health lit clinicians
TRANSCRIPT
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Manual or clinicians
Second edition
Barry D. Weiss, MD
Removing barriers to better, safer care
A continuing medical education opportunity
Sponsored in part by AstraZeneca
Health literacy and patient safety:
Help patients understand
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2007 American Medical Association Foundation and American Medical Association.
All rights reserved. The contents o this publication may not be reproduced in any orm without writtenpermission rom the American Medical Association Foundation.
Release date: May 2007Expiration date: May 2009
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Health literacy and patient safety:
Help patients understand
Manual or clinicians
Second edition
Author:
Barry D. Weiss, MD
University o Arizona College o Medicine, Tucson
With contributions rom:
Joanne G. Schwartzberg, MD, American Medical Association, Chicago
Terry C. Davis, PhD, Louisiana State University, Shreveport
Ruth M. Parker, MD, Emory University College o Medicine, Atlanta
Patricia E. Sokol, RN, JD, American Medical Association, Chicago
Mark V. Williams, MD, Emory University College o Medicine, Atlanta
Removing barriers to better, safer care
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The Health Literacy Educational Toolkit, 2nd edition has been
re-approved for CME credit through May 2012. Please read the
following page for new instructions effective May 2009.
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Health literacy educational toolkit, 2nd ed
Important Continuing Medical Education Information for Physicians
Effective May 2009
PLEASE NOTE THE NEW INSTRUCTIONS FOR CLAIMING CREDIT EFFECTIVE MAY 2009:
Physicians may earnAMA PRA Category 1 CreditTM for this activity Health literacy educationaltoolkit, 2nd ed. by viewing the accompanying instructional video, reading this manual for clinicians,studying the case discussions, and completing the enclosed evaluation and post-test. The estimatedtime to complete the activity is 2.5 hours. Physicians must then complete the CME questionnaire(including both the evaluation and the post-test) provided at the back of thi s manual andsubmit it v ia mail or fax to:
American Medical Association FoundationAttn: Health Literacy515 N. State St.
Chicago, IL 60654Fax: (312) 464-4142
Al l submiss ions must be s igned and dated.
A certificate documenting your participation in the CME activity will be forwarded to you uponsuccessful achievement of a score of at least 70%.
Original release date: May 2007Date of most recent activity review: April 2009Activi ty exp iration date: May 2012
Disclosures for Content ReviewersClaudette Dalton, MD, Rockingham Memorial Hospital, Harrisonburg, Va. Nothing to discloseDaniel Oates, MD, M.Sc., Boston University School of Medicine, Boston, Mass. Nothing to disclose
Accred itation Statement
The American Medical Association is accredited by the Accreditation Council for Continuing MedicalEducation to provide continuing medical education for physicians.
Designation Statement
The American Medical Association designates this enduring material for a maximum of 2.5AMA PRACategory 1 Credits. Physicians should claim only the credit commensurate with the extent of theirparticipation in the activity.
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An AMA continuing medical education program
Accreditation statement
The American Medical Association is accredited by the Accreditation Council or Continuing MedicalEducation to provide continuing medical education or physicians.
Designation statementThe American Medical Association designates this educational activity or a maximum o 2.5 AMA PRACategory 1 Credits. Physicians should only claim credit commensurate with the extent o their participationin the activity.
Non-physicians may receive a certicate o participation or completing this activity.
Learning objectives
The enclosed materials will enable physicians to: Dene the scope o the health literacy problem.
Recognize health system barriers aced by patients with low literacy. Implement improved methods o verbal and written communication. Incorporate practical strategies to create a shame-ree environment.
Instructions or obtaining CME credit
Ater viewing the accompanying instructional video, reading this manual or clinicians, and completing thecase discussions, record your answers to the continuing medical education (CME) questionnaire on the CMEanswer sheet provided at the back.
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Disclosure policy
To ensure the highest quality o CME programming, and to comply with the Accreditation Council orContinuing Medical Education Standards or Commercial Support, the American Medical Association(AMA) requires that all aculty and planning committee members disclose relevant nancial relationships with
any commercial or proprietary entity producing health care goods or services relevant to the content beingplanned or presented. The ollowing disclosures are provided:
AuthorDr. Weiss: Research grants and consulting ees, Pzer Inc.
ContributorsDr. Schwartzberg: Nothing to discloseDr. Davis: Nothing to discloseDr. Parker: Nothing to discloseMs. Sokol: Nothing to disclose
Dr. Williams: Nothing to disclose
CME Planning CommitteeLouella L. Hung, MPH: Nothing to discloseAmerican Medical Association Foundation, ChicagoJoanne G. Schwartzberg, MD: Nothing to discloseAmerican Medical Association, ChicagoBarry D. Weiss, MD: Research grants and consulting ees, Pzer Inc.University o Arizona College o Medicine, Tucson
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Introduction 6
Health literacy 8
National Assessment o Adult Literacy ..............................................................................................................8
Procient skills ...........................................................................................................................................10
Intermediate skills ......................................................................................................................................10
Basic skills ..................................................................................................................................................10
Below basic skills........................................................................................................................................10
Population groups at risk or limited health literacy ..........................................................................................10
Day-to-day problems associated with limited health literacy ............................................................................12
Implications o limited health literacy ...............................................................................................................13Literacy and health knowledge ..................................................................................................................13
Literacy and health outcomes ....................................................................................................................13
Literacy and health care costs....................................................................................................................14
Literacy and the law ..................................................................................................................................15
You cant tell by looking 16
How can I tell i an individual patient has limited health literacy skills?
Red fags .....................................................................................................................................................17
The social history .......................................................................................................................................19
Medication review .....................................................................................................................................19
Measuring health literacy ...................................................................................................................................20
Strategies to enhance your patients health literacy 22
Making your practice patient-riendly ...............................................................................................................22
Attitude o helpulness ..............................................................................................................................25
Scheduling appointments ..........................................................................................................................25
Oce check-in procedures ........................................................................................................................25
Reerrals and ancillary tests .......................................................................................................................27
Table o contents
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Improving interpersonal communication with patients 28
Communication and malpractice lawsuits .........................................................................................................28
Communication and medical outcomes ............................................................................................................29
Steps to improving communication with patients .............................................................................................29
Slow down ..................................................................................................................................................30
Use plain, nonmedical language ................................................................................................................30
Show or draw pictures to enhance patients understanding and recall .....................................................32
Limit the amount o inormation given at each visitand repeat it ........................................................32
Use the teach-back technique ................................................................................................................33
Create a shame-ree environment: Encourage questions ..........................................................................34
- Ask-Me-3 .....................................................................................................................................34
Creating and using patient-riendly written materials 35
Written consent orms and patient education handouts ...................................................................................35
Principles or creating patient-riendly written materials .........................................................................35
- Depth and detail o the message..................................................................................................37
- Complexity o text.......................................................................................................................38
- Format ..........................................................................................................................................39
- User testing ..................................................................................................................................39
Nonwritten patient education materials ............................................................................................................40Graphic illustrations (pictures, pictographs, models) ...............................................................................40
Audiotapes and compact discs ...................................................................................................................40
Videotapes ..................................................................................................................................................41
Computer-assisted education .....................................................................................................................41
Final comments 43
Case discussions 45
Useul resources 48
CME questionnaire 49
CME answer sheet 51
Reerences 53
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Introduction
Health literacy and patient safety: Help patients understand
Communication is essential or the
eective delivery o health care, and
is one o the most powerul tools in
a clinicians arsenal. Unortunately,
there is oten a mismatch between a
clinicians level o communication and
a patients level o comprehension. In
act, evidence shows that patients oten
misinterpret or do not understand much
o the inormation given to them byclinicians. This lack o understanding
can lead to medication errors, missed
appointments, adverse medical
outcomes, and even malpractice
lawsuits.
