication matters across the continuum of care, from taking histories, to prevention and screening, to explaining diagnoses and treatments.

"Doctors need to assume that patients will not understand or integrate most of what is said," says Dean Schillinger, MD, of the Primary Care Research Center at University of California-San Francisco. "It is important not to try to do too much in one visit, but to have a follow-up plan such as a phone call to reinforce a few key messages between visits."

Both Schillinger and Davis have worked in health literacy groups with people who have diabetes, and with doctors, nutritionists, and diabetes educators. They report finding differences between provider and patient perceptions of communication about the disease and its management.

Fortunately, tools and interventions have been developed to improve patients' understanding of health information (see FYI for resources). Yet many health practitioners continue to distribute health education materials, medical instructions, consent forms, and self-report questionnaires without considering a patient's ability to read and understand them. A 2003 study found that when conveying new information to their patients with diabetes, primary care physicians assessed recall and comprehension for only 15 of 124 new concepts.⁴

In addition to using plain language, practitioners can look for red flags that signal a patient's misunderstanding, such as missed appointments, incomplete registrations, lack of follow-through, or an inability to name medications or explain their purpose.

What You Say May Not Be What Patients Hear Health practitioners can communicate more effectively when they examine their patient-centered interactions and create messages that are sensitive to health literacy concerns. Why Patients Do Not Take in Information Heightened emotions due to diagnosis or condition (shock, denial, stress, fear, the "white coat syndrome") Failure to understand relevance or importance and/or medical terminology Fear of asking for clarification Condition that impedes ability to listen, comprehend, or remember Inability to interpret information as written or to translate generalized instructions to specific actions Problems with reading or math literacy (numeracy) or cognitive problems (problem solving, following instructions) Difficulty accessing care within the health system Failure to remember Failure to ask questions Why Health Care Providers Do Not Communicate Well Time constraints leading to rushing, not listening to patients, dispatching information too quickly, misreading patient cues Inability to distinguish between immediate "need to know" and other medical information Lack of cultural competence or personal bias based on sex, race, or age, resulting in poor provider/patient relations Inability to relay, in simple terms, complex medical information (print or verbal) Failure to coordinate instructions among several health care providers Dissemination of overly complex print materials to patients Failure to write down individual instructions/diagnoses

 

"Teaching Back" and Other Clear-Communication Practices Health care providers can use the four-stage "teach back" method to introduce new information, medical advice or instructions, or changes in medical management. The provider explains and demonstrates a new concept. The provider assesses patient recall and comprehension by asking the patient to explain or demonstrate the concept. If needed, the provider clarifies and recasts the explanation to improve patient understanding. The provider reassesses patient recall and comprehension by again asking the patient to demonstrate the concept. To assure effectiveness, "practitioners need to have patients restate messages in their own words rather than simply saying, `yes, I understand,' since often patients either overestimate their understanding or are too uncomfortable to report misunderstanding," says Dean Schillinger, MD, of the Primary Care Research Center at University of California-San Francisco. Source: Archives of Internal Medicine4 Other strategies to adopt in practice: Find out what the patient already knows and doesn't know. Ask, "What do you know about heart disease and diabetes?" Build on that existing knowledge and fill in the gaps. Speak in concrete, everyday language. For example, explain, "The A1C test is a way to see what your blood sugar has been for the last 2 to 4 months," instead of, "The hemoglobin A1C test is a measure of how much glucose in your blood has been glycated." Encourage the patient to ask questions. Focus on a few key messages at a time. Use short sentences. Schedule phone or other follow-up support shortly after appointments. Practical Help Gretchen Youssef, MS, RD, CDE, program manager of the MedStar Diabetes Institute in Washington, D.C., recommends several common-sense strategies for supporting patients with diabetes who are implementing changes in their regimen. "I use hands-on approaches, including actual medication bottles and food models with portion sizes," she says. Supporting a patient in developing new self-care behaviors can be as simple as marking changes in blood glucose monitoring on a patient's personal calendar. For example, a provider can note that the patient should test fasting blood glucose on Monday, Wednesday, and Friday and check levels after eating breakfast on Tuesday, Thursday, and Saturday. The use of pictograms can illustrate each step in a regimen, such as how to use a particular insulin. Youssef also regularly checks a patient's injection technique and the injection sites, even if the patient has been on insulin for a while.

