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Comprehension Test

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Schillinger advocates eliminating all jargon, using pictures, and applying the “teach-back” method. “Doctors say, ‘Oh, I do that,’” says Schillinger. “They ask, ‘Do you understand? Have I been clear?’ But the teach-back method is, ‘So, we’ve talked a lot about your fibroids and the different treatment methods we have. When you go home and your husband asks what the doctor told you, what will you say? Because I want to make sure I’ve explained it to you clearly.’”

Technological solutions might also help improve patient literacy—or they could make things worse. Increasingly, patients are being directed to online portals to get access to lab results and medical records and to help manage their own care, and anyone who isn’t comfortable using a computer may be at a disadvantage. Still, according to a 2009 study, some patients with low health literacy would prefer to “interact” with a well-designed computer program than speak with a clinician, who may be condescending or explain things poorly.

One interesting technological innovation is the “embodied conversational agent”—a character on a computer screen that looks at users, gestures to them and utilizes programmed “best practices” for health education. Research suggests patients may learn more from such characters than from humans and may tend to ask them more questions. It also helps that patients can spend as much time as they want with these virtual teachers.

In 2004, Michael Wolf, professor of medicine and learning sciences at Northwestern University’s Feinberg School of Medicine, established the Health Literacy and Learning Program (HeLP). The program may be the only one of its kind in the United States to “link the fields of medicine and education in order to improve how health systems educate patients and families on their health.” Researchers at HeLP investigate ways to improve health literacy, and one of the biggest lessons so far, says Wolf, is that the problems transcend individual doctors or patients.

“The level of difficulty of any health care task is determined by the health system that created the task,” says Wolf. “So, you can’t look at individuals without understanding the context of the system in which they’re situated.” A study published by Wolf’s group in 2011, in which subjects were given hypothetical regimens of seven drugs and asked to determine when they would take each drug, found that the subjects significantly overcomplicated their daily schedules. Absent additional guidance, many created a schedule to take medicine seven times a day when it could have been taken four or fewer times a day, and maintaining such a schedule may be particularly difficult for those with low health literacy. And in the real world, the instructions patients receive can also be overly complex. In one practice that Wolf’s team examined, clinicians had 53 ways to say “Take one tablet a day.”

Wolf’s group has been addressing this prescription problem by coordinating clinician and pharmacy efforts through electronic health records. They found that a simple solution, such as having pharmacists divide medications into morning, noon, evening and bedtime blocks, can significantly ease the burden on patients.

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Sounding It Out

A look at two tests designed to determine a patient's health literacy.


1. “Health Literacy and 30-Day Postdischarge Hospital Utilization,” by Suzanne E. Mitchell et al., Journal of Health Communication, October 2012. Details of the finding that patients with low health literacy are significantly more likely to be readmitted to the emergency department within 30 days of discharge than people with adequate health literacy.

2. “Health Literacy Screening Instruments for eHealth Applications: A Systematic Review,” by Sarah A. Collins et al., Journal of Biomedical Informatics, June 2012. This review of 11 health literacy screens found that asking a single question (such as “How often do you have someone help you read hospital materials?”) can reliably pinpoint people who need additional help understanding the medical system.

3. “Babel Babble: Physicians’ Use of Unclarified Medical Jargon with Patients,” by Cesar M. Castro et al., American Journal of Health Behavior, September-October 2007. Reviewing audiotaped physician interactions with patients with low health literacy, researchers found that patients mostly did not understand physicians’ instructions, even when physicians were sure they did.

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