May/June 2012

Health Literacy’s Critical Importance

By Daniel J. Oates, MD, MSc, and Ryan M. Zitnay, MD
Aging Well
Vol. 5 No. 3 P. 34

Numerous studies have demonstrated that failure in provider-patient communication compromises healthcare outcomes. Clear communication is essential to the delivery of efficient and effective medical care. Simply stated, one can possess the most impressive knowledge base or be a world-renowned authority in his or her field, but without the ability to communicate effectively with patients using language they can easily understand, failure is imminent.

One of our patients was scheduled for a routine screening colonoscopy. The advanced practice nurse with more than 30 years of geriatrics experience visited the patient to go through all the preprocedure instructions. “She’s all set for the colonoscopy. I called in the script for the Golytely and went over everything,” she reported. I was thrilled, as this prep is often challenging.

The patient visited the office a few weeks later, a week before her procedure. To be absolutely certain that the procedure would go well I asked, “Mrs G, I know that the nurse was out to see you, but just to be sure, please tell me what you’re going to do the day before your colonoscopy.” She rolled her eyes at me and replied, “Dr Oates, she was here. I know what to do.” I asked again, “Just so we are on the same page, please tell me.”

“OK,” she replied. “I am going to collect my urine in that bottle over there [pointing to the empty 4 L bottle of Golytely on the couch] the day before I go for my colonoscopy and bring it with me to the procedure.” I paused, took hold of the situation, and started again.

It’s an all-too-common scenario between providers and patients: Communication breakdown leads to missed opportunities and frustration for all involved parties. It seems as though it should be the most straightforward aspect of complex medical care. So why, in reality, is it so challenging?

As an aspect of this complex issue, providers must consider a patient’s health literacy. Health literacy is defined as a patient’s ability to understand, use, and act on health information to make informed decisions regarding their healthcare. According to the 2003 National Assessment of Adult Literacy, 36% of adults in the United States possess basic or below-basic health literacy skills. In the geriatric population, the statistics are even more striking, with more than 50% of patients aged 80 to 84 and more than 70% of those aged 85 and older having marginal or limited health literacy.

For most people with basic health literacy skills, common documents such as patient education brochures, informed consent forms, and even pill bottles are beyond comprehension. After further investigation of our Golytely situation, this complex colonoscopy prep strategy did not stand a chance.

So how do healthcare providers tackle this seemingly insurmountable obstacle? The fix is actually quite intuitive and surprisingly, for once, has no added cost. Use effective techniques such as speaking slowly in simple and specific language, limiting the amount of information discussed in one session, and mastering the “teach back” (“Tell me what you are going to tell your family about what we talked about today. We discussed a lot of information, and I want to ensure I did a good job conveying it to you.”).

Such techniques can effectively promote patient understanding and retention. Be creative in your modes of communication by integrating pictures, drawings, or gestures to stress important aspects of the plan. And when closing the conversation, leave adequate time for patient questions, ensuring that the opportunity is framed in an inviting manner, such as “What questions do you have for me?” rather than the more directive “Do you have any questions?”

In our geriatric practice, being attentive to health literacy and implementing these tried-and-true techniques has increasingly led to a true on-the-same-page scenario between clinicians and our elderly patients. Our clinic sessions are more seamless and time efficient. The techniques optimize professional satisfaction while minimizing unnecessary time and frustration. And most importantly, there are far fewer cancelled procedures and far more successful colonoscopies, controlled blood pressures, and happy patients.

— Daniel J. Oates, MD, MSc, an assistant professor of medicine at Boston University School of Medicine and a geriatrician at Boston Medical Center, is interested in health literacy, particularly in developing educational interventions for trainees and practicing providers.

— Ryan M. Zitnay, MD, is a fellow in geriatric medicine at Boston Medical Center and has an interest in using reflective teaching to promote trainee and physician self-care and awareness to improve patient care experiences and professional satisfaction.