A 42-year-old university professor comes to see you because his blood pressure was borderline elevated when measured recently at a health fair. On evaluation, he indeed has a borderline elevated blood pressure but is otherwise normal, including his weight and lab tests. You recommend that he reduce his sodium intake and see if that lowers his blood pressure. He agrees and schedules a follow-up visit in one month.

At the return visit, his blood pressure is unchanged. When you ask how he is doing with his low-sodium diet, he meekly confesses that he doesn't actually know what sodium is, nor does he know what foods contain sodium. He hasn't changed anything in his diet.

A few weeks later, a 3-year-old patient of yours is taken to the emergency department and later admitted to the local hospital because of acute liver failure. The girl had an upper respiratory infection with fever, and you had instructed the mother at a prior visit to give her daughter acetaminophen for the fever. However, the mother didn't understand the bottle's dosing instructions, believing the abbreviation “tsp” meant tablespoon instead of teaspoon. She' d given her daughter three times the appropriate dose, resulting in subsequent liver damage.

Health literacy is the ability of patients to find, understand, and use health-related information to make good decisions about their medical care and personal health. Unfortunately, many people have limited health literacy, but physicians often don't consider that when communicating with patients. This can lead to patients misunderstanding their physicians' recommendations, health education materials, medication labels, or discharge instructions. They may be unable to look up additional information about their medical conditions or may not know what to do with appointment slips and referral forms. Simply put, patient confusion can lead to more hospitalizations, worse health status, and higher health care costs.

As a physician, it is your responsibility to bridge this literacy gap by changing how you communicate with all patients, regardless of how well you think they understand you. This article will explain how to go about making those changes.

Low health literacy – more common than you realize

Large national studies show that about one third of American adults have limited health literacy. However, among many population subgroups, including older adults and some racial/ethnic minorities, the rate exceeds 50 percent, meaning that most individuals in those groups have limited health literacy (see “Prevalence of limited health literacy among adults”).¹ It is likely, then, that you see patients every day who have limited health literacy.

Remember that there is a difference between health literacy and basic literacy, the ability of individuals to read and write, look up information, and use it to get along in society. Just because someone has good literacy skills – for example, a college professor, clergy member, or corporate executive – does not mean he or she necessarily has good health literacy skills. Indeed, studies have shown that physicians, including both practicing physicians and family medicine residents, routinely overestimate the health literacy skills of their patients and assume that patients understand more than they actually do.²

Several tools are available to assess individuals' health literacy. Two of them, the Rapid Estimate of Adult Literacy in Medicine and the Newest Vital Sign, are short and can be administered in two to three minutes in an office setting.^3,4

But most health communication experts, along with organizations ranging from the American Medical Association (AMA) to the Agency for Healthcare Research and Quality (AHRQ), recommend against using routine health literacy assessments to identify patients with limited health literacy because there is no evidence that routine health literacy assessments in clinical practice result in improved patient outcomes.^5,6 Instead, these groups recommend adopting universal literacy precautions.

Putting universal literacy precautions into practice

Because limited health literacy is so common, you should assume that all patients need and want easy-to-understand explanations about their medical problems and what they need to do about those problems. Here are five recommendations for communicating with all patients, not just the ones you suspect have limited health literacy:

1. Explain things without using medical terms. Most physicians, at some point in their careers, have been asked by a relative or friend to explain or “translate” something their doctor told them. You likely responded by using concepts and words that people with no medical training would understand. So, why didn't their physician do that in the first place? Why don't you do that with your patients?

Physicians often worry that they will offend their patients if they use simple, nonmedical terms when talking to them. But if you are respectful and tailor your explanation to the patient's level of past understanding and motivation to participate in health decisions, it shouldn't be offensive. Instead, patients will appreciate that they understand what you are talking about. The table “Medical terms and their plain-language alternatives” gives a few examples of terms to substitute for words we often use in clinical practice. After you've been working with a patient for a while and listening to the terms they use when discussing their medical problems, you will be able to better match your communication to their level of understanding. But for starters, err on the side of simpler, rather than more complicated, explanations.

2. Focus on only two or three key messages. In any individual encounter, such as in a medical office visit, people tend to retain only two or three key messages. But physicians often bombard patients with information, sometimes even providing anatomy lessons by drawing diagrams of internal organs and coronary arteries. Studies show that patients interviewed right after a visit with their doctor recall less than half of what they were told, partly because their physician didn't adequately focus on key information.⁷

Pick the things your patients most need to know and emphasize those, rather than telling patients everything there is to know about their problem. If they want to know more they can ask, and patients with chronic problems will learn more over time. Not overloading them with information helps ensure that they will remember most of your messages and know what was most important.

A useful model is the “Ask-Me-3” approach, recommended by the National Patient Safety Foundation.⁸ With Ask-Me-3, the physician is encouraged to answer – even if the patient doesn't ask – three questions:

• What is the main problem being treated?

• What does the patient need to do about it?

• Why is it important to do that?

Using the Ask-Me-3 framework can help clinicians focus on the key messages and avoid unnecessary information.

3. Speak more slowly. Speaking at a slower pace will make you easier to understand when talking about topics that might be unfamiliar to the listener.⁹ If you are worried that your office visits will take too long if you speak slowly, consider that limiting your discussion with patients only to the key messages, as discussed above, will reduce visit length.

4. Use teach-back. Have your patients repeat your instructions back to you in their own words so that you can be sure that you explained it to them in a way that was understandable.

Physicians who use the “teach-back” method have better outcomes. Indeed, patients whose physicians use teach-back are 15 times more likely to have good diabetes control than patients of physicians who do not.¹⁰

5. Use easy-to-understand written materials. Just like your spoken instructions, any written information provided to the patient should be easily understandable. Write down the key things your patient needs to do, whether it is preparing for a lab test, scheduling an appointment with a consultant, or taking a new medication, and make sure it is free of medical jargon.

Numerous guidelines describe how to create patient information materials with health literacy in mind, but few available materials actually meet those criteria. The list “Characteristics of patient education handouts that make them easier to understand” provides some guidelines you can employ when evaluating materials or creating your own. Other guides are available in the AMA's health literacy training manual,⁶ AHRQ's Health Literacy Universal Precautions Toolkit,⁷ and from other sources (see the resources box).

Even patients who are well-educated and have seen you for years likely don't understand everything you tell them. Adopting the universal health literacy precautions described in this article – communicating in plain language, focusing on one or two key messages, speaking slowly, using the teach-back technique, and using written materials that are clear – can help ensure understanding and improve outcomes for all of your patients.