There are many reasons why patients do not
understand what clinicians tell them, but key among
them is inadequate health literacyi.e., a limited
ability to obtain, process, and understand basic health
inormation and services needed to make appropriate
health decisions and ollow instructions or
treatment. Clinicians can most readily improve what
patients know about their health care by conrming
that patients understand what they need to know and
by adopting a more patient-riendly communication
style that encourages questions.
The need or todays patients to be health literate
is greater than ever, because medical care has grownincreasingly complex. We treat our patients with an
ever-increasing array o medications, and we ask them
to undertake more and more complicated sel-care
regimens. For example, patients with congestive heart
ailure were prescribed digoxin and diuretics in the
past, while todays patients take loop diuretics, beta
blockers, angiotensin converting enzyme inhibitors,
spironolactone, and digoxin. They may also receive
a biventricular pacemaker that needs monitoring,
and they oten take medications or hypertensionand hyperlipidemia. In the past, these patients were
simply instructed to decrease their physical activity,
but now they weigh themselves daily, report weight
gain to their clinicians, eat low-sodium and oten
low-at diets, and participate in structured exercise
regimens. Similarly, therapy or patients with asthma
was once limited to theophylline pills, but today
these patients must learn to use inhalers with spacers
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and understand the dierence between controller
medications and rescue medications. They must
also test their peak fow rate, take tapering doses o
prednisone, and identiy and eliminate allergens rom
their homes. Patients with diabetes may have the
most dicult task o all, as they need to understand
actors aecting blood glucose control so they can
modiy insulin regimens on a meal-to-meal basis in
response to nger-stick glucose measurements.
Unortunately, current data indicate that more
than a third o American adultssome 89 million
peoplelack sucient health literacy to eectively
undertake and execute needed medical treatmentsand preventive health care. Inadequate health
literacy aects all segments o the population, but
it is more common in certain demographic groups,
such as the elderly, the poor, members o minority
groups, and people who did not speak English during
early childhood. The economic consequences o
limited literacy or the US health care system are
considerable, estimated to cost between $50 billion
and $73 billion per year.
Since publication o the rst edition o this manual,
a great deal o new inormation has become available
about the eects o literacy on health care and
health outcomes. Much o this inormation has been
described in research papers and in a report on health
literacy rom the Institute o Medicine.
In the pages that ollow, this manual reviews the
problem o health literacy, its consequences or
the health care system, and the likelihood that a
clinicians practice includes patients with limited
literacy. The manual then provides practical tips
or clinicians to use in making their oce practices
more user riendly to patients with limited literacy,and gives suggestions or improving interpersonal
communication between clinicians and patients.
Finally, the manual concludes with several case
discussions based on vignettes in the accompanying
instructional video.
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Health literacy
Health literacy and patient safety: Help patients understand
Health literacy, as dened in a report by
the Institute o Medicine, is the ability
to obtain, process, and understand
basic health inormation and services
needed to make appropriate health
decisions and ollow instructions or
treatment.1 Many actors can contribute
to an individuals health literacy, the
most obvious being the persons general
literacythe ability to read, write, andunderstand written text and numbers.
Other actors include the individuals
amount o experience in the health
care system, the complexity o the
inormation being presented, cultural
actors that may infuence decision-
making, and how the material iscommunicated.
National Assessment o Adult Literacy
Every 10 years, the US Department o Education
conducts a national survey to document the stateo literacy o the American public. The most recent
survey, the National Assessment o Adult Literacy
(NAAL) conducted in 2003, provides the most
comprehensive view o the general literacy and
health literacy skills o American adults. The NAAL
tested a stratied representative national random
sample o some 19,000 adults who were interviewed
in their place o residence. Each participant
was asked to provide personal and background
inormation and to complete a comprehensive seto tasks to measure his or her ability to read and
understand text, interpret documents, and use and
interpret numbers (Table 1).
While the main purpose o the NAAL was to
measure the general literacy skills o American adults
specic items were devoted to specically assessing
health literacy. These items ocused on the ability o
individuals to understand and use text, documents,
and numbers pertinent to commonly encounteredhealth care situations. These situations included
care o illness, dealing with preventive care, and
navigating the health care system.
The NAAL results were reported by dividing the
health literacy skills o subjects into our levels2:
procient, intermediate, basic, and below
basic (Figure 1). Most doctoral-level clinicians all
into the small percentage o the population that has
procient skills, while 36% o American adults78
million peoplehave only basic or below basic
skills. Add to this gure the approximately 5% o
individuals that could not be tested in the NAAL
because they lacked sucient skills to participate in
the survey, and the total number o Americans with
limited health literacy totals more than 89 million!
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Table 1. Examples o health literacy tasks on the National Assessment o Adult Literacy
Level Sample tasks
Profcient Calculate an employees share o health insurance costs or a year, using a table that shows
how the employees monthly cost varies.
Find the inormation required to dene a medical term by searching through a complex
document.
Evaluate inormation to determine which legal document is applicable to a specic health
care situation.
Intermediate Determine a health weight range or a person o specied height, based on a graph that
relates height and weight to body mass index. Find the age range during which children should receive a particular vaccine using a chart
that shows all the childhood vaccines and the ages children should receive them.
Determine what time a person can take a prescription medication, based on inormation
on the prescription drug label that relates the timing o medication to eating.
Identiy three substances that may interact with an over-the-counter drug to cause side
eects, using inormation on the over-the-counter drug label.
Basic Give two reasons why a person with no symptoms o a specic disease should be tested or
the disease, based on inormation in a clearly written pamphlet.
Explain why it is dicult or people to know i they have a specic chronic medical
condition, based on inormation in a two-page article about the medical condition.
Below basic Identiy how oten a person should have a specied medical test, based on inormation in
a clearly written pamphlet.
Identiy what is permissible to drink beore a medical test, based on a set o short
instructions.
Circle the date o a medical appointment on a hospital appointment slip.
Source: Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy o Americas Adults: Results rom the 2003 National Assessment o Adult Literacy. USDepartment o Education. National Center or Education Statistics (NCES) Publication No. 2006-483; September 2006.
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Procient skills
At the procient level, individuals have ullydeveloped health literacy skills and can read
and understand virtually all text and numerical
inormation they might encounter in health care
settings. These individuals, however, account or only
about 13% o the American adult population.
Intermediate skills
The next highest skill level is termed intermediate.
Individuals with intermediate health literacy skills
constitute about 53% o the population. They candeal with most o the text and numerical inormation
they encounter in health care settings, although
they would have diculty dealing with dense or
complicated text and documents. Examples o
intermediate skills include checking a reerence
source to determine which oods contain a particular
vitamin or calculating body mass index rom
inormation provided on a graph.
Basic skillsPeople with basic health literacy skills, who make up
22% o the population, can perorm the basic tasks
o reading and understanding a short pamphlet that
explains the importance o a screening test. They
would not be able to reliably perorm intermediate-
level tasks. Most would have diculty understanding
typical patient education handouts or lling in health
insurance applications.
Below basic skills
About 14% o the American adult population hashealth literacy skills below even the basic level. These
individuals are typically unable to perorm the basic
tasks needed to achieve ull unction in todays society,
including interactions with the health care system.
They can only perorm rudimentary literacy tasks like
identiying the date o a medical appointment rom a
hospital appointment slip given to them. They would
typically have diculty with basic-level tasks.
