Volume 9, No. 1 Spring/Summer 2001

Dear Colleague:

Patients with poor health literacyskills have a complex array of communication problems, which may interact to influence health outcomes. This newsletter is presented to increase your awareness of this issue and to focus on strategies designed toenhance patient comprehension.

D. Ted Lewers, M.D.Chair of the BoardMEDICAL MUTUAL Liability Insurance Society of Maryland

A Letter from theChair of the Board

Healthcare professionals routinely provide patients and their

family members with written appointment instructions,

informed consent forms, pre-procedure materials, diagnostic

information, medication labels and inserts, self-care direc-

tives and even patient satisfaction surveys. Many of these

materials contain numbers, acronyms, and specialized

medical terminology. Health literacy refers to that set of skills

needed to read, understand, and act on basic health care

information. Most of this information is written at a 10th

grade reading level. However, according to a 1993 study of

adult literacy in the United States, nearly half of all adult

Americans read at or below an eighth grade reading level.

No study has directly measured the health literacy of the U.S.

population. However, it is possible to estimate the number

of people who have low health literacy skills using results

from the 1992 National Adult Literacy Survey (NALS). The

survey reported that some 40 to 44 million of the 191 million

adults in the country are functionally illiterate. They read at

or below a fifth grade level, or cannot read at all. Another 50

million are marginally illiterate. They are generally able to

locate and assimilate information in a simple text, but are

unable to perform tasks that require them to assimilate or

synthesize information from complex and lengthy texts.

Because of the literacy demands upon patients in an

increasingly complex health care system, adults who are

functionally illiterate or marginally illiterate are likely to

have low health literacy skills which create difficulties in

understanding basic health materials provided by their

physician.

Poor Health Literacy —The Hidden HealthcareDilemma

Continued on next page

Numbers you should know!

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Doctors RX

Elizabeth A. Svoysky, J.D., EditorDirector of Risk Management Services

D. Ted Lewers, M.D., Chair of the BoardMEDICAL MUTUAL Liability Insurance Society of Maryland

© Copyright, 2001. All rights reserved.

MEDICAL MUTUAL Liability Insurance Society of Maryland

Articles reprinted in this newsletter are used with permission. The information

contained in this newsletter is obtained from sources generally considered to be

reliable, however, accuracy and completeness are not guaranteed. The information

is intended as risk management advice. It does not constitute a legal opinion, nor is

it a substitute for legal advice. Legal inquiries about topics covered in this newsletter

should be directed to your attorney.

All faculty participating in continuing medical education programs sponsored by

MEDICAL MUTUAL are expected to disclose to the program participants any real or

apparent conflict(s) of interest related to the content of their presentation(s).

To obtain more information about the relationship between health

and literacy, the U.S. Department of Education and the American

Medical Association are working together to include questions in

the National Adult Literacy Survey of 2002 on topics such as health

status, health behaviors, and difficulties communicating with

health care professionals.

In the meantime, we have the following statistics:

� Approximately 75% of American adults who report having a

physical or mental health condition scored in the two lowest

literacy levels of the National Adult Literacy Survey. (Kirsch,

et al., 1993)

� Over one-third of English-speaking patients at two public

hospitals showed inadequate functional health literacy. For

example, they were unable to understand information regarding

medication, appointments, and informed consent. This finding

was most pronounced among the elderly; 80% of those ages >

60 years had inadequate functional health literacy

knowledge. (Williams, et al., 1995)

� In a study of new Medicare enrollees in

a national managed care organization,

33.9% of English speaking and 53.9%

of Spanish speaking respondents had

poor health literacy knowledge.

(Gazmarian, et al., 1999)

� That same study found that inadequate

health literacy increases steadily with age,

from 16% of those age 65-69 to 58% of

those over age 85. (Gazmarian, et al., 1999)

� A study found that 39% of women

reading below a fourth grade level did not

know why women are given mammograms,

compared with 12% of those reading at or

above a ninth grade level. Patients who had

inadequate reading skills did not know that

mammography was associated with cancer, looking for a lump,

or an examination of the breast. Conversely, women with

adequate literacy skills who read on at least a 9th grade level

appeared to be adequately informed about mammography.

(Davis, et al., 1996)

� In an inner city hospital, results indicated that the literacy skills

of patients with diabetes, hypertension, and asthma are the

strongest correlates of knowledge about their illness and

disease management skills. (Williams, et al., 1998)

The National Academy on an Aging Society examined the impact

of literacy on the use of health care services. The study determined

that people with low health literacy skills use more health care

services.

