This past August, I attended the American College of Obstetricians and Gynecologists (ACOG) District VI meeting in Wisconsin. The theme of this year’s meeting was “Bringing it Back Home,” with a keynote presentation focused on developing the emotional habits to influence others and “embody the inner attitude of a leader.”
After a day of much self-reflection, I decided to stop by the poster presentations during a break between the major talks. One, in particular, stood out to me — a poster on medical illiteracy.
The presenter was an earnest third-year resident who was happy to speak with me about her findings. After listening to her for several minutes, and trying to keep in the spirit of the weekend, I found myself thinking hard as to whether this was an area that I might not be addressing well with the patients I cared for every day. So when I returned to my hospital the next week, I decided to test it.
To my surprise, I found that I needed to challenge my assumptions about patients’ health literacy — and tailor my communication to better address their needs.
As a hospitalist, I generally rotate among a few hospitals in the area. However, my primary hospital site is located in the south suburbs of Chicago. The patient population is mostly African American and/or Hispanic, and the vast majority are on some form of public aid. I pride myself on my communication skills and go to great lengths to make sure I explain to my patients what is going on with their health or the health of their unborn child. This includes discussing what medical issues I recognize, the treatment options I recommend to address them, and why I’m recommending it. Often, I assume that because I come from a similar background as many of my patients (I’m also African-American), they’ll find me more relatable, approachable, and easier to understand.
Shortly after I returned home from the conference, I encountered a patient in the labor and delivery emergency department (OBED). The patient was a 20-year-old G1P0 (pregnant for the first time and had not yet delivered) African American woman with oligohydramnios, meaning her amniotic fluid was well below the expected volume for being 37 weeks into her pregnancy. On top of this, her ultrasound revealed that she had an abnormal biophysical profile (BPP).
We admitted her, and the decision was made to induce labor. I gave a long and very thorough description of her diagnosis, as well as the pros and cons of delivering the baby for these reasons to the patient. The 19-year-old father of the baby was also present in the room and listened closely as I shared my concerns.
After a detailed description of the medical issues involved, I tried to boil down all that language into a simple, easy to understand phrase that I have used perhaps a thousand times in a situation like this: “The bottom line is, the placenta is just not working as well as it should, and that’s why we need to deliver the baby now, even though it’s still three weeks before the due date.”
The father of the baby listened closely with a serious and concerned look on his face and nodded in agreement. But unlike previous conversations, this time, it occurred to me to ask a follow-up question: “Do you know what the placenta is?”
A look of relief spread over his face and, looking slightly embarrassed, he asked, “Actually, what is the placenta?”
My encounter with that young couple reminded me that even if I empathize with the patient, or have a lot in common with them, I cannot assume that they have the same vocabulary as I do. My interaction with the young couple after the conference reminded me of that way I feel every time I go to the auto-mechanic — while I have devoted a lot of time and energy to understanding the complex workings of the human body, I know next to nothing when it comes to fixing a car (i.e., when they tell me: “your catalytic converter is punishing your transmission,” I just do my best to look very serious and nod in agreement until they tell me how much it’s going to cost me).
Many of the readmissions that we see as OB hospitalists may be linked to medical illiteracy and to a patient’s inability to comprehend or comply with all of the instructions they were given upon discharge from the hospital. According to the U.S. Health and Human Services Office of Disease Prevention and Health Promotion, only 12 percent of U.S. adults have proficient health literacy, meaning a staggering 88 percent do not. Medical illiteracy (or low health literacy) has been linked to poor health outcomes, such as increased risk for hospitalization, increased racial disparities and less frequent use of preventive services. Populations most likely to experience medical illiteracy are older adults, racial and ethnic minorities, and people with less than a high school degree, low-income levels, and/or for whom English is not their primary language.
As OB hospitalists, we often treat patients who are already incredibly vulnerable — be it that they don’t have an assigned physician or usual source of care, or through our work at large inner-city hospitals or rural health centers.
Many of the populations most likely to have poor health literacy are the very patients we serve. And we are in a unique position to be able to impact both their short- and long-term health outcomes.
While it’s important to explain the diagnosis and treatment options to our patients, it’s equally, if not more important for us to ensure that they understand what we’re saying to them. Be it asking for confirmation, gaining trust to help them know it’s OK to ask questions, or making ourselves vulnerable to help them feel safe (catalytic converters, anyone?), hospital-based physicians should call on our emotional intuition on health literacy to ensure that the excellent care we are delivering in the hospital continues to have good effect outside of the hospital as well, when that patient goes home.
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