Population groups at risk orlimited health literacy
Persons with basic and below basic health literacy
skills are ound in all segments o society. In act,
most are white, native-born Americans. Nonetheless,
limited health literacy is much more common in
certain segments o the population.
Table 2 shows the percentage o certain high-risk
population groups in which many individuals scored
in the basic or below basic levels on the NAAL.These groups include the elderly, persons with limited
education, members o ethnic minorities, and people
who spoke a language other than English in their
childhood home. Unemployed persons, those with
limited income, and individuals insured by Medicaid
are also more likely to have limited health literacy.
Visual diculties and learning disabilities such as
dyslexia account or health literacy decits in only a
very small percentage o NAAL subjects.
Figure 1.
0 0 0 20 0 20 0 0 0 100
14 22 53 12Graph illustrates the percentage o participants inthe National Assessment o Adult Literacy (NAAL)with health literacy scores in each o the our literacyprociency categories.
Source: Kutner M, Greenberg E, Jin Y, Paulsen C.The Health Literacy o Americas Adults: Resultsrom the 2003 National Assessment o Adult LiteracyUS Department o Education. National Center orEducation Statistics (NCES) Publication No. 2006-483; September 2006.
Below basic Basic Intermediate Profcient
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I your patient population includes many individuals
in any o the groups mentioned above, it is likely that
your practice includes persons with limited health
literacy skills. It is important, however, to keep in
mind that persons with limited health literacy do
not t into easy stereotypes. Indeed, one study o
afuent individuals living in a geriatric retirement
community ound that 30% scored poorly on a test
o unctional literacy in health care situations.3 And
a cover article in Fortune magazine told the stories o
several billionaire executives who had limited general
literacy skills.4 As with nearly all poor readers, they
had developed coping mechanisms that worked in
their business and social lives, but might not work
well in an urgent health care situation.
Group Belowbasic
Basic Total
% % %
Age (years)
19-24 10 21 31
25-39 10 18 28
40-49 11 21 32
50-64 13 21 24
65 and older 29 30 59
Highest education level completedLess than or some high school 49 27 76
High school graduation (no college study) 15 29 44
High school equivalency diploma 14 30 44
Racial/ethnic group
White 9 19 24
Asian/Pacic Islander 13 18 31
Black 24 34 58
Hispanic (all groups) 41 25 66
Health insurance statusEmployer provided 7 17 24
Privately purchased 13 24 37
Medicare 27 30 57
Medicaid 30 30 60
No insurance 28 25 53
Source: Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy o Americas Adults: Results rom the 2003 National Assessment o Adult Literacy. USDepartment o Education. National Center or Education Statistics (NCES) Publication No. 2006-483; September 2006.
Table 2. Percentage o adult population groups with health literacy skillsat NAAL below basic and basic levels
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Day-to-day problems associated withlimited health literacy
Numerous studies in health care settings demonstratethat persons with limited health literacy skills oten
have a poor understanding o basic medical vocabulary
and health care concepts. For example, one study o
patients with limited health literacy ound that many
did not really understand the meanings o words that
clinicians regularly use in discussions with patients
words like bowel, colon, screening test, or blood
in the stool (Table 3).5 In another study, one out o
our women who said they knew what a mammogram
was turned out not to know.6
Table 3. Common medical words that patients withlimited literacy may not understand
Blood in the stool
Bowel
Colon
Growth
Lesion
Polyp
Rectum
Screening
Tumor
Source: Davis TC, Dolan NC, Ferreira MR, Tomori C, Green KW, Sipler AM,Bennett CL. The role o inadequate health literacy skills in colorectal cancerscreening. Cancer Invest. 2001;19:193-200.
Lack o understanding is not just limited to medical
terms. Several studies, conducted in both primary
care and specialty practices in dierent parts o the
United States, show that persons with limited health
literacy skills also do not understand, or are not awareo, concepts basic to common diseases. For example,
ewer than hal o low literacy patients with diabetes
knew the symptoms o hypoglycemia,7 and the
majority o low literacy patients with asthma could
not demonstrate proper use o an asthma inhaler.8
Table 4 shows some other problems experienced
by persons with limited health literacy when they
interact with the health care system.9,10,11,12
Table 4. Some other health systemproblems experienced by persons with
limited literacy skills
26%did not understand when their
next appointment was scheduled
42%did not understand instructions
to take medication on an empty
stomach
(Up to)
78%
misinterpret warnings on
prescription labels
86%could not understand rights
and responsibilities section o a
Medicaid application
Sources: (a) Williams MV, Parker RM, Baker DW, et al. Inadequate unctionalhealth literacy among patients at two public hospitals.JAMA. 1995; 274:1677-1682; (b) Baker DW, Parker RM, Williams MV, et al. The health care experienceo patients with low literacy.Arch Family Med. 1996; 5:329-334; (c) Fact Sheet:Health literacy and understanding medical inormation. Lawrenceville, NJ: Center orHealth Care Strategies; 2002; (d) Wol MS, Davis TC, Tilson HH, Bass PF III,
Parker RM. Misunderstanding o prescription drug warning labels among patientswith low literacy.Am J Health Syst Pharm. 2006; 63:1048-1055.
It is important to emphasize that limited
understanding o health concepts and health
inormation is not solely a problem o persons with
low literacy skills. Highly literate, well-educated
individuals also report diculty understanding
inormation provided to them by cliniciansusually
because clinicians use vocabulary and discuss
physiological concepts unamiliar to those whodo not have a medical education. Even patients
with average reading levels are oten unable
to understand consent orms used or research
studies on cancer drugs and may not comprehend
medication instructions, such as those or what to
do about missed oral contraceptive pills.13,14 And, in
a well-known anecdote, a prominent obstetrician
reported that he was unable to ully understand the
12 Health literacy and patient safety: Help patients understand
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explanation he received rom an orthopedist about
his upcoming orthopedic surgery.
Implications o limited health literacy
The limited ability to read and understand health-
related inormation oten translates into poor health
outcomes. Most clinicians are surprised to learn that
literacy is one o the strongest predictors o health
status. In act, all o the studies that investigated the
issue report that literacy is a stronger predictor o an
individuals health status than income, employment
status, education level, and racial or ethnic group.15,16,17
Be aware that education level is a poor surrogate
or general literacy skills and or health literacy.
Education level only measures the number o years
an individual attended schoolnot how much the
individual learned in school. Thus, asking patients
how many years o school they completed does
not adequately predict their literacy skills. Indeed,
ully 39% o NAAL participants with a high school
education had only basic reading skills, and 13% had
skills below the basic level.
2
Literacy and health knowledge
Patients with limited health literacy have less
awareness o preventive health measures and less
knowledge o their medical conditions and sel-care
instructions than their more literate counterparts.
This knowledge decit has been documented or a
variety o health conditions, ranging rom childhood
ever to asthma to hypertension. Persons with
limited health literacy skills also exhibit less healthybehaviors (Table 5).18,19
Literacy and health outcomes
Persons with limited health literacy skills have poorer
health status than the rest o the population.15,16,17,20
Indeed, several studies in diverse settings have
shown that, even ater controlling or a variety o
sociodemographic variables, limited understanding
o health concepts (i.e., poor health literacy) is
associated with worse health outcomes. This may
be due to the aorementioned decits in health
knowledge, as well as medication errors, poor
understanding o medical instructions, and lack o
sel-empowerment.
