Poor health literacy linked with unnecessary health complications

An elderly woman sent home from the hospital develops a life-threatening infection because she doesn’t understand the warning signs listed in the discharge instructions.

A man confused by an intake form in a doctor’s office reflexively writes “no” to every question because he doesn’t understand what is being asked.

A young mother pours a drug that is supposed to be taken by mouth into her baby’s ear, perforating the eardrum.

And a man in his 70s preparing for his first colonoscopy uses a suppository as directed, but without first removing it from the foil packet.

These are not isolated events.

A 2006 study by the U.S. Department of Education found that 36 percent of adults have only basic or below-basic skills for dealing with health material. This means that 90 million Americans can understand discharge instructions written only at a fifth-grade level or lower. About 52 percent had intermediate skills: They could figure out what time a medication should be taken if the label says “take two hours after eating,” while the remaining 12 percent were deemed proficient because they could search a complex document and find the information necessary to define a medical term.

Studies have linked poor health literacy, which disproportionately affects the elderly, the poor and recent immigrants, to higher rates of hospital readmission, expensive and unnecessary complications, and even death. A 2007 study estimated the problem cost the U.S. economy as much as $238 billion annually. This problem will become even more severe in 2014 when tens of millions become insured.

The Joint Commission, which accredits hospitals, is requiring them to use plain-language materials and to “communicate in a manner that meets the patients oral and written communication needs” in providing care. For example, instead of “myocardial infarction”, use heart attack; instead of “febrile”, use fever; replace “hyperlipidemia” with high cholesterol. Doctors are also encouraged to replace “diet” with food; many folks when they hear diet believe doctors want them to go on a diet. It is also recommended replacing “exercise” with walking. In this case when patients hear exercise they believe they have to go to the gym. Replacing ”medicalese” with plain language will save lives.

If you want to be sure you’re getting the right care, you have to be able to understand instructions. If you don’t understand, speak up! Don’t be embarrassed; you’re not alone. These are life and death situations. There is no room for embarrassment.

Jeffrey I. Kreisberg served on the faculty the University of Texas Health Science Center at San Antonio where he was a Professor of Pathology, Medicine, Surgery, Urology, and Molecular Medicine.  He is the author of Taking Control of Your Healthcare.


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  • http://www.drdarrellwhite.com drdarrellwhite

    Even more than replacing “medspeak” with “people-speak”, one must also use an appropriate level of understandability. IIRC there is a nice bit of research that suggests that medical conversations/written material should use what would be considered a typical 8th grade vocabulary.

  • Bruce Small

    I’m not trying to be mean, but remember what George Carlin said: Think of how dumb the average person is, and half of them are dumber than that.

    She poured an oral medication in the baby’s ear? I’m sorry, but she shouldn’t be allowed loose without supervision.

  • Melissa gastorf

    I deal with functional illiterates to completely illiterate every day. I find that in many cases the language has to be that of a third grader, because the vast majorty don’t understand. Part of the problem is the system allows for this and has taken away all personal responsibility. And I don’t care if you use the word cholesterol instead of lipids, this group still does not comprehend why they should care.

  • ninguem

    Is that our fault, or the school’s fault?

  • ninguem

    I usually don’t have trouble with baby care with my immigrant patients.

    The Mexicans, Ukranians, Nepalese, Hmong, Asian Indians, etc., from the old country. They may have been impoverished over there and may still be impoverished here, and maybe they don’t speak English, but there are certain basics that I usually don’t have to show them.

    Not so the native-born. Makes me sad for my country.

  • http://frugalpharmacies.com Emily

    I taught middle school for several years and one of the biggest lessons to me in the first year was how to break the simplest instructions down into (almost) no-fail steps. I learned quickly how instructions could be interpreted 20+ ways!

    Maybe that’s the key. Take the instructions to a group of average to below average students and ask them what they think the instructions mean. You would see very quickly where any confusion might be.

  • http://englishfornursingandhealth.blogspot.com/ Virginia Allum

    (Mis)Communication is always a problem at any level but what must be remembered is that people who are stressed , in pain, frightened (hospital visit), not ‘in’ with healthcare jargon or indeed the healthcare culture and who are also non-native speakers or poorly educated.. will need extra attention to ensure they have understood what we, as healthcare providers communicate as a ‘given’. The eardrops and suppository examples are not isolated!

  • http://www.cancertreatmentsurvival.org Chris Walsh

    I work with people who have cancer. Unfortunately, the worst time to educate a person about health is when he/she is sick. Even more rare is the person who wants to learn when he/she is healthy. Thus, we teach people to seek health care advocates for any and all aspects of their care. There needs to be an intermediary here. The literacy problem in health care can be eased somewhat, but not solved. We need to bring someone we trust to the clinic with us. This person has the knowledge and the time to fill the gaps in our knowledge so we can make the best decisions in our care.

  • Finn

    @Bruce Small, don’t assume the mother was an idiot. It’s likely that the baby was being treated for an ear infection, and the mother previously had used eardrops for the same problem. If the doctor then said “Give her half a teaspoon of this medicine three times a day,” the mother would not know this meant “FEED her half a teaspoon.”

    • gzuckier

      Diagrams might be nice. If we can manage to put quasi-intelligible diagrams on the controls in cars, we oughta be able to do at least that well on packages of eardrops and oral medicines to give the user a clue.

  • Evon-OT

    Someone has to take responsobility for making sure people do understand their instructions. I work with all populations and I make sure they understand their precautions. Healthcare providers should take the time to educate patients. If it were my mother, my child, my patient I would expect that discharge instructions were explained in laymen terms. You have to account for patients stress, fear nd the fact that multiple things are happening at once. Then after it is all said and done there will still be some errors but if everyone took the time to care a little more there would be less errors. That is what we should expect from each other. Let us learn to be empathetic and compassionate for those in need.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    Due to financial constraints many of the life skill health and hygiene courses have been eliminated from school curriculums. Despite the current fiscal constraints of the country , it might be wise to re-introduce these public health courses including basic first aid , care of a wound, medication storage and administration, when to call the doctor etc. In the long run it would save the system money and provide better care. Simplifying instructions is always an outstanding goal. With the diversity of our population plus the difference in patients and families literacy skills this is a difficult goal to achieve but one well worth continuing to work at improving

  • Carrie Vaughn

    Most of the people this is affecting and who need to know to speak up, that they’re not alone like the end of this article so helpfully point out probably aren’t reading the article on the internet. Most of them are probably working three dead end jobs to try and put food on the table and are being told every day how stoops and worthless they are for being poor and uneducated, so telling them to speak up doesn’t do anything for them. It just educates the people who would be treating those people. Write to your audience.

    I also have to give props to three Carlin reference. He was a man before his time.

  • gzuckier

    A certain MD with whom I’m closely acquainted once asked a patient how many times a day she “passed water”; she replied twenty or thirty. In clarification, she explained that there was a fountain in the hallway, you see……..

  • http://www.reachhealth.com Jennifer

    As a marketing communication professional working in the healthcare technology space, and familiar with healthcare specific technical writing programs at local universities, I have to imagine there are some documented standards for modified language for communicating with patients. If anyone reading this post has any recommended resources I am all ears.

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