Understanding a physician’s instructions is crucial for positive patient outcomes. How often do you ask your patients to repeat treatment directions to determine if they fully understand what they need to do? Observational studies report this occurs in less than 20 percent of patient encounters, even with complex diseases and treatment changes. This is a lost opportunity to reduce mortality, morbidity as well as lower health care costs.

Health literacy is complex

Health literacy affects more than basic care instructions or how to take a medication. It determines a patient’s understanding about his or her health conditions, preventive treatments, compliance with treatment plans, health insurance options, informed consent and every aspect of the health care system.

Health literacy means having the ability to obtain, process and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment. However, only about 12 percent of American adults fully meet this health literacy standard. More than a third of American adults cannot understand typical medication information, according to the Agency for Healthcare Research and Quality (AHRQ).

The Arkansas Department of Health estimates that 37 percent of adult Arkansans have low health literacy. Less than 60 percent of the United States adult population has English as their first language, according to the National Institutes of Health (NIH). The Office of Management and Budget estimated in a 2002 report that there are 66 million patient encounters across language barriers annually.

The average American adult has an eighth-grade reading level; 20 percent of the population reads at or below a fifth-grade level, says the U.S. Department of Education. However, most medical information is written at a 12th-grade level or higher.

Health literacy includes more than reading level. Is means having the ability to analyze and decode instructions, understand charts and diagrams, understand and weigh risks and benefits, and mathematical skills needed to understand dosages, and calculate premiums, copays and deductibles. The NIH says it is increasingly difficult for people to separate evidence-based information, especially online, from misleading ads, gimmicks or “fake” news. Adding to this uncertainty are increasingly complex treatment regimens and medications, the use of multiple clinicians, the need to initiate lifestyle changes and self-monitor changes in health status.

Patients can recall or comprehend barely half of what physicians tell them. However, it is safe to say that health care professionals try to and believe they are communicating effectively in every patient encounter. Likewise, many patients believe they understand their provider’s instructions. Some patients, fearing their provider will think they are “stupid,” are unwilling to ask questions to confirm their understanding.

Complex instructions, explained rapidly and delivered to a patient in a stressful situation, from unfamiliar clinicians, using unknown medical jargon are not likely to be understood, much less retained. Additionally, everyone – including highly educated people – can misunderstand health information when the issue is emotionally charged or complex.

Misunderstanding increases costs

The costs of low health literacy are staggering – $106 to $236 billion annually. The NIH estimates that low-literacy Medicare beneficiaries’ health care costs were four times higher than for those with high-level literacy. Low health literacy correlates with worse health status and a greater use of health services.

Health literacy is a fundamental component of efforts to reduce health disparities and improve population health. Patients with low health literacy have poorer control over managing chronic diseases and have less understanding of and participation in disease prevention programs.

Universal problem

People of all ages, races, and income and education levels are challenged by health literacy. Those who are especially vulnerable in a health care setting include immigrants, people with English as a second language, minorities, older adults, persons with limited formal education, low-income people and homeless people. Among Americans over age 65, the low-health-literacy rates exceed 80 percent, according to the U.S. Department of Education. Health literacy can have more impact on elderly patients because many have multiple illnesses and chronic conditions, and are prescribed more medications than any other age cohort. Their vision, hearing and cognition status also influences their reading and comprehension abilities.

It is impossible to determine health literacy by observation alone. Low-literacy adults have learned to hide their inadequacy due to feelings of shame and decreased self-worth about their skills and knowledge deficits. Most are too embarrassed to ask questions or fear asking a “stupid” question. Other clues to low literacy include excuses such as “I forgot my glasses.” Low-health-literacy patients have difficulty explaining their medical or health concerns and cannot explain what their medications are for or how to take them. They may ask office staff for help or bring a person with them who can read. They don’t follow through with tests and appointments, and are non-compliant with medications, recommended interventions and treatments. They will postpone decision making “until I can talk to my family about this,” or “I’ll read this when I get home.” They may have many papers folded up in their purse or pocket. They seldom ask questions and if they do, the questions are very basic.

Communication strategies

The following list of strategies can increase communication with your patients and improve outcomes. It was included in AFMC’s column, A Closer Look at Quality in the Journal of the Arkansas Medical Society:

  • Use plain language; avoid medical jargon. Speak slowly. Listen to the patient and use his or her terms.
  • Keep instructions short and avoid vague terms. Reinforce and repeat instructions.
  • Focus on one to three key messages. Ask the patient to list top concerns and combine those with your key messages to focus instructions on a manageable amount of information.
  • Focus your instructions on specific actions the patient needs to take and personalize instructions.
  • Develop short, simple explanations for side effects and common medical conditions.
  • Include what condition the medication will treat when writing prescriptions.
  • Avoid using BID on a prescription; change to “take with breakfast and supper,” or give exact times.
  • Communicate with the pharmacist when you stop a patient’s medication.

Asking patients to “teach back” what they have been told improves medical outcomes. It is also one of the top patient safety practices for reducing medical errors. After explaining a new concept, new medication or treatment plan, ask the patient to repeat what you said, in his or her own words. The response will tell you far more about his or her understanding than asking, “Do you understand?” Continue to reassess comprehension and adjust your response until the patient has a full understanding. Putting the burden of effective communication and understanding on yourself, makes patients more at ease and willing to make an effort to comprehend.

The AHRQ recommends implementing a universal precautions approach, one that simplifies and reinforces all communications for all patients.

For more information, visit this website for additional ways to improve your patient-communication strategies from CMS.  It includes free downloadable tools to help you with low-literacy patients.

The onus of effective communication lies with the health care provider. Educating the patient is one of the three main functions of medical encounters. Don’t assume your patients understand you without carefully checking their ability to use their own words to repeat your instructions – with every patient, in every encounter. Remember George Bernard Shaw’s advice, “The main problem with communication is the assumption that it has occurred.”