Table 5. Some health knowledge defcits and riskybehaviors o persons with limited literacy skills
Health knowledge decits
Patients with asthma less likely to know how to
use an inhaler Patient with diabetes less likely to know symptoms
o hypoglycemia
Patients with hypertension less likely to know that
weight loss and exercise lower blood pressure
Mothers less likely to know how to read a
thermometer
Less likely to understand direct-to-consumer
television advertising
Less healthy behaviors
More smoking, including during pregnancy
More exposure to violence
Less breasteeding
Less access to routine childrens health care
Sources: (a) Davis TC, Arnold C, Berkel HJ, Nandy I, Jackson RH, GlassJ. Knowledge and attitude on screening mammography among low-literate,low-income women. Cancer. 1996;78:1912-1920; (b) Williams MV, Baker DW,Parker RM, Nurss JR. Relationship o unctional health literacy to patients
knowledge o their chronic disease: a study o patients with hypertension ordiabetes.Arch Intern Med. 1998;158:166-172; (c) Davis TC, Byrd RS, ArnoldCL, Auinger P, Bocchini JA Jr. Low literacy and violence among adolescentsin a summer sports program. J Adolesc Health. 1999; 24:403-411; (d) ArnoldCL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status,reading level, and knowledge o tobacco eects among low-income pregnantwomen. Prev Med. 2001; 32:313-320; (e) Kaphingst KA, Rudd RE, DejongW, Daltroy LH. Comprehension o inormation in three direct-to-consumertelevision prescription drug advertisements among adults with limited literacy.
J Health Commun. 2005;10:609-619; () Yu SM, Huang ZJ, Schwalberg RH,Nyman RM. Parental English prociency and childrens health services access.Am J Public Health. 2006;96:1449-1455.
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The relationship between limited health literacy
and poorer health occurs in all socioeconomic groups
and in many disease states. For example, Medicaremanaged care enrollees (mostly older individuals)
are 29% more likely to be hospitalized i they have
limited health literacy skills (Figure 2).21 Medicaid
enrollees (mostly individuals with limited income)
with diabetes are less likely to have good glycemic
control i they have limited health literacy (Figure
3).22 Indeed, although not all research has come to
a similar conclusion, evidence suggests that literacy
may be the mediating actor in determining which
patients have good diabetes control.
23,24
Figure 2. Percentage o Medicaremanaged-care enrollees requiringhospitalization over a 3-year period
18%
14%Percent
20 ____________________________________
15 ____________________________________
10 ____________________________________
5 ____________________________________
0 ____________________________________
Low-literacy Adequate literacy
Source: Baker DW, Gazmararian JA, Williams MV, et al. Functional healthliteracy and the risk o hospital admission among Medicare managed careenrollees.Am J Public Health. 2002;92:1278-1283.
Figure 3. Patients with tight diabetes control
35 ____________________________________30 ____________________________________
25 ____________________________________
20 ____________________________________
15 ____________________________________
10 ____________________________________
5 ____________________________________
0 ____________________________________
Percent
Low-literacy Adequate literacy
Tight diabetes control defned as a glycated
hemoglobin level 7.2%
20%
33%
Data rom: Schillinger D, Grumbach K, Piette J, et al. Association o healthliteracy with diabetes outcomes.JAMA. 2002;288:475-482.
Literacy and health care costs
The adverse health outcomes o low health literacy
translate into increased costs or the health care
system. In one small study, the average annual healthcare costs or all Medicaid enrollees in one state was
$2,891 per enrollee, but the annual cost or enrollees
with limited literacy skills averaged $10,688 (Figure
4).25 Another study, this one o 3,260 Medicare
enrollees in sites around the country, ound higher
costs or emergency room and inpatient care or
people with limited health literacy.26
1 Health literacy and patient safety: Help patients understand
18%
14%
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Figure 4. Annual health-care costs oMedicaid enrollees
$12,000 ________________________________
$10,000 ________________________________
$8,000 ________________________________
$6,000 ________________________________
$4,000 ________________________________
$2,000 ________________________________
$0 ________________________________
All enrollees Enrollees with limited
literacy
$2,891
$10,688
Data rom: Weiss BD, Palmer R. Relationship between health care costs andvery low literacy skills in a medically needy and indigent Medicaid population.
J Am Board Family Pract. 2004;17:44-47
The combination o medication errors, excess
hospitalizations, longer hospital stays, more use o
emergency departments, and a generally higher
level o illnessall attributable to limited health
literacyis estimated to result in excess costs or the
US health care system o between $50 billion and$73 billion per year.27 According to the Center or
Health Care Strategies, this is equal to the amount
Medicare pays or physician services, dental services,
home health care, drugs, and nursing home care
combined.28
Literacy and the law
The Joint Commission and the National Committee
or Quality Assurance have both adopted guidelines
speciying the need or patient education inormationand consent documents to be written in a way that
patients can understand.29,30 Accordingly, ailure to
provide understandable inormation to patients may
be a negative actor in the accreditation status o
a health care organization. The Joint Commission
recently published a white paper on health
literacy.31
Our legal system recognizes the patient-physician
relationship as a duciary relationship, which is the
highest standard o duty implied by law. In the case
o inormed consent, courts consistently state that
because o the duciary relationship between patients
and physicians, physicians have a duty to ully
disclose, in good aith and in general terms, the risks
and benets o medical interventions and procedures.
With consistency, courts have described inormed
consent as a process o educating patients so they
understand their diagnosis and treatment. A Virginia
court stated that consent is not a piece o paper
but rather a process o physicians helping patientsunderstand their condition or the purpose o making
inormed decisions.32 The South Carolina Supreme
Court declared that a patient must have a true
understanding o procedures and their seriousness.33
Moreover, in Ohio, a court said that the physicians
duty to patients includes ully disclosing inormation
and, as ully as possible, ascertaining that patients
understand the inormation on the documents they
are signing.34
For patients with limited health literacy skills,
clinicians thus need to deliver this inormation in a
clear, plain language ormat. In act, clinicians can
best serve their patient population by providing all
patients with easy-to-understand inormation.
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You cant tell by looking
1 Health literacy and patient safety: Help patients understand
Given that 89 to 90 million adults in
the United States have limited health
literacy, you probably see patients every
day who have trouble reading and
understanding health inormation. In
addition, even persons with adequate
skills may have trouble understanding
and applying health care inormation,
especially when it is explained in
technical, unamiliar terms. Patientsmay be verbally articulate and appear
well-educated and knowledgeable,
yet ail to grasp disease concepts or
understand how to carry out medication
regimens properly.
Patients with limited health literacy can be dicult
to identiy. The population groups listed in Table
6 are known to be at higher risk or limited health
literacy, but keep in mind that many patients within
these groups actually have well-developed skills.
Conversely, many patients with limited health
literacy do not all into any o the population groups
listed in Table 6.
The important message is that you cant tell by looking
whether someone has sucient skills to adequately
understand health concepts and carry out health
care instructions. Because you cant tell just by
looking, clinicians and medical practices can bestdeliver eective medical care by providing easy-to-
understand inormation to all patients. Later in this
manual, we will show you how you can do this.
Table 6. Key risk actors or limited literacy
Elderly
Low income
Unemployed Did not nish high school
Minority ethnic group
(Hispanic, Arican American)
Recent immigrant to United States
who does not speak English
Born in United States but English
is second language
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How can I tell i an individual patient has limitedhealth literacy skills?
Red fags
While you cant tell by looking, some o your
patients may drop clues, or red fags, indicating
they have limited health literacy. I your patients
have ever lled out their registration orms or health
questionnaires incompletely or incorrectly, or taken
their medications the wrong way, they may have
done so because o limited literacy skills or because
they were not amiliar with the medical terms and
concepts in these orms. Other clues to limited
literacy are listed in Table 7.
