Teaching About Health Literacy and Clear Communication

Sunil Kripalani, MD, MSc,1 Barry D. Weiss, MD 2

1
Emory University School of Medicine, Atlanta, GA, USA; 2University of Arizona College of Medicine, Tucson, AZ, USA.

longer and more interactive session, such as a 90 to 120 min-

utes workshop, offers a better forum not only to review basic
KEY WORDS: health literacy; medical education; physician-patient
communication. information about health literacy but also for hands-on prac-
DOI: 10.1111/j.1525-1497.2006.00543.x tice with recommended communication skills.
J GEN INTERN MED 2006; 21:888–890. Considering that entire books have been devoted to health
literacy and patient education,16,17 where is the educator to
begin when teaching about health literacy? It is useful to first
define the concept, describe the scope of the problem, and

P hysician-patient communication is considered a funda-

mental aspect of medical care; yet, research shows that
patients commonly have difficulty in understanding medical
emphasize that low health literacy affects all segments of
society, not only those with limited educational attainment or
socioeconomic status.12,14,18,19
instructions from physicians.1,2 Physicians often use medical A powerful means of describing the health care experi-
jargon, deliver too much information at a time, and do not ences of patients with low health literacy is to invite local pa-
confirm patients’ understanding of what was discussed.3,4 At tient advocates or adult literacy students to provide first-hand
the end of the medical encounter, patients remember less than information about their experiences with the health care
half of what the physician tried to explain, and they may be system.20 If this is not feasible, then showing selected patient
uncertain about what steps to take next.3,5,6 testimonials from the AMA’s or Institute of Medicine’s health
Low health literacy contributes to the communication gap literacy video is also an effective technique. Many of the pa-
between physicians and patients.4,7 Patients with low health tients featured in these videos are intelligent and articulate,
literacy may have less familiarity with medical concepts and and their stories help emphasize that low health literacy can be
vocabulary, and they ask fewer questions (S. Kripalani, unpub- present in any patient.
lished data). They may also hide their limited understanding out A brief review of the association between low literacy and
of shame or embarrassment.8 Research shows that physicians health outcomes is also helpful. The 2004 systematic review by
commonly overestimate patients’ literacy levels, and they rarely DeWalt et al.,21 commissioned by the U.S. Agency for Health-
consider limited literacy skills in their assessment of whether care Research and Quality, provides an excellent synthesis of
patients understand what they need to do.9,10 Furthermore, the pertinent information that educators can use. This review
when provided information about patients’ literacy levels, phy- describes the relationship of literacy with knowledge, screen-
sicians appear ill-prepared to communicate effectively.11 ing behaviors, immunization, health care utilization, and con-
In their reports on health literacy, the American Medical trol of several chronic diseases, including HIV infection and
Association (AMA) Ad Hoc Committee for the Council on Sci- depression. Some of the latest research on health literacy,
entific Affairs, the National Work Group on Literacy and published in this special issue of JGIM or presented at the
Health, and the Institute of Medicine each called for greater 2006 Society of General Internal Medicine annual meeting, al-
efforts to educate physicians and other health professionals so demonstrates an association of low health literacy with
about issues related to health literacy, including techniques to comprehension of informed consent documents and a variety
communicate more clearly.12–14 In this article, we describe ef- of health outcomes, including control of hypertension and
fective strategies for teaching about health literacy and clear asthma.22–25 Importantly, 2 of these studies reveal an inde-
communication. We highlight the most important educational pendent association of limited literacy skills with higher
content areas and discuss methods for teaching about health mortality rates.26,27
literacy through both clinical precepting and more formal cur- Having set the stage by informing learners about the
ricula. While the focus of this article is on teaching medical scope of the problem, the health care experiences of patients
students and residents, its lessons could be applied to de- with low literacy, and the association between literacy
veloping programs for practicing physicians. Indeed, some and health outcomes, educators should next empower their
of the methods outlined in this article are used in the AMA’s trainees by teaching them how to communicate more
health literacy training program for physicians.15 The approach clearly with patients. Most health literacy experts emphasize
described in this article is also applicable to the training of several important behaviors to foster clear communication
students and practitioners in all of the health care professions. (Table 1).7,15,28,29
These strategies should be effective with all patients, but
they will be of particular benefit when communicating with
DEVELOPING A HEALTH LITERACY WORKSHOP patients who have limited literacy skills. Most of the strategies
If the goal is to raise awareness about low health literacy, then are based on clinical observation and expert opinion, but ev-
a short didactic lecture may suffice. However, a smaller, but idence of their effectiveness is emerging. For example, a study
of patients who have diabetes revealed that when physicians
Address correspondence and requests for reprints to Dr. Kripalani: used the teach-back technique, patients had better glycemic
Emory University School of Medicine, Atlanta, GA (e-mail: skripal@ control.30 The teach-back is also recommended as a top
emory.edu). patient safety practice by the National Quality Forum.31
888
JGIM Kripalani and Weiss, Teaching About Health Literacy and Clear Communication 889

