You're in the middle of a busy ED shift when a new patient arrives in bed 7.
Her breathing is labored and her lungs are riddled with crackles. She tells you she was diagnosed with "a heart problem" a few months ago. She recently ran out of her medications and did not refill them because she "wasn't sure what they were doing anyway." You ask if she sees a cardiologist. "A what?" she responds.
As emergency clinicians, we encounter scenarios like this one more often than we might hope. At times it is easy to label patients as "non-compliant" and assign them blame for their conditions, but providing compassionate and equitable care requires us to analyze the underlying cause. We must consider what circumstances precipitated this presentation. What can be done differently this time to help prevent a repeat scenario? Many underlying issues stem from flaws in the healthcare system that we cannot individually fix, but optimizing communication and promoting health literacy is something that we can easily do.
Health literacy is defined by the U.S. Department of Health and Human Services as the ability to access and understand basic health information and services needed to make appropriate health decisions.1 A national survey performed in 2003 revealed that over one-third of U.S. adults have basic or below-basic health literacy.2 Health literacy has gained recognition in recent decades for its association with a multitude of health outcomes. In the US, low health literacy is associated with higher rates of hospitalization and emergency care use, greater healthcare costs, less frequent use of preventive services such as screenings and vaccines, improper medication use, and greater morbidity and mortality.3-6 It is important to note that low health literacy disproportionately affects individuals of minority, low-income, and low-education groups.2 These groups, often impacted by other social determinants of health, are at further risk of health inequities when additionally affected by low health literacy.
While health literacy was traditionally thought of as an individual trait, the definition has evolved over recent years to incorporate the role of clinicians and healthcare systems. Health literacy is now described as occurring when society and its healthcare system "provide accurate health information and services that people can easily find, understand, and use to inform their decisions and actions."7 Emergency physicians are equipped to play an important role in addressing and promoting health literacy. We often take care of patients who struggle with proper medication use, demonstrate limited understanding of their conditions, or are unable to access appropriate health services. We have the ability to provide clear and helpful information in order to enhance patient understanding and increase health potential - or we can deepen a patient’s confusion.
The COVID-19 pandemic illuminated the detrimental power of misunderstanding health information. As the virus swept through society, so too did misinformation, disinformation, and confusion. Uncertainty regarding how and when to wear masks, the importance of social distancing, and vaccine safety overwhelmed communities and social media. One thing was plainly evident: clear and effective communication plays a critical part in societal health literacy. Equally important