Table 7. Behaviors and responses that may indicate limited literacy
Behaviors
Patient registration orms that are incomplete or inaccurately completed
Frequently missed appointments
Noncompliance with medication regimens
Lack o ollow-through with laboratory tests, imaging tests, or reerrals to consultants
Patients say they are taking their medication, but laboratory tests or physiological parameters do not
change in the expected ashion
Responses to receiving written inormation
I orgot my glasses. Ill read this when I get home. I orgot my glasses. Can you read this to me?
Let me bring this home so I can discuss it with my children.
Responses to questions about medication regimens
Unable to name medications
Unable to explain what medications are or
Unable to explain timing o medication administration
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It is important to understand, however, that the
absence o such clues does not indicate that a patient
has adequate health literacy. Most individuals with
limited health literacy are undetected by the health
care system. In act, patients with limited general
literacy skills go to great lengths to hide this rom
others, some even going so ar as to bring decoy
reading materials with them to the clinicians oce
or handing articles about medications or treatments
to their clinician. The majority o patients with
limited literacy skills have never told anyone in the
health care system, and most have never even told
amily members (Figure 5).35 Similarly, patients with
well-developed literacy skills who ail to understandhealth inormation may also avoid asking questions
or ear o appearing stupid or annoying to the
clinician.
In other words, you cant tell by looking and you cant
expect your patients to tell you.
Figure 5. Non-disclosure olimited literacy
Percent
90 ____________________________________
80 ____________________________________
70 ____________________________________
60 ____________________________________
50 ____________________________________
40 ____________________________________
30 ____________________________________
20 ____________________________________
10 ____________________________________0 ____________________________________
Co- Health Spouses Friends Childrenworkers care
providers
Histogram bars indicate the percentage o persons
with limited literacy skills who had never told co-
workers, health-care providers, spouses, riends,
or their children about their limited literacy.
85%
75%68%
62%
52%
Data rom: Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shameand health literacy: the unspoken connection. Patient Educ Couns. 1996;27:33-39,
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The social history
Some physicians have ound it helpul to add a
question about literacy skills to the social history.Ater asking about occupation and education, they
add How happy are you with the way you read? or
What is the best way or you to learn new things?
Use o these and similar questions gives the patient
an opportunity to open up and discuss the issue
i desired.
Recent research in this area has ocused on patients
responses to any one o several specic questions
as indicators o limited health literacy skills.36,37,38
The two questions or which the most validation
data are available are How oten do you need to
have someone help you when you read instructions,
pamphlets, or other written material rom your doctor
or pharmacy? and How condent are you lling
out medical orms by yoursel? (Table 8). These
questions have been studied in several settings and
have sensitivities or detecting limited literacy skills
ranging rom 54% to 83%.
The discussion that ollows can lead the patient
and clinician to agree on the importance o
understanding health inormation, and on the need
to nd alternate ways or patients to learn what they
need to know to care or themselves. It is essential
that such discussions, and indeed any questions about
reading skills, be conducted in a private, sae, and
supportive environment, and that all questions are
asked in a neutral, nonjudgmental ashion.
Medication review
Another suggested method or identiying patients
who have limited health literacy skills is the brown-bag medication review. At the time an appointment
is made, ask the patient to bring in all medications
(prescription and over-the-counter medications,
nutritional and herbal supplements, etc). When the
patient comes to the oce, the clinician or medical
assistant can conduct the medication review by
asking the patient to name each medication and
explain what it is or and how it is taken.
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As patients respond to these questions, note whether
they identiy medications by reading the label or by
opening the bottle and looking at or pouring the
pills into their hands. Identiying the medication
by looking at the pills may be a clue to limited
literacy skills. When responding to questions about
how to take the medication, the patient may have
memorized instructions such as take one pill three
times per day. However, when probing urther with
questions such as When was the last time you took
one o these pills? and When was the time beore
that? the patients conusion may become apparent.
Measuring health literacy
A number o instruments have been developed to
assess the health literacy skills o patients (Table
8). For the most part, these tools have been used
or research. Some clinicians, however, have used
these instruments in their own clinical settings
to measure the literacy skills o a sample o their
practices patients. Doing so permits the entire sta
to develop a better sense o the literacy level o
their overall patient population, thereby helpingensure that patient education materials and other
communication modalities are targeted appropriately
to patients level o understanding.
While many clinicians and most patient advocacy
groups have expressed concern that patients are
ashamed and will not want to have their literacy
skills assessed when they come to see a physician,
a recent study suggests otherwise. The study, which
involved nearly 600 patients, randomized 10 private
and 10 public practices in Florida into practices that
did and did not assess literacy skills o their patients.
In the practices that conducted literacy assessments,
the assessment was perormed by the practices
nursing sta at the time nurses obtained patients
vital signs. Fully 99% o patients in the practices
that assessed literacy were willing to undergo the
assessment, and doing so did not decrease patientsatisaction. In act, patient satisaction was slightly
higher in the practices that perormed literacy
assessments, perhaps because the literacy assessment
provided an opportunity or more interaction and
communication between patients and practice sta.43
20 Health literacy and patient safety: Help patients understand
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Table 8. Some methods or assessing literacy skills
Methods Description Validated in Length
English Spanish (minutes)
Single question screens3,3, 3
How oten do you need to have someone help you when you read
instructions, pamphlets, or other written material rom your doctor or
pharmacy? (positive answers are sometimes, oten, or always)
Yes No 1
How condent are you lling out medical orms by yoursel? (positive
answers are somewhat, a little bit, or not at all)
Yes No 1
Assessment instruments
Newest Vital Sign39
(www.NewestVitalSign.org)
Screening instrument or use in
clinical settings. Patients review
a nutrition label and answer 6
questions about the label.
Yes Yes 3
Rapid Estimate o Adult Literacy
in Medicine40Used in both clinical and research
settings. Word recognition
list. Patients read list o 66
words and are scored on correct
pronunciation.
Yes No 2
Short Assessment o Health
Literacy or Spanish-speaking
Adults41
Patient is presented with 50
words, each with a correct and
incorrect meaning, and patient
must select correct meaning.
No Yes 5
Short Test o Functional Health
Literacy in Adults42Used mostly in research. Patients
questioned about 4 numerical
items and 2 prose passages about
medical issues rom which specic
words have been deleted, andpatient must select appropriate
words rom a list o multiple-
choice options.
Yes Yes 8
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Strategies to enhance yourpatients health literacy
22 Health literacy and patient safety: Help patients understand
While there is little that clinicians can
do to boost the general literacy skills
o their patients, there are strategies
you can use to enhance patients
understanding o medical inormation.
In act, by making your practice more
patient-riendly, communicating in
easy-to-understand language, creating
and using patient-riendly written
materials, and veriying patientsunderstanding o inormation you
provide, you can deliver more eective
care to all o your patients.
Making your practice patient-riendly
Imagine that you are one o the nearly 36% o adults
in the United States who had basic or below basicgeneral and health literacy skills on the NAAL.
You cant read and ully understand an article in a
newspaper. You cant ll in a government application
or Social Security, Medicare, or Medicaid benets.
You cant ollow a bus schedule or a map. You dont
really understand what a cancer screening test is,
or the meaning o words like rectum, tumor,
prostate gland, or mammogram. Perhaps English
is your second language.
