Health Literacy Perspective of a Hospital Clinician and Educator

Health Literacy WorkshopSydney, November 2014

Professor Imogen MitchellSenior Staff Specialist, Intensive Care, The Canberra Hospital

Deputy Dean, ANU Medical School

Immediate Challenge

• 60% Adult Australians have a low health literacy

• Patients remember and understand less than half of what clinicians explain to them

Immediate Challenges• Health literacy not an immediately approachable term for hospital clinicians• Many traditions embedded for over a century, if not longer

paternalistic view doctor knows best (no need to question)language of mystery allows supremacy (too intimidating to engage with)time jealous open conversations deemed not as important

assumptions patient/families will undertake instructions delivered• Many variables affect health literacy particularly in hospitals

acutely unwell just want someone to sort something outdelirious the illness creates confusionemotional shock not in any frame of mind to take something in

Health Literacy• Clinicians need to deliver an outcome where information is provided

in such a way that the information is:UnderstoodApplied to enable decision making and action

• Medical educators describe a learning outcome where a concept is:UnderstoodApplied to make decisions and act to ensure patients are safe

• Can a similar approach be taken?

Approach to Teaching and Learning• Gap Analysis

What are the differences between what the student understands and what you would like them to understand• Set Learning Outcomes

Describe what it is you want your students to do by the end of their time• Spiral curriculum

Start with simple concepts and build upon themprior knowledge not assumed, language not assumed, repetition

• Questions and ReflectionAllow students to apply concepts and understand how they arrived at their answer

Approach to Health Literacy• Gap Analysis

What does your patient understand so far? What gaps need to be filled?• Set Learning Outcomes

What is it that needs to happen? Help patient arrive at a decision? Correct medication to be taken? Understand the implications of a diagnosis?

• Spiral curriculumUse language that can be understood, allow time, chunk information into small, manageable sound bytes building upon their pre-existing knowledge

• Questions and ReflectionCheck for understanding using teach back

AMC Graduate Outcome

• Elicit patients’ questions and their views, concerns and preferences, promote rapport, and ensure patients’ full understanding of their problem(s). Involve patients in decision making and planning their treatment, including communicating risk and benefit of management options

• Provide information to patients, family/carers where relevant, to enable them to make a fully informed choice among various diagnostic, therapeutic and management options.

The ANU Medical School

Year 1 and 2: Clinical Skills: Doctor-Patient CommunicationCalgary Cambridge Guide to the Medical Interview• Initiating the session• Gathering information• Providing structure• Building relationship• Explanation and planning• Closing the session

Calgary Cambridge Guide to the Medical Interview

Gathering information• Exploration of problems• Additional skills for understanding the patient’s perspective

• Actively determines and appropriately explores:• Patients ideas (i.e. beliefs re cause)• Patients concerns (i.e. worries) regarding each problem• Patients expectations (i.e., goals, what help the patient had expected for each

problem)• Effects: how each problem affects the patients life

• Encourages patient to express feelings

ANU Medical School

Year 3 and 4: Professionalism and LeadershipLearning Outcome:“You will demonstrate excellent communication skills that are patient

centred, and enable patients and carers to understand their health problems and share decision making around their health care choices; support the maintenance of a patient’s privacy and dignity; recognise the impact of your own values and your professional status in engaging with patients, carers and colleagues”

Teach Back*• Asking patients to repeat in their own words what they need to

know or do, in a non-shaming way.

• NOT a test of the patient, but of how well you explained a concept.

• A chance to check for understanding and, if necessary, re-teach the information.

*Iowa Health System Literacy Collaborative

Teach Back ExamplesAsk patients to demonstrate understanding,• using their own words:• “I want to be sure I explained everything clearly. Can you please

explain it back to me so I can be sure I did?”

• “What will you tell your husband about the changes we made to your blood pressure medicines today?”

• Creates an opportunity for dialogue in which the clinician gives information, then asks the patient to respond and confirm understanding before adding any new information.

Teach Back: Using it Well

• Responsibility is with the clinician• Use a caring tone of voice and attitude• Use plain language• Ask patient to explain using their own words (not yes/no)• Use for all important patient education, specific to the condition• Document use of and response to teach-back

Improving Health Literacy

Engage clinicians• At an early stage, provide understanding of health literacy and its critical

importance• Provide data that supports its importance particularly in terms of current

status of communication, better outcomes with better communication• Embed health literacy into every day activities and change the language• Continually provide the linkage between health literacy activities and better

outcomes for the patient• Remind them continuously “No decision about me without me”

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