Monday, February 10, 2014

Overcoming "noncompliance" with universal literacy precautions

- Jennifer Middleton, MD, MPH

I suspect that most family physicians try to provide health information to their patients in a lay-friendly way. Like them, I try to avoid jargon, give clear instructions, and use techniques like "teach-back" to maximize my patients' understanding.

Unfortunately, an article in the current issue of Family Practice Management highlights a common divide between physicians' perceptions of their patients' health literacy and their patients' true health literacy. The article defines health literacy as
the ability of patients to find, understand, and use health-related information to make good decisions about their medical care and personal health.
When patients are confused about how to take their medications or implement their physicians' instructions, they are much less likely to comply with these instructions.  Frustrated physicians may then label these patients as "noncompliant," and assign reasons for this noncompliance that have nothing to do with the true cause.

The article, written by AFP medical editor Dr. Barry Weiss, cites studies showing that 1/3 of US adults have low health literacy; and, in some population groups (older adults, African-Americans, Hispanics, American Indian/Alaska Natives), it can be 1/2 or more of adults. I know that, myself, I had not considered that such a high proportion of my patients might have difficulty understanding me.

Although there are screening instruments to identify low health literacy, the author argues that we should use "universal literacy precautions" for all patients instead. Words such as "benign," "cardiologist," and "bacteria" can confuse patients with even good health literacy; Dr. Weiss suggests using "not cancer," 'heart doctor," and "germs" instead.  (He provides multiple other examples and suggested changes in a table on page 16 of the article.) Speaking more slowly and limiting the information we provide to the essentials benefits all patients. And, yes, the "teach back" technique can also help. This 2005 article from AFP provides additional suggestions.

This article has changed my practice; as a naturally quick speaker who was liberally lacing my patient dialogues with some of these words, I now wonder how many of my "noncompliant" patients were struggling to understand me. I focus on slowing down and define an echocardiogram for patients as a "picture of your heart" instead of just handing them the order. I gently correct medical students when I hear them tell patients to take their medication orally instead of "by mouth," and I make sure that patients know that an MRI provides me with "pictures" of their body.

How are you doing with your patients with low health literacy? Will this article change your practice?