Imagine also that you, the patient, are coming to visit
your practice or the rst time today. What will you
nd there? What paperwork will the sta ask you to
produce or complete? What rules and procedures will
they ask you to ollow? What kinds o paperwork will
you receive i you are reerred or ancillary tests or
consultations with other clinicians, and how will you
nd your way to those tests and consultations? Will
you receive handouts and consent orms? I so, will
you be able to understand them (Figure 6)? What doyou know about your medical insurance coverage
assuming, o course, you are not one o the more than
40 million Americans without medical insurance?
This section o the manual provides suggestions and
tips or making your practice more patient-riendly
(summarized in Table 9). While the paragraphs above
use the example o a patient with limited general
literacy skills, implementing the recommendations
in this section will benet all the patients in your
practice.
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Figure 6.
Your naicisyhp has dednemmocer thatyou have a ypocsonoloc. Ypocsonolocis a test or noloc recnac. It sevlovnignitresni a elbixel gniweiv epocsinto your mutcer. You must drink alaiceps diuqil the thgin eroeb thenoitanimaxe to naelc out your noloc.
The text above, which provides basic inormation
about colonoscopy, provides a sense o what it might
be like or a person with limited literacy skills to read
a handout similar to those you may give to patients
in your oce. The words are spelled backwardscan
you read it?
Individuals with limited literacy skills preerinormation with short words and short sentences,
and that contains only essential inormation. Long or
unamiliar words, written backwards in the example
above, are oten dicult to decipher. Dicult words
slow down reading speed and as a result, decrease
understanding. Similar concerns apply to oral
communicationsimple, plain language is the best
way to communicate.
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Table 9. Checklist or patient-riendly ofce procedures
Exhibit a general attitude o helpulness.
When scheduling appointments
Have a person, not a machine, answer the phone.
Only collect necessary inormation.
Give directions to the oce.
Help patients prepare or the visit. Ask them to bring in all their medications
and a list o any questions they might have.
Use clear and easy-to-ollow signage.
Ask sta to welcome patients with a general attitude o helpulness.
During oce check-in procedures
Provide assistance with completing orms.
Only collect essential inormation.
Provide orms in patients language.
Provide orms in an easy-to-read ormat.
When reerring patients or tests, procedures, consultations
Review the instructions.
Provide directions to the site o reerral. Provide assistance with insurance issues.
When providing patients with inormation
Routinely review important instructions.
Provide handouts in an easy-to-read ormat.
Use nonwritten modalities.
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Attitude o helpulness
A general attitude o helpulness rom you and other
members o your sta can go a long way towardshelping your patients eel comortable in your
practice. This attitude starts rom the top; through
example, clinician leaders and oce managers
can encourage all employees to help patients eel
comortable asking questions about oce procedures
and their medical care. While everyone is involved,
one o the most important individuals is the person
the patient encounters rstthe receptionist.
To advertise the attitude o helpulness to patients,
it may be useul to have all members o the ocestaincluding the clinicians and clerical sta
wear a button that states, Ask me. I Can Help
(Figure 7).
Figure 7.
Scheduling appointments
When patients call the oce to make an
appointment, a person should answer the phonenot a machine asking the patient to select numerical
options. Ideally, the person answering the phone
should be able to converse with the patient in the
patients preerred language.
Inormation collected on the phone should include
only what is needed to process the appointment
and expedite oce fow. It should omit nonessential
inormation or inormation that duplicates what
others will ask later.
Ask i the patient needs directions to the oce. For
rst-time patients, oer to send (or ax or e-mail)
directions to the oce.
Finally, help patients prepare or the visit by asking
them to bring in all their medications and to make a
list o the questions they wish to ask. Let them know
that they are welcome to have someone accompany
them to the visit and be a part o the discussion.
Oce check-in procedures
Oce check-in proceduresparticularly the
completion o registration orms and health
questionnairesoten present an obstacle or
patients with limited general and health literacy. The
next time you receive a patient registration orm that
is incomplete or completed incorrectly, consider that
the patient may have had diculty reading it.
Ask me.I can help.
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Solutions to this problem are simple and benecial
to all patients who have diculty completing
registration orms (e.g., persons with limited literacy,
as well as persons with vision decits, tremors).
They are summarized in Table 10.
Table 10. Tips or assisting patients withregistration orms
Routinely oer all patients assistance in
completing orms.
Only collect inormation that is essential.
Collect inormation and/or provide assistance inthe patients preerred language.
Be sure orms are designed in
reader-riendly ormat.
First, and perhaps most importantly, oce sta
should routinely oer all patients the opportunity
to have someone assist them with the completion
o registration orms. This can be done by stating,
Some o these orms can be dicult to ll out. Iyou need help with them, please dont hesitate to
ask me or help. Assistance should be provided in a
condential manner. Patients should be brought to a
cubicle or empty examination room so they will not
have to discuss their health problems, nancial status,
or other personal matters aloud in the waiting area.
Second, registration orms should be simple and
request only necessary inormation. For example,
i a nurse or physician will later ask a patient about
medication allergies, there may be no added value
in having the patient provide this inormation on
the registration orm. Similarly, i oce sta asks or
and photocopies an insurance card, there may be
no reason to have the patient complete insurance
inormation on a registration orm. Asking patients
or unnecessary inormation serves no good purpose
and intimidates those who nd it dicult to provide
this inormation.
Third, inormation should be collected in a patientspreerred language whenever possible. Forms should
be provided in the patients preerred language, or
someone who speaks the patients preerred language
should be available to provide assistance.
In addition to the three aorementioned
recommendations, make certain that the physical
appearance and ormat o the registration orm
complies with the principles o easy-to-read patient
materials. These principles are presented in the nextsection o this manual.
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Reerrals and ancillary tests
When patients are sent or blood tests and
imaging studies, or reerred to other clinicians orconsultations, treatments, or procedures, they are
oten handed a piece o paper and told to make an
appointment. For many patients, and especially
those with limited literacy skills, making that
appointment can be dicult. Again, imagine you are
the patient with limited health literacy skills. You, as
the patient, must read the reerral instructions, then
call and make an appointment in another practice
that may have its own registration system and orms
to complete. You also need to determine i insurancecoverage will pay or this service (an advanced health
literacy task mastered only by those with procient
skills), and complete additional paperwork or the
insurance company. Then you will need to ollow pre-
appointment instructions, which could include bowel
preparation or a colonoscopy or proper adjustment o
medications beore a procedure. Finally, you will need
to get to the site o the consultation or procedure and
be present at the correct time.
Most clinicians have dealt with tasks like these and
know they can be rustrating. For a patient who has
below basic NAAL health literacy skills, these tasks
may be overwhelming.
The solutions to this problem are straightorward.
Any written instructions should be clear and simple
and, as discussed in the next section, they should be
written in easy-to-understand language and ormat.
Oce sta should review instructions with patients
and check that patients understand. It is a good idea
to read written inormation out loud, rather than
assume that your patients can read and understand
the inormation on their own.
Business oce sta should be available to assist
patients with issues related to insurance coverage.
Complicated procedures (e.g., bowel preparation)
should be reviewed in detail, as should directions tothe reerral site. It can be useul to have a simple map
on the back o reerral orms, appointment notices,
and test requisition slips, so that the directions can be
highlighted and reviewed with the patient.
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Improving interpersonalcommunication with patients
2 Health literacy and patient safety: Help patients understand
Clinician-patient communication is
an important actor in health literacy.
Good communication is crucial or a
successul clinician-patient relationship
and eective exchange o inormation.
Breakdowns in communication can
lead to conusion or patients, poor
health outcomes, and even malpractice
lawsuits against clinicians.