� Among adults who stayed overnight in a hospital in 1994, those

with low health literacy skills averaged 6% more hospital

visits, and stayed in the hospital nearly two days longer than

adults with higher health literacy skills.

� Among adults with at least one doctor visit in 1994, those with

low health literacy skills had on average one more doctor visit

than adults with higher health literacy skills.

Overall, the study found that the major source of higher health care

expenditures for persons with low health literacy skills is longer

hospital stays. Other factors, such as the ineffective use of

prescriptions or misunderstandings about treatment plans may also

have financial as well as medical consequences. When patients do

not follow medical instructions because they cannot understand

them, the result can be life threatening.

Patients with low literacy are at much higher risk for errors and

poorer than expected outcomes in the current health care delivery

system than they would have been 30 years ago. Ineffective

communication between health care providers and patients

can result in medical errors due to misinformation about medications

and self-care instructions.

With new medical knowledge, patients are

out of the hospital in less time than ever

before. Today’s patients are quickly on

their own, with long lists of instructions,

medications, and appointments in hand.

Health literacy problems have grown as

patients are asked to assume more

responsibility for self-care in a more

complex health care system.

Additionally, most people with low

literacy skills are deeply ashamed and

have struggled to keep their

difficulties hidden. They would never

confide in their doctor. In fact, some

have never even confided in their

spouse! How can you know whether

you’re being understood?

Making a difference

Simplifying the written word can make a difference in patients’

lives. Here are some things to do to get started:

� Look over the materials you are currently providing patients in

the office. Notice which ones are read and which ones are

discarded and then ask patients and their families about their

preferences.

� Talk with staff members and managers about the need for

clearly written materials.

� Form a team to work on assessing, writing, editing and testing

new documents and revamping old ones.

� Simply rewriting your forms for a lower reading level may not

be enough. Establish relationships with patients and family

members who can help you develop and test new written

material

Working with Seniors to help them understand

Learning new health care information requires strong reading skills

as well as strong math and problem-solving skills. Studies have

shown, however, that older adults often have difficulty in these

three areas. Many factors can contribute to learning difficulties in

seniors, according to Joanne Schwartzberg, M.D., The American

Medical Association's Director of Aging and Community Health.

When they were growing up, many people only went to school for

a few years before they entered the work force. Consequently, they

may never have acquired strong reading skills. In addition, reading

skills decline if they are not used, and many older adults obtain

their information from TV or radio rather than from reading.

Other factors that may affect a senior’s ability to read and learn

new information are the sensory and cognitive changes that occur

as one ages. Additionally, medication side effects can impair both

cognitive processing and problem-solving ability.

Here are ways that you as a health care professional can make it

easier for all patients to read, understand and follow medical

instructions:

� Create a "shame-free" environment for learning. Use a gentle

and supportive approach, and be non-judgmental about a

patient’s reading difficulties. Let the patient know that many

people have difficulty learning new information.

� Encourage the patient to invite family members into the teach-

ing sessions. Not only does this help to create a warm and

supportive environment, but it also educates others who can

later reinforce and clarify the information.

� Choose teaching materials that use large print for older

patients. Also, look for materials that are written at a sixth

grade or lower reading level. (Remember that "reading level"

is not an indication of the content of the material but rather a

measurement suggesting the ease at which the content can be

accessed.)

� Pictures, diagrams and videotapes help communicate

information to patients, even those with low literacy skills.

Most people, even those who read well, use visual clues to

reinforce learning.

� Use models patients can hold and touch.

� Verify understanding by finding out what a patient understands

and what he or she doesn’t. Determine what the patient thinks

is happening and what they still need to learn. You can

accomplish this by asking concrete questions and offering

opportunities for patients to let you know how they will

implement your treatment plan.

� Repeat, repeat, repeat. Have nurses review and repeat the

instructions before the patient leaves the office. Provide

written instructions, diagrams, or sources for further

information. Make telephone calls within a day or two of the

visit to make sure the patient is on track.

Communication is the cornerstone of the doctor-patient

relationship. It is a critical component of all medical interaction.

Whether verbal, written or computer-assisted, what people convey,

"hear" and remember has important implications for the successful

delivery of quality health care.

