Clearing the Confusion

Physicians Turn Attention to Low Health Literacy Concerns

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Public Health Feature -- June 2004

By  Ken Ortolon
Senior Editor

"Take one tablet four times a day."

That sentence is on countless medicine bottles and sounds like a simple instruction. Yet nearly half of adult Americans may have trouble understanding and following such instructions from their physician, pharmacist, or other health care professional.

An April report by the Institute of Medicine (IOM) shows that limited health literacy causes 90 million American adults to have difficulty understanding and using health information. And that leads to poorer health outcomes and higher, otherwise avoidable, health care costs.

Health experts warn that low health literacy could have far-reaching ramifications as more Americans suffer from chronic illnesses, such as diabetes, that require them to assume at least some responsibility for their own care.

Physicians and other health care professionals must be more aware of the literacy issue and look at how they communicate with patients, they say.

"The health care system at every level has got to be cognizant that one of the reasons for poor compliance of patients is that they simply don't understand what they're being asked to do," said William Smith, EdD, executive vice president of the Washington, D.C.-based Academy for Educational Development and a member of the committee that produced the IOM report.

A Matter of Recognition

The IOM found that comprehending medicine's arcane jargon is difficult for even some highly educated Americans, but almost impossible for millions who cannot read well, have only limited English proficiency, or suffer from vision or cognitive problems caused by age.

While the IOM report garnered considerable media attention, its conclusions were not really new. In 1998, the American Medical Association became the first national organization to recognize limited patient literacy as a barrier to medical diagnosis and treatment. Since then, the AMA Foundation has worked to raise awareness and to train physicians to better communicate with patients with low literacy.

U.S. Surgeon General Richard Carmona, MD, also has made the issue a priority, and pilot programs to help Medicaid patients or people in adult reading classes better understand health instructions are under way in several states.

But the IOM report focused attention on the pervasiveness of the literacy problem. Members of the IOM committee called their findings "shocking" and recommended a national effort to improve health literacy.

"The striking thing about this finding is that it's even simple things -- things that you and I would consider simple things -- that people have a great deal of trouble dealing with," Dr. Smith said. He said medicine must "take a very serious look at the materials that we expect people to be able to understand."

The IOM report also spurred the AMA Foundation to step up its campaign against low health literacy. The group will convene a summit meeting next year to address improving health literacy in clinical settings.

Houston, neonatologist Michael E. Speer, MD, and College Station gastroenterologist Josie R. Williams, MD, have completed an AMA Foundation program that prepares physicians to train their colleagues about health literacy. They say the problem is not just that millions of Americans have low literacy but that few physicians recognize the problem.

"The average physician thinks he or she speaks in plain English, and that's not the case for their patients," Dr. Williams said.

According to the 1993 National Adult Literacy Survey, 21 percent of adult Americans read at the third-grade level or lower, and 27 percent read at the seventh-grade level or lower.

They can sign their names, total a bank deposit, and find certain information in short articles, but they may have trouble reading a bus schedule, filling out medical history forms, understanding a consent form, or entering information into a vaccination record.

"In other words, if you try to give them instructions on how to take their medicine and it's a paragraph, forget it," Dr. Speer said. "They're not going to be able to do that."

Dr. Williams says these Americans "are not stupid and they don't want you to think they're stupid." Frequently, they are embarrassed by their literacy problem and will hide it from their doctor.

The bottom line, she says, is that patients with low literacy have more problems complying with treatment and therefore have poorer health outcomes.

"We know that people with literacy issues have higher risks. They're less likely to know how to use their inhalers. They're less likely to understand the symptoms of hypoglycemia."

They are also more likely to miss their next doctor's appointment and to be readmitted.

Dr. Smith says the IOM committee did not put a price tag on the cost of low health literacy, but the AMA Foundation estimates the cost at $50 billion annually in missed appointments, hospital readmissions, unnecessary emergency room visits, and the like.

IOM recommends that the federal government do more research on the relationship between low health literacy, poor health outcomes, and health costs. It also suggests insurers and other groups develop creative ways to communicate clear health information, and use cultural and linguistic competency to measure care quality.

Some Good Advice

Drs. Speer and Williams have been training physicians in health literacy, including a seminar at TexMed 2004 in Austin in May. They recommend physicians use these techniques to improve their communication with patients:

  • Talk slowly, using simple language.
  • Simplify written materials. Use two or three bullet points, with the most important information at the top.
  • Never ask patients if they understand. Ask them to repeat the instructions you gave them.

While these steps take extra time, they don't always have to be done by the physician. Front office staff can be trained in these techniques.

Dr. Williams says these steps just might save the patient and the physician some late nights in the emergency room.

"It takes a few more seconds but it may prevent medication errors, or it may prevent you having to meet patients in the emergency room because they didn't know what you asked them to do," she said.

Additional information on health literacy is on the AMA Web site at and on the IOM site at

Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.  


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