Communication and malpractice lawsuits
Poor communication between patients and
clinicians is a major actor leading to malpracticelawsuits. In act, attorneys estimate that a clinicians
communication style and attitude are major actors
in nearly 75% o malpractice suits.44 The most
requently identied communication errors are
inadequate explanations o diagnosis or treatment,
and communicating in such a way that patients
eel that their concerns have been ignored
(Table 11).45,46,47,48
Table 11. Clinician-patient communicationproblems involved in malpractice lawsuits
Inadequate explanation o diagnoses
Inadequate explanation o treatment
Patient eels ignored
Clinician ails to understand perspective o patient
or relatives
Clinician discounts or devalues views o patients
or relatives
Patient eels rushed
Sources: (a) Vincent C, Young M, Phillips A. Why do people sue doctors? astudy o patients and relatives taking legal action. Lancet. 1994; 343:1609-1613; (b) Hickson GB, Clayton EW, Githena PB, Sloan FA. Factors thatprompted amilies to le medical malpractice claims ollowing perinatalinjuries.JAMA. 1992; 267:1359-1363; (c) Hickson GB, Clayton EW, EntmanSS, et al. Obstetricians prior malpractice experience and patients satisactionwith care.JAMA. 1994; 272:1583-1587.
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Communication and medical outcomes
Studies have shown that eective communication
with patients has a benecial eect on medicaloutcomes. These benets include lower rates o
anxiety, pain, and psychological distress, and higher
rates o compliance and symptom resolution.49
In particular, it has long been known that patients
adherence to therapy is heavily infuenced by
communication style. Specically, clear and concise
instructions delivered to patients by clinicians the
patients trust are associated with improved rates o
adherence.50
Steps to improving communication with patients
General consensus exists among health literacy
and communication experts that there are six basic
methods or improving communication with patients
(Table 12).51,52 Although initially recommended
based on expert opinion, research results are
providing evidence that these methods work.
Table 12. Six steps to improving interpersonalcommunication with patients
1. Slow down.
Communication can be improved by speaking
slowly, and by spending just a small amount o
additional time with each patient. This will
help oster a patient-centered approach to the
clinician-patient interaction.
2. Use plain, nonmedical language.
Explain things to patients like you would explain
them to your grandmother.
3. Show or draw pictures.Visual images can improve the patients
recall o ideas.
4. Limit the amount o inormation provided
and repeat it.
Inormation is best remembered when it is given
in small pieces that are pertinent to the tasks at
hand. Repetition urther enhances recall.
5. Use the teach-back technique.
Conrm that patients understand by asking them
to repeat back your instructions.
6. Create a shame-ree environment: Encourage
questions.
Make patients eel comortable asking questions.
Consider using the Ask-Me-3 program. Enlist
the aid o others (patients amily or riends) to
promote understanding.
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Slow down
Communication is improvedand the risk o
malpractice claims decreasedwhen clinicians spendmore time with patients. Only a short amount o time
is needed to make a dierence. Data rom multiple
US states indicate that primary care physicians who
have been the target o malpractice liability claims
spend an average o 15 minutes per patient on
routine visits, while physicians who have never had
a malpractice claim against them spend an average
o 18 minutes. This is a dierence o a mere three
minutes.53
In addition to spending more time, clinicians can
optimize the use o this time by creating a patient-
centered visit. In a patient-centered visit, the
clinician ocuses on addressing the patients concerns.
Behaviors such as sitting rather than standing,
listening rather than speaking, and speaking slowly
can urther create an impression that you are ocused
on the patient, and patients may respond to these
behaviors by perceiving that you have spent more
time with them than you actually have. These and
other useul behaviors are listed in Table 13.
Table 13. Behaviors that improve communication
Use orienting statements: First I will ask you
some questions, and then I will listen to your
heart.
Ask patients i they have any concerns that have
not been addressed.
Ask patients to explain their understanding otheir medical problems or treatments.
Encourage patients to ask questions.
Sit rather than stand.
Listen rather than speak.
Clinicians oten express concern that a patient-
centered approach results in a substantial increase
in the duration o oce visits. Research shows
otherwise. In one important study, patients who
were allowed to talk without interruption or as
long as they liked spoke or an average o only one
minute and 40 seconds.54 In another study, patients
were permitted to voice their initial concerns at the
beginning o an oce visit, again or as long as they
wished without interruption. The mean spontaneous
talking time was only 92 seconds, with a median
value o 59 seconds.55
While patient-centered visits do not takesubstantially longer than traditional visits, they create
an atmosphere in which patients eel that their needs
have been met. This aids in the development o an
eective patient-clinician alliance, with potential
benets such as increased patient compliance and
decreased risk o malpractice suits.
Use plain, nonmedical language
You should always seek to use plain, nonmedical
language when speaking to patients. Words that
clinicians use in their day-to-day conversations
with colleagues may be unamiliar to the majority o
nonmedically trained persons.
A good approach is to explain things to patients
in language that you might use when talking to
your grandmother. This is sometimes called living
room language, the language o the amily, or
conversational language. Table 14 gives some
examples o plain language alternatives to medicalwords. Conversational language creates opportunities
or dialogue between the clinician and patient, rather
than limiting communication to a monologue by
the physician.
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Table 14. Plain language alternatives to medical terms patients may not understand
Medical term Translation into plain language
Analgesic Pain killer
Anti-infammatory Lessens swelling and irritation
Benign Not cancer
Carcinoma Cancer
Cardiac problem Heart problem
Cellulitis Skin inection
Contraception Birth control
Enlarge Get biggerHeart ailure Heart isnt pumping well
Hypertension High blood pressure
Inertility Cant get pregnant
Lateral Outside
Lipids Fats in the blood
Menopause Stopping periods, change o lie
Menses Period
Monitor Keep track o, keep an eye on
Oral By mouth
Osteoporosis Sot, breakable bones
Reerral Send you to another doctor
Terminal Going to die
Toxic Poisonous
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Show or draw pictures to enhance patients
understanding and recall
The saying that a picture is worth a thousandwords is particularly true when communicating
with patients who may have trouble understanding
medical concepts delivered in words.It has long been
known that visual images are remembered better
than letters and words.56 That is why we oten recall
a persons ace but not their name, or the picture on
a books cover, but not the name or author o the
book.57
Research shows that pictures enhance patientsunderstanding o what they need to do.58,59 Pictures
are not substitutes, however, or written or verbal
communication, as understanding is best when
pictures are combined with written or verbal
explanations.
Furthermore, the most eective pictures are simple
ones. For example, i you are trying to explain that
an aortic valve needs to be replaced, the illustration
should display a heart, an aorta, and an aortic
valve. Additional details, such as coronary arteries
and other heart valves, and perhaps all the cardiac
chambers, should not be included i they are not
relevant to the patients specic health problem.
Inclusion o irrelevant details distracts the patient
and diminishes the eectiveness o the picture as a
teaching tool.
Limit the amount o inormation given at each
visitand repeat it
Another key to eective communication is to limitthe amount o inormation provided to patients at
each visit. This does not mean you should withhold
important inormation. Rather, it means that you
should ocus your communication on the one or the
ew most important things a patient needs to know
at the time o the visit. The principle behind this
approach is that advice is remembered better, and
patients are more likely to act on it, when the advice
is given in small pieces and is relevant to the patients
current needs or situation.
For example, at a patients rst visit ollowing a
diagnosis o type 2 diabetes, the most important
message oten is that the sugar level in your blood
is high, and you must start taking medicine to lower
the sugar level. Inormation about physiology o
glucose control, while ultimately important or the
patients ability to sel-regulate diabetes control, is
not important at the rst visit and should not be
discussed at that time. Inormation about potential
complications o diabetes might be mentioned, but is
not the main ocus o the visit. The ocus o the rst
visit is the initiation o treatment.
