Imagine this scenario at the end of your patient’s session:
Psychiatrist: “Do you understand the directions on the new medication I prescribed?”
Patient: “Err, I think so.”
Psychiatrist: “Here are pamphlets on the medications I prescribed. Read them if you have any questions.”
While this may sound reasonable, how can you be sure your patient understands the treatment plan and the medication regimen you just explained to him/her?
Patients with low health literacy are active in your practice but you may not know they are; there are no visible signs of low health literacy. Patients with low health literacy cannot be identified by casual conversation or by appearance; they may be of varying social economic status; they may be U.S. born or an immigrant. Even patients who read well can face health literacy issues when they are unfamiliar with medical terms or given information that is too difficult to understand; if they have to assimilate a lot of information and are asked to quickly evaluate the risks and benefits of treatment that may affect their health and safety; if they are scared and confused or in denial; or if they have a behavioral health condition that requires complicated self-care.
Patients who may be at higher risk for low health literacy include the elderly, individuals with language barriers, persons with developmental delays, persons with lower education, and persons with chronic disease.
Health Literacy is defined in the Institute of Medicine report, Health Literacy: A Prescription to End Confusion, as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”1
Why is low health literacy important to psychiatrists?
Low health literacy can lead to poor outcomes. It is believed that health literacy is a stronger predictor of health outcomes than social and economic status, education, gender, and age. What this means to the psychiatrist is that these patients have less ability to assume positive self-management; there are higher medical costs due to more medication and treatment errors; ineffective use of prescriptions; over-utilization of the emergency room and urgent care services; more frequent hospitalizations; longer hospital stays; more visits to their healthcare provider; and a lack of necessary skills to obtain needed services.
There is also an association with medical malpractice allegations, especially related to inadequate explanation of diagnosis, inadequate explanation of treatment, inadequate or negligent informed consent, and communicating in such a way that patients feel that their needs have been ignored.
What are the communication barriers that can interfere with a patient’s ability to comprehend medical instruction and participate in health care decisions?
Many patients work hard to hide the fact that they have trouble understanding something they are told or given to read because they may be embarrassed about their lack of understanding or are concerned about what the psychiatrist will think about them. In addition, there could be language challenges if the psychiatrist and patient do not speak the same language or if the patient is deaf or hearing impaired.
Why can’t we use friends or family members to translate for patients?
You may think it is easier, more convenient, and less expensive to use family members or friends to translate for a patient with language, hearing, or speech impairment. But doing so is not in your best interest. Friends and family members may not be impartial, do not know medical terminology, may not use the patient’s own words but supply their own responses to the questions asked, may not be comfortable asking sensitive or potentially embarrassing questions (consider a teenager asking her grandfather about his sexual history). Inappropriate/inaccurate translation increases the risk of medication errors, wrong procedures, avoidable readmissions and other adverse events. According to the Agency for Healthcare Research and Quality, nearly 9% of the U.S. population is at risk for an adverse event because of language barriers.2 If a patient suffers a negative outcome and sues on the allegation that it would not have occurred but for the psychiatrist’s failure to inform the patient appropriately, that psychiatrist may be held liable for the consequences.
What are the laws and regulations on patient communication?
The Federal laws include:
- Title II of the Americans with Disabilities Act: mandates equal access for all patients on all public (state and local) health care providers.
- Title III of the Americans with Disabilities Act: mandates equal access on all private health care providers.
- Title VI of the Civil Rights Act of 1964: mandates appropriate language access in the health care setting to individuals who have limited English proficiency.
There are state statutes, regulations and case law on patient communication that mirror the federal laws or may have a heightened level of protection. For states, there are regulations on the informed consent process that require explanations of the benefits and risks of treatment alternatives. It is important to be aware of your specific state regulations on these issues.
What can you do to address low health literacy?
Simplify your communication to reduce medical errors, improve patient care, and reduce lawsuits. That means:
- Use simple, plain language – replace medical or technical terms with words that people use every day in their conversations with one another. Example: “abstain from” is more understandable as “don’t use,” or “go without.”
- Avoid medical jargon, acronyms or abbreviations – to make your communication clear to your patients. Examples: instead of “therapeutic modality” use “treatment;” instead of “OTC” state “over the counter” or “medications you can buy without a prescription at the local drugstore;” instead of “PRN” for a medication to assist with sleep state “use only as needed if you can’t sleep but only take one pill a day.”
- Employ the “teach back” method – teach back confirms the patient’s understanding of treatment and medication instructions by asking patients to repeat the instructions using their own words. Keep in mind, however, that asking patients to tell you about the medication regime, for example, that doing so is not a test of the patient’s knowledge but rather a test of how well you explained the instructions in a language and manner the patient understands. Use teach back with all your patients. Imagine the initial scenario but with the teach back method:
Psychiatrist: I want to be sure I explained your medication correctly. Can you tell me how you are going to take this medication?
Patient: Ummmm. I’m not sure. Do I take one pill twice a day or two pills once a day?
Psychiatrist: I am glad you asked. You need to take one pill in the morning and one pill in the evening every day.
- Provide written materials that are written at the 5th grade reading level – and avoid developing information with your handouts or website that may be “over the head” of your patients. Health literacy best practices does not mean “dumbing-down” the information but makes sure the information is presented accurately and in ways that people can understand. Patients at all reading levels have been shown to better understand and indeed, have a preference for simpler rather than complex language. Use bullets to emphasize your recommendations and plenty of white space rather than a “busy” page filled with medical verbiage and long sentences.
- Provide certified interpreters – language or sign. As noted, Federal laws require health care providers to ensure that effective communication takes place between the provider and patients, including those who do not speak English or are deaf or severely hearing-impaired. If face-to-face interpreters are not available, then video or phone remote interpreting services should be offered.
- Document – how any language or communication needs are addressed with each patient at each visit. This should also include any reason why accommodations were declined by the patient.
Low health literacy is not just a public health problem. It affects psychiatrists directly because they have a duty to educate patients and involve them in health care decisions irrespective of their level of health literacy. But psychiatrists have the opportunity to anticipate and address low health literacy, which will improve patient safety and reduce the potential liability risk to the psychiatrist.
- Agency for Research and Quality Health Literacy Toolkit: http://www.improvingchroniccare.org/downloads/health_literacy_universal_precautions_toolkit.pdf
- Agency for Health Research and Quality (2014). Health Literacy Interventions and Outcomes, Update: https://www.ahrq.gov/research/findings/evidence-based-reports/er199-abstract.html
- Agency for Health Research and Quality (2015), Health Literacy Universal Precautions Toolkit, 2nd Edition: https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool5.html
- American Medical Association, Understanding Health Literacy: Implications for Medicine and Public Health (2005)
- CDC Gateway to Health Communication and Social Marketing Practice: https://www.cdc.gov/healthcommunication/
- CDC Plain Language/Health Literacy: https://www.cdc.gov/healthliteracy/developmaterials/plainlanguage.html
- Institute of Healthcare Improvement, Always Use Teach Back! http://www.ihi.org/resources/Pages/Tools/AlwaysUseTeachBack!.aspx
- North Carolina Health Literacy Council, The Teach Back Method: http://www.nchealthliteracy.org/toolkit/tool5.pdf
- Plain Language: Improving Communication from the Federal Government to the Public: http://www.plainlanguage.gov/
- The Gerontological Society of America, Public Policy & Aging Report: https://www.geron.org/programs-services/policy-center
1 The Institute of Medicine report, Health Literacy: A Prescription to End Confusion (April 8, 2004)
2 Agency for Research and Quality, Improving Patient Safety Systems for Patients with Limited English Proficiency (2012): https://www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf