A patient with few family or social connections is also cause for concern, adds Dr. Halasyamani: “Lack of social support means there’s not another set of eyes and ears taking in the information.” Yet another red flag to her is the patient who cannot describe his plans for pursuing his care at home.
When patients have their medications with them, Dr. Williams asks how they take them. Those who can read simply look at the label, but a patient with literacy problems must open the bottle and look at the pills to identify them.
How can physicians ensure that these patients understand and can follow instructions? Perhaps the easiest and most effective way is the “teach-back” approach, in which you ask the patient to repeat or teach back to you what you’ve just explained to him. For example, you might have him show you how to use an asthma inhaler or how to measure his blood glucose. In this way, you can rapidly assess and correct any deficiencies in the patient’s understanding.
“I’ve seen it take less than 90 seconds for physicians to confirm patient understanding in the context of a clinical visit,” says Dr. Kripalani.
A related technique that might help save time is to resist the temptation to tell the patient too much in a single visit. “Don’t try to give the patient too much information,” he advises. “People can process and retain maybe three nuggets of information at a time, so tell the patient the three most important things and then confirm their understanding of those three things.”
Dr. DeBuono suggests using visual aids like pictures or cartoons to help get important points across. If written material is necessary, have it printed in large type, which might appear less daunting than a page covered in dense, tiny print.
Above all, never embarrass a patient by bluntly asking him if he can read. “Explore the issue sensitively and respectfully,” Dr. Williams says. “Ask if they ever struggle with written materials or what the best way is for them to learn.” Adds Dr. DeBuono, “just by being sensitive to the fact that the patient may not understand is half the game.” TH
Norra MacReady is a medical journalist based in Southern California.
*“There’s no use crying over spilt milk.”
- Rudd RE. Literacy and implications for navigating health care. Harvard School of Public Health: Health Literacy Website. Slide 20. 2002. Available at www.hsph.harvard.edu/healthliteracy/slides/2002/2002_01.html. Last accessed December 1, 2006.
- Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002 Jul 24;288(4):475-482.
- Paasche-Orlow MK, Schillinger D, Greene SM, et al. How health care systems can begin to address the challenge of limited literacy. J Gen Intern Med. 2006 Aug;21(8):884-887.
- Marcus EN. The silent epidemic—the health effects of illiteracy. N Engl J Med. 2006 Jul 27;355(4):339-341. Erratum in N Engl J Med. 2006 Sept 7;355(10):1076.
- Williams MV. Recognizing and overcoming inadequate health literacy, a barrier to care. Cleve Clin J Med. 2002 May;69(5):415-418.
- Weiss BD. Health literacy: a manual for clinicians [American Medical Association Web site]. American Medical Association Foundation and the American Medical Association, 2003. Available at: www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf. Last accessed December 16, 2006.
- Powers BJ, Bosworth HB. Revisiting literacy and adherence: future clinical and research directions. J Gen Intern Med. 2006;21:1341-1342.
Just asking, “Do you understand?” rarely works because the patient may just nod yes. Physicians need to assess the patient’s comprehension proactively.—Mark Williams, MD, professor of medicine and director of the hospital medicine unit at Emory University School of Medicine, Atlanta.