Table 1. Strategies Recommended for Clear Communication

1. Assess patients’ baseline understanding before providing extensive information

Example for a patient newly diagnosed with hypertension: ‘‘Before we go on, could you tell me what you already know about high blood pressure?’’
This allows educational content to be tailored to the patient’s informational needs
2. Explain things clearly using plain language. Avoid medical jargon, vague terms, and terms with different medical and lay terms
Example: say ‘‘chest pain’’ instead of ‘‘angina’’
Example: say ‘‘hamburger’’ instead of ‘‘red meat’’
Example: say ‘‘You don’t have HIV’’ instead of ‘‘Your HIV test results were negative’’
3. Emphasize 1 to 3 key points
Repeat these points throughout the visit
4. Effectively encourage patients to ask questions. Use an open-ended approach
Example: ask ‘‘What questions do you have?’’ instead of ‘‘Do you have any questions?’’
5. Use a teach-back to confirm patient understanding
Place the burden on your shoulders to have explained the information clearly, normalize the process, and be specific
Example: ‘‘I always ask my patients to repeat things back to make sure I have explained them clearly. I’d like you to tell me how you’re going to take
the new medicine that we talked about today.’’
Example: ‘‘When you get home, your [husband/wife] will ask you what the doctor said. What will you tell them?’’
To confirm understanding of a skill, ask the patient to demonstrate the behavior (e.g., use of a metered dose inhaler)
6. Write down important instructions
This lets patients know exactly what they should do after the visit
7. Provide useful educational materials
This gives patients more time to absorb the information. Such materials are accessible to family members who may be helping patients at home

Busy medical residents and practicing physicians may, workshops. At 1 institution, health literacy themes have been
however, be reluctant to adopt new interviewing behaviors that added to a variety of required classes for medical students,
they believe will lengthen the medical encounter. In our expe- from basic medical interviewing courses to seminars on prob-
rience, assessing patients’ baseline understanding usually lem-based learning. A website describes some of the curricular
takes less than 30 seconds, and the teach-back takes only 1 elements and offers resources for other medical schools
to 2 minutes.30 However, time is saved by tailoring information considering a similar approach.34
to the patient’s individual needs, and by limiting the amount of
information provided to the most important points. The net
effect on time from implementing the strategies in Table 1 is
HEALTH LITERACY AND THE CLINICAL ENCOUNTER
usually neutral; some physicians actually save time. Further- Considering the many ways in which health literacy influences
more, if improved communication results in better under- patient care and health outcomes, it is surprising how rarely
standing by patients of what they need to do, with resultant health literacy is discussed as part of the patient assessment
improvement in disease control, future office visits may be and plan.10 Clinician educators should take greater advantage
shorter or needed less frequently. of the myriad opportunities to do so when working with med-
Like most new behaviors, these communication skills ical students and residents in clinical settings.
require practice to use them effectively. Structured small Low health literacy can be brought up as part of the dif-
group exercises offer a useful venue for skill development, ferential diagnosis (i.e., reason for disease exacerbation), or a
with 1 trainee playing the role of the physician, another train- factor to consider when selecting treatment. For example,
ee playing the patient, and a third providing feedback as an when a patient is readmitted for an exacerbation of heart
observer. In such groups of 3, students and residents can take failure, the assessment could include a determination of the
turns practicing most of the behaviors listed in Table 1. patient’s ability to understand complex medication instruc-
Showing a trigger videotape is another effective strategy to tions and any recent changes to the regimen. Rather than sim-
engage learners. Such a tape consists of a short physician-pa- ply prescribing new medications, a complete plan would
tient interaction in which the physician demonstrates poor include a discussion of how additional help may be provided
communication skills. Learners react to the tape, point out the by using a pill box, providing more extensive counseling, or
specific elements that could be improved, and model ways to involving family members. To provide another example, when
communicate the same information more clearly. seeing a patient newly diagnosed with asthma, the physicians
An even more effective technique is to videotape each should teach the patient how to use an inhaler and ask the
trainee interacting with a standardized patient who has been patient to demonstrate the skill to confirm understanding. Re-
trained to play the role of an adult with low health literacy.32,33 search indicates that patients with limited literacy skills do not
Watching the video with a faculty facilitator provides trainees understand how to use inhalers correctly,35 and instructions
with an opportunity to reflect on their own communication that come with inhalers are complicated and written at diffi-
skills, get feedback from the faculty member, and develop spe- culty levels that exceed the average reading skill of American
cific areas for improvement. adults.36
Educators will note that much of the content and ac- In addition to including health literacy in the patient as-
tivities described above could be incorporated into existing sessment and plan, clinical faculty are in a key position to
curricula, such as courses on medical interviewing and provide feedback on trainees’ communication skills. Whether
physician-patient relationships. In fact, it would likely be more seeing patients in the clinic or hospital setting, faculty may
effective to address health literacy longitudinally through mul- observe students and residents using complex terminology
tiple established courses than to address the topic in isolated with patients, trying to cover too much information, not pro-
890 Kripalani and Weiss, Teaching About Health Literacy and Clear Communication JGIM

