Grand Rounds: State of the Science: Current/Future Directions and Controversies in Health Literacy Research

October 29, 2008

Bellevue Amphitheater

Commentary by Rosemary Adamson MD, PGY-3

Please also see the clinical vignette presented before last week’s grand rounds. 

The topic of medicine grand rounds this week, health literacy, seemed likely to be dear to the heart of any Bellevue doctor, but I was astounded to learn that the average reading level in the US is that of a 7th or 8th grader, making this topic much more widely applicable than I had thought. Research has demonstrated that low literacy levels are associated with increased use of preventive services and hospitalization, delay in diagnosis, poor adherence to instructions and increased healthcare costs. This suggests that it is worth trying to overcome poor health literacy not only to improve patient outcomes but also to contain healthcare costs. However, health literacy is a complex topic to research and this is compounded by the fact that the definition of health literacy is increasingly complex: it is one’s ability to obtain, process, and understand health information to make informed decisions.  Last week’s Grand Rounds speaker was Michael S. Wolf, MA, MPH, PhD, Assistant Professor of Medicine & Director for the Center of Communication in Health Care and the Health Literacy and Learning Program, Northwestern University Feinberg School of Medicine. Dr. Wolf stated that health literacy can be thought of as a person’s “health learning capacity”. It encompasses a cognitive skill set, which is beyond simply the ability to read, and a psychosocial skill set, which includes communications skills.

Dr.Wolf listed 4 targets for intervention to enable patients with low literacy to better navigate the healthcare system: patient skills, clinician skills, health materials and health system design. I will concentrate on his suggestions for the latter 3 targets, since these are interventions which we can use in our practice.

Clinician Skills

Clinicians are responsible for minimizing the cognitive load on patients and helping the patient to contextualize the information. Dr. Wolf suggested the following techniques:

  • Decide what you think is most important for the patient to learn at that visit and do not try to teach too much in one visit.

  • “Chunk” information about one topic together.

  • Repeat information.

  • Assess patient’s memory of what you have told them.

  • Ask the questions to help the patient contextualize the concept. For example, when prescribing a twice daily medicine, ask the patient what times she is going to take it and where is she going to keep the medicine so that she does not forget it

Health Materials 

Patient learning can be aided by leaflets, booklets or even videos.

Health System Design

Dr. Wolf gave examples of ways in which interventions can be incorporated into healthcare systems to make the interventions sustainable.

  • Standardized handouts on medications explaining the reasons for prescribing them and side effects.

  • A booklet on diabetes which can be used during visits to teach on a topic chosen by the patient.

  • Use down-time in the clinic, waiting for the doctor, to show patients videos explaining diagnoses or screening tests.

Dr. Wolf explained that low health literacy is likely to be an increasing problem in the US, due to a stagnant education system, changing economy, and aging society. This highlights the importance for each of us to develop effective techniques for teaching patients and assessing their understanding.