Since a large percentage of the population will have difficulty

understanding health care information, it makes sense that

physicians take steps to make this information accessible for all

patients. This means consciously leaving time in the discussion to

ensure the patient’s understanding of the information. Sit down,

take extra time and actively listen. Studies have shown that

currently this is being done only two percent of the time. It is

essential that you make a concerted effort within your own health

care environment to improve communication and give all patients

their best chance at a good health outcome.

Portions of this article are reprinted with permission from On Call.On Call is published by Globe Specialty Products, Inc., a wholly-

owned subsidiary of The Boston Globe.

If you would like to obtain additional information on "Poor Health

Literacy — The Hidden Healthcare Dilemma," please contact the

Risk Management Services Department at 410-785-0050 or 800-

492-0193.

Professionals Advocate Insurance Company

MEDICALMUTUALLiability Insurance Society of Maryland

225 International Circle, P.O. Box 8016

Hunt Valley, MD 21030 • 410-785-0050 • 800-492-0193

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and Professionals Advocate are pleased to present a FREE, online educational

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can access it 24/7, at your convenience, on the internet.

Act today! Increase your understanding of Stress Management and take

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1. Low health literacy is only associated with elderly

patients.

A. True B. False

2. The health literacy of United States citizens is

measured annually by the U.S. Census Bureau.

A. True B. False

3. A study by the National Academy on an Aging Society

found that persons with low health literacy skills have

longer hospital stays.

A. True B. False

4. Large print materials written at an eighth grade reading

level will work for older patients.

A. True B. False

5. 50 million people in the United States are functionally

illiterate.

A. True B. False

CME Test Questions

Instructions for CME Participation

CME Accreditation Statement--MEDICAL MUTUAL Liability Insurance Society, which is affiliated with Professionals Advocate, is accredited by the

Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. MEDICAL MUTUAL designates this

educational activity for a maximum of one hour in category 1 credit towards the AMA Physician’s Recognition Award. Each physician should claim

only those hours of credit that he/she actually spent in the educational activity.

Instructions--to receive credit, please follow these instructions:

1. Read the articles contained in the newsletter and then answer the test questions.

2. Mail or fax your completed answers for grading to the address or fax number provided below:

Med•Lantic Management Services, Inc.

P.O. Box 64100

Baltimore, MD 21298-9134

FAX 410-785-2631

3. One of our goals is to assess the continuing educational needs of our readers so we may enhance the educational effectiveness of the Doctors RX.

To achieve this goal, we need your help. You must complete the CME evaluation form to receive credit.

4. Completion Deadline: July 1, 2001.

5. Upon completion of the test and evaluation form, a certificate of credit will be mailed to you. Please allow three weeks to receive your certificate.

Strongly Strongly

Agree Disagree

Part I. Educational Value: 5 4 3 2 1

I learned something new that was important. ❑ ❑ ❑ ❑ ❑

I verified some important information. ❑ ❑ ❑ ❑ ❑

I plan to seek more information on this topic. ❑ ❑ ❑ ❑ ❑

This information is likely to have an impact on my practice. ❑ ❑ ❑ ❑ ❑

Part 2. Commitment to Change: What change(s) (if any) do you plan to make in your practice as a

result of reading this newsletter?

Part 3. Statement of Completion: I attest to having completed the CME activity.

Signature: Date:

Part 4. Identifying Information: Please PRINT legibly or type the following:

Name: Telephone Number:

Address:

CME Evaluation Form

Statement of Educational Purpose

"Doctors RX" is a newsletter sent bi-annually to the insured physicians of MEDICAL MUTUAL/Professionals

Advocate. Its mission and educational purpose is to identify current health care related risk management

issues and provide physicians with educational information that will enable them to reduce their malpractice

liability risk.

Readers of the newsletter should be able to obtain the following educational objectives:

1) gain information on topics of particular importance to them as physicians,

2) assess the newsletter's value to them as practicing physicians, and

3) assess how this information may influence their own practices.

CME Objectives for Health LiteracyEducational Objective: To provide participants with an understanding and awareness of the issue of health

literacy and how it affects their patient population. Additionally, strategies are provided for enhancing

physician-patient communication.

6. "Reading level" refers to a material’s content, not the

ease at which it can be accessed.

A. True B. False

7. Most people use visual means to reinforce written

information.

A. True B. False

8. Asking a patient how they will implement your

treatment plan aids in determining their health literacy.

A. True B. False

9. The literacy skills of patients strongly correlate with

their knowledge of illness and disease management.

A. True B. False

10. Health literacy increases with age.

A. True B. False