In “Have You Really Addressed Your Patient's Concerns?” [March 2008], the authors discuss a topic that deserves more attention than it is often given – patient-centered communication. While the article is excellent, I would like to raise an important issue that it did not address – the concept of health literacy, or the patient's ability to obtain, process and understand basic health information to make appropriate health decisions.

The article suggests that practices use written or online forms to help the patient prepare for the visit. Although these methods have been studied and have been found useful to some, they may not be useful to the 89 million Americans with limited health literacy.

I think the article would be more complete if it encouraged physicians to be aware of the prevalence of low health literacy by using simple terms that patients can understand, using visual aids, avoiding acronyms, creating a shame-free environment and using the “teach-back” method to verify a patient's understanding of the instructions given. The article appropriately points out that patients remember only half of the physician's recommendations, and other research suggests that half of what is remembered is actually incorrect. Clear communication is essential for better health outcomes, and health literacy is integral to patient-centered communication.

Authors' response:

Health literacy is one of several important barriers to communication, which we have addressed in greater detail in a recent publication.¹ We agree that the ability to read, write and understand basic health concepts is a major communication barrier. We would also suggest that cognitive impairment, cultural context, access to care, illness beliefs and representations, issues of power in the patient-physician relationship, assertiveness and primary language influence the likelihood that messages intended will correspond with messages received. In addition to the helpful suggestions provided by Dr. Bazaldua, use of interactive visual electronic media can provide individualized patient education and counseling. They, too, can enhance the efforts of clinicians in overcoming barriers to care imposed by disparities in health literacy.