The problems can start as soon as a patient steps into the doctor’s office, or beforehand if the patient has trouble understanding how to get to the office and arrives late. When the patient tells the receptionist he is there for his appointment, he is typically asked to fill out intake forms. Leaving them blank can be a key sign of low health literacy.
Explore this issue:September 2012
“They’ll have some kind of excuse for why it’s not filled out,” said Dr. Chen. “Or they’ll sign their name on the consent form, and they don’t know where the signature line is. Usually the handwriting is pretty poor. Or else they won’t complete the form and say, ‘It’s easier for me to just tell you rather than write it down.’”
During the exam, doctors will explain why they are examining the patient and what the results of that exam, or prior test results, are. Patients who don’t interact, Dr. Eloy said, may also be showing poor health literacy. “Usually when a patient doesn’t ask questions, or he just nods when you ask questions about the process that has been explained before, you can tell that he’s not getting it,” he said. “When a patient understands, they usually have multiple questions.”
Asking how a patient will follow up can also be a tip-off. “Glassy-eyed nods are bad,” said Dr. Beitler. “Vague answers to specific questions are bad. ‘How are you going to get to Dr. Smith tomorrow, Mr. Jones?’ ‘I don’t know,’ is not an encouraging answer. Not having a notebook and taking notes is bad. Writing steps down and having concerned family members around is important.”
Dr. Chen said that once she realizes her patients—who are typically facing surgery for head and neck tumors—don’t understand exactly what she is telling them, she calls upon resources such as certified social workers, speech pathologists or head and neck cancer patient support groups who can help the patients understand what they are facing. “A patient visitor can meet with the patient to discuss what’s to come and to help put them at ease,” she said. “There are a lot of patient resources.”
Dr. Eloy works to ensure his patients understand their own diagnoses and his proposed surgical procedures by giving them two copies of paperwork before any procedure is scheduled. “I want them to go home with the material, read it and discuss it with a family member,” he said. “I tell them to call me in one week, and I ask them to write down every single question they have.” Dr. Eloy only schedules surgeries after he is sure he has answered a patient’s questions and the patient has shown him she understands what is happening with her health.
How to Make Changes
Health literacy has been studied within many medical fields, not just otolaryngology, and there are several steps all physicians can take to help patients improve their health literacy. The American Medical Association produces a health literacy kit that includes the clinician’s manual mentioned above, along with a video and other resources, all available at ama-assn.org. The Agency for Healthcare Research and Quality publishes a Health Literacy Universal Precautions Toolkit, available at ahrq.gov/qual/literacy, which helps guide doctors through the process of assessing their practices for areas where change could be helpful and discusses how to train staff members about the issue.
- Use straightforward language. Implementing changes isn’t a quick fix, but they’re a step in the right direction toward making health information understandable to all. Using plain language to explain medical terms and procedures is one of the cornerstones of the health literacy movement. “If I had to provide one piece of advice, it would be to explain things to patients in simple terms, like you might explain them to your grandmother if she called on the phone to ask for a translation of what the doctor told her,” said Barry D. Weiss, MD, a professor of family and community medicine at the University of Arizona College of Medicine in Tucson and the author of the American Medical Association’s health literacy clinician’s manual. “Physicians often forget that words they use every day are totally unfamiliar to ‘normal’ people.”
- Practice “teach back.” Using plain language also helps when doctors use “teach back,” a method in which doctors ask patients to repeat back what they have been told to do about a particular health issue and what the next step should be—such as making a follow-up appointment or filling a prescription and taking a particular medicine a certain way. Having a patient accurately explain his health issue and how it should be treated, as the doctor explained it to him, is a way to ensure that the patient understands exactly what should be done to treat a particular health problem. “Physicians tend to overestimate what a patient is understanding,” said Dr. Eloy.
- Pay attention to reading level and native language. Dr. Eloy also suggested providing health information that is written at an appropriate reading level. He uses a feature popular in many word processing programs called the Flesch-Kincaid Grade Level, a readability formula that determines how challenging a material will be to understand. The AMA and AHRQ literacy kits propose that all patient material be written at a sixth grade reading level or below, and Dr. Eloy suggested writing to an even lower grade reading level if a physician works with a large number of patients with low health literacy. He found that the online patient education materials on the American Academy of Otolaryngology’s website were written above the recommended sixth grade level and suggested that revision may be necessary (Otolaryngol Head Neck Surg. 2012. April 3).
Providing patient materials in other languages can make information easier to understand for non-native English speakers.
Incorporating health literacy practices needn’t add time to a physician’s day, said Osborne. “Usually the No. 1 recommendation is to use teach back. You don’t do it for everything,” she said. “Use teach back for key points, and just try it on your last patient of the day. You’ll get into the habit of doing it more after trying it when you are not as pressed for time.”