Ater discussing the key inormation with a patient,
this inormation should be reviewed and repeated,
because repetition is the key to learning and memory.
Ideally, the inormation will be reviewed and
repeated by multiple members o the health care
teamperhaps by a physician, nurse, pharmacist,
dietician, and others.
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Repetition can be achieved even ater the patients
visit through handouts to reinorce the inormation
provided in person. Consider reading handouts
to patients to emphasize the importance o the
inormation. I the handout is too long to read out
loud, it may be too complex and consideration should
be given to developing and using simpler handouts.
Preparation o patient-riendly handouts will be
discussed in the next section o this manual.
Some experts suggest calling patients several days
ater delivering important inormation to urther
reinorce learning.60 While not routinely necessary,
such phone calls can be helpul or reinorcingparticularly important inormation. When making
this call, try to avoid making it seem that you are
calling only to repeat the instructions or to check
up on the patient. Rather, make it clear that you
want to help by stating, I just wanted to be sure
that everything I told you was clear, and to
nd out how are you doing with the treatments I
recommended.
Use the teach-back technique
The teach-back technique is an eective method
or ensuring that patients understand what you have
told them (Table 15). It involves asking patients to
explain or demonstrate what they have been told. For
example, you can say, I want you to explain to me
how you will take your medication, so I can be sure I
have explained everything correctly, or Please show
me how you will use the asthma inhaler, so I can be
sure I have given you clear instructions, or When
you get home your spouse will ask you what thedoctor saidwhat will you tell your spouse?
Table 15. The teach-back technique
Do not ask a patient, Do you understand?
Instead, ask patients to explain or demonstratehow they will undertake a recommended
treatment or intervention.
I the patient does not explain correctly, assume
that you have not provided adequate teaching. Re-
teach the inormation using alternate approaches.
In using the teach-back technique, clinicians take
responsibility or adequate teaching. I patients
cannot explain or demonstrate what they shoulddo, clinicians must assume that they did not
provide patients with an adequate explanation or
understandable instructions. The result should be
new eorts to ensure that patients learn what they
need to know. And, o course, it is important not
to appear rushed, annoyed, or bored during these
eortsyour aect must agree with your words.
Research indicates that the teach-back technique
is eective, not just or improving patients
understanding, but also or improving outcomes.
For example, patients with diabetes whose physicians
assess patients comprehension and recall with the
teach-back technique have signicantly better
diabetes control than patients whose physicians do
not use the technique.61
The teach-back technique should replace the more
common practice o simply asking a patient, Do you
understand what I have told you? Experience shows
that patients oten answer yes to such questions,even when they understand nothing.
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Create a shame-ree environment:
Encourage questions
To oster eective communication with patients, itis essential to create a shame-ree environment in
which patients eel comortable asking questions
about what they do not understand. Without such an
environment, many patients, even those with well-
developed literacy skills, may eign understanding
material to avoid seeming stupid or annoying to
the clinician.
One simple strategy to encourage questions is to
let patients know that many people have dicultyreading and understanding the medical inormation
I give them, so please eel comortable asking
questions i theres something you dont understand.
Make certain to ollow up on this by answering any
questions your patient may have.
Another strategy is to ask patients during the visit
i they would like a amily member or riend to be
with them during discussions about diagnoses and
options or treatment. Research shows that patients
with limited health literacy oten seek the assistance
o amily or riends ater visits with clinicians in
interpreting what their clinicians told them.62 By
oering this opportunity in a routine, nonjudgmental
way, patients will eel comortable bringing others
into the examination room.
Ask-Me-3
The Ask-Me-3 program is a more ormal, but
potentially eective approach to encouragingquestions.63 Sponsored by the Partnership or Clear
Health Communication, a large consortium o
proessional organizations that includes the AMA
Foundation, Ask-Me-3 encourages patients to ask,
and physicians to answer, three basic questions during
every medical encounter. The questions are shown in
Table 16.
The Ask-Me-3 questions serve as an activation tool
that encourages patients to ask questions. Patientsare made aware o the program through posters and
brochures displayed in the oce. Evidence shows
that even long ater Ask-Me-3 is implemented in a
practice, many patients continue to ask the questions
and nd them a useul ramework or engaging in
conversation with their clinician.64
Table 16. The Ask-Me-3 questions
What is my main problem? What do I need to do (about the problem)?
Why is it important or me to do this?
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Written consent orms andpatient education handouts
The readability o consent orms and patienteducation handouts has received more attention than
perhaps any other health literacy issue. Countless
studies in a variety o health care settings have
shown that there is a mismatch between patients
reading skills and the reading skills needed to
comprehend the consent orms and handouts they
are given.65,66,67,68,69,70 More recent studies reveal that
patient education materials on the Internet are also
too dicult or the average reader.71,72,73 Indeed, most
written materials intended or patients are writtenat a diculty level that exceeds the reading skills o
average Americans.
Medical practices should ensure that the reading
diculty level o their patient materials matches
the reading skills o the patients. Clinicians can
use a variety o approaches to reach this goal. One
approach is to develop practice-specic written
materials; the principles or doing this are discussed
below and shown in Table 17. Alternatively,clinicians can purchase materials that have already
been developed on the basis o these principles;
such reader-riendly written materials may be ound
through the list o useul resources at the end o
this manual.
Whatever written materials are used, their
eectiveness may be increased i the clinician or
sta reads them aloud and highlights, underlines,
circles, or numbers key points or the patient to
remember. Drawing supplemental pictures and
writing out steps and directions or individual
patients can also be helpul.
Principles or creating patient-riendly
written materials
Written materials that are easy or patients toread and understand are benecial to all patients.
Indeed, evidence indicates that all patientsnot just
those with limited literacy skillspreer easy-to-
read materials to more complex or comprehensive
materials.
The basic principles (Table 17) or creating patient-
riendly written materials involve attention to
(a) the depth and detail o the content, (b) the
complexity o the text itsel, (c) the ormat inwhich the material is prepared, and (d) user testing.
The practical application o these principles is
reviewed in the ollowing paragraphs. Readers who
desire more detailed inormation on creating easy-
to-read written materials or patients can consult
standard textbooks74,75,76 on creating eective
patient education inormation, or attend seminars or
workshops oered by experts in the eld (see Useul
resources at the end o this manual).
Creating and using patient-riendlywritten materials
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Table 17. Formatting checklist or easy-to-read written materials
General content
Limit content to one or two key objectives. Dont provide too much inormation or try to
cover everything at once.
Limit content to what patients really need to know. Avoid inormation overload.
Use only words that are well known to individuals without medical training.
Make certain content is appropriate or age and culture o the target audience.
Text construction
Write at or below the 6th-grade level. Use one- or two-syllable words.
Use short paragraphs.
Use active voice.
Avoid all but the most simple tables and graphs. Clear explanations (legends) should be placed
adjacent to the table or graph, and also in the text.
Fonts and typestyle
Use large ont (minimum 12 point) with seris. (Seri text has the little horizontal lines that you see in this
text at the bottoms o letters like , x, n, and others. This text, on the other hand, is non-seri.) Dont use more than two or three ont styles on a page. Consistency in appearance is important.
Use upper- and lower-case text. ALL UPPER-CASE TEXT IS HARD TO READ.
Layout
Ensure a good amount o empty space on the page. Dont clutter the page with text or pictures.
Use headings and subheadings to separate blo