viding an open opportunity for patients to ask questions, or 13. Institute of Medicine. Health Literacy. A Prescription to End Confusion.
not confirming patient understanding. Using some portion of Washington, DC: National Academies Press; 2004.
14. National Work Group on Literacy and Health. Communicating with
the clinical encounter to provide feedback in these areas and
patients who have limited literacy skills. J Fam Pract. 1998;46:168–76.
others will allow trainees to improve their communication 15. Weiss BD. Health Literacy: A Manual for Clinicians. Chicago: American
skills continually. Medical Association; 2003.
Clinical faculty can also play a vital role by modeling clear 16. Doak CC, Doak LG, Root JH. Teaching Patients with Low Literacy
communication, including the use of lay language and patient Skills. 2nd edn. Philadelphia: JB Lippincott Co; 1998.
17. Schwartzberg JG, VanGeest JB, Wang CC. Understanding Health Lit-
teach-back. Trainees are more likely to adopt such skills long eracy: Implications for Medicine and Public Health. Chicago: American
term if they repeatedly see them practiced by a large cadre of Medical Association Press; 2005.
dedicated faculty. 18. Selden CR, Zorn M, Ratzan S, Parker RM. Current Bibliographies in
Medicine: Health Literacy. Bethesda, MD: National Library of Medicine;
2000.
CONCLUSION 19. Kutner M, Greenberg E, Baer J. National Assessment of Adult
Literacy (NAAL). A first look at the literacy of America’s adults in the
Almost 10 years have passed since the AMA Ad Hoc Committee 21st century. Available at: http://nces.ed.gov/naal. Accessed May 2,
on Health Literacy first emphasized the importance of incor- 2006.
porating health literacy training into graduate medical educa- 20. Baker DW, Parker RM, Williams MV, et al. The health care experience of
tion.12 While some progress has been made, greater attention patients with low literacy. Arch Fam Med. 1996;5:329–34.
21. DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy
to health literacy is still needed in medical education. Many
and health outcomes: a systematic review of the literature. J Gen Intern
opportunities exist to educate medical students and residents Med. 2004;19:1129–39.
about health literacy and the communication skills recom- 22. Sudore RL, Landefeld CS, Williams B, Barnes D, Lindquist K, Schil-
mended for clear communication. We encourage clinician ed- linger D. Use of a modified informed consent process among vulnerable
patients: a descriptive study. J Gen Intern Med. 2006;21:867–73.
ucators to implement health literacy workshops and other
23. Kripalani S, Bengtzen R, Henderson LE, Robertson R, Jacobson TA.
curricula, and clinical faculty to role model and reinforce Literacy affects comprehension of even simplified informed consent.
techniques to foster clear patient communication. J Gen Intern Med. 2006;21(S4):81.
24. Kripalani S, Litle H, Bengtzen R, Robertson R, Jacobson TA. Associ-
ation between literacy and hypertension control. J Gen Intern Med.
2006;21(S4):16–7.
Dr. Kripalani is supported by a K23 Mentored Patient-Oriented 25. Mancuso CA, Rincon M. Impact of health literacy on longitudinal
Research Career Development Award (K23 HL077597). asthma outcomes. J Gen Intern Med. 2006;21:813–7.
26. Wolf MS, Feinglass JM, Carrion V, Gazmararian J, Baker DW. Literacy
and mortality among Medicare enrollees. J Gen Intern Med. 2006;
REFERENCES 21(S4):81.
1. Weiss BD, Reed RL, Kligman EW. Literacy skills and communication meth- 27. Sudore RL, Yaffe K, Satterfield S, et al. Limited literacy and mortality
ods of low-income older persons. Patient Educ Couns. 1995;25:109–19. in the elderly: the Health, Aging, and Body Composition Study. J Gen
2. Gibbs R, Gibbs P, Henrich J. Patient understanding of commonly used Intern Med. 2006;21:806–12.
medical vocabulary. J Fam Pract. 1987;25:176–8. 28. Mayeaux EJ, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T.
3. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient commu- Improving education for patients with low literacy skills. Am Fam
nication: a review of the literature. Soc Sci Med. 1995;40:903–18. Physician. 1996;53:205–11.
4. Schillinger D, Bindman AB, Wang F, Stewart AL, Piette J. Functional 29. Williams MV, Davis TC, Parker RM, Weiss BD. The role of health liter-
health literacy and the quality of physician-patient communication acy in patient-physician communication. Fam Med. 2002;34:383–9.
among diabetes patients. Patient Educ Couns. 2004;52:315–23. 30. Schillinger D, Piette J, Grumbach K, et al. Closing the loop. Physician
5. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communica- communication with diabetic patients who have low health literacy. Arch
tion at hospital discharge and patients’ understanding of the postdis- Intern Med. 2003;163:83–90.
charge treatment plan. Arch Intern Med. 1997;157:1026–30. 31. National Quality Forum. Safe Practices for Better Healthcare. Wash-
6. Makaryus AN, Friedman EA. Patients’ understanding of their treatment ington, DC: National Quality Forum; 2003.
plans and diagnosis at discharge. Mayo Clin Proc. 2005;80:991–4. 32. Davidson R, Duerson M, Rathe R, Pauly R, Watson RT. Using stand-
7. Weiss BD, Coyne C. Communicating with patients who cannot read. ardized patients as teachers: a concurrent controlled trial. Acad Med.
N Engl J Med. 1997;337:272–4. 2001;76:840–3.
8. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and 33. Howley LD. Utilizing standardized patients to enhance health literacy
health literacy: the unspoken connection. Patient Educ Couns. 1996;27: communication skills: the development phase. Educ Primary Care.
33–9. 2004;15:123–4.
9. Bass PF III, Wilson JF, Griffith CH, Barnett DR. Residents’ ability to 34. Dalton C. Building a health literacy curriculum, University of Virginia.
identify patients with poor literacy skills. Acad Med. 2002;77:1039–41. Available at: http://www.healthsystem.virginia.edu/internet/som-hlc/.
10. Powell CK, Kripalani S. Resident recognition of low literacy as a risk Accessed May 3, 2006.
factor in hospital readmission. J Gen Intern Med. 2005;20:1042–4. 35. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate
11. Seligman HK, Wang FF, Palacios JL, et al. Physician notification of literacy is a barrier to asthma knowledge and self-care. Chest. 1998;
their diabetes patients’ limited health literacy. A randomized, controlled 114:1008–15.
trial. J Gen Intern Med. 2005;20:1001–7. 36. Wallace LS, Roskos SE, Weiss BD. Readability characteristics of
12. American Medical Association Council on Scientific Affairs. Health consumer medication information for asthma inhalation devices.
literacy. JAMA. 1999;281:552–7. J Asthma. 2006 (in press).