 

The Rapid Estimate of Adult Literacy in Medicine (REALM) and the Test of Functional Health Literacy in Adults (TOFHLA) are screening tools designed to help physicians identify patients with limited reading skills. The REALM, which takes 3–5 minutes to administer and score, appears to be a practical instrument to estimate patient literacy in primary care, patient education, and medical research.⁵ When used in a clinical setting, screening tools should be administered with sensitivity to a patient's potential shame of being tested and with communications tailored to the patient.

"We need to move beyond knowledge transfer and be sure that we are passing on essential information," Davis says. "People are overwhelmed with the communications that are coming at them, so we must be aware of the emotional consequences, too."

To make sure patients understand their messages, health care providers should see themselves as teachers, Davis continues. "Teaching back" and using demonstrations can help ensure that patients understand and put into practice the important health information practitioners provide (see "Teaching Back" sidebar).

BEYOND CLINICAL CARE

Researchers have found that many of the health literacy challenges individuals face are embedded in the health system. Health practitioners can enhance patient care by tapping into diabetes education opportunities outside the clinic setting that may be more convenient and comfortable for patients. Davis recommends that health practitioners refer patients to diabetes support groups and other community-based diabetes education organizations.

"It is difficult for an older patient to get on the bus and come across [town] every other week for a 15-minute follow-up with a clinician," Davis points out. "Through a support group, they may learn some strategies from others in their community who are dealing with diabetes."

In addition, providers need to take a careful look at the communication environment and streamline the maze of paperwork (registration forms, procedural consent, etc.) that patients must fill out.

Patient education materials should be written as close to a sixth-grade level as possible. This means sentences no longer than 14 words, with no more than three words longer than three syllables per 100-word passage. Recent research reviews show that most patient education materials currently are written at a 10th-grade reading level or higher.

"It is surprising that people with diabetes do as well as they do given the barriers they face at times within the health care system," Schillinger says.

Footnotes

FYI

The American Medical Association Foundation works to raise awareness of health literacy through its health literacy toolkits, videos, and partnerships. More information is available online at www.ama-assn.org/ama/pub/category/8115.html.

The Patient-Centered Health Literacy Program of the American College of Physicians Foundation also offers numerous health literacy resources and links. Visit the program online at http://foundation.acponline.org/healthcom/hli.htm.

Pfizer's Clear Health Communication Initiative supports programs to build the health literacy research base, provide training on health literacy issues, and raise awareness of health literacy among patients and providers. Find more details on the Web at www.pfizerhealthliteracy.com/partnerships.html.

References

1. U.S. Department of Health and Human Services: Healthy People 2010, 2nd ed. Washington, D.C., U.S. Government Printing Office, 2000.

2. Schillinger D, Grumbach K, Piette J, et al.: Association of health literacy with diabetes outcomes. JAMA 288: 475–482, 2002.[Abstract/Free Full Text]

3. Institute of Medicine: Health Literacy: A Prescription to End Confusion. Washington, D.C., The National Academies Press, 2004.

4. Schillinger D, Piette J, Grumbach K, et al.: Closing the loop: Physician communications with diabetic patients who have low health literacy. Arch Intern Med 163:83–90, 2003.[Abstract/Free Full Text]

5. Davis TC, Crouch MA, Long SW, et al.: Rapid assessment of literacy levels of adult primary care patients. Fam Med 23: 433–435, 1991.[Medline]

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Services Email this article to a friend Similar articles in this journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Brown, J. Articles by Baker, C. Search for Related Content PubMed Articles by Brown, J. Articles by Baker, C. Social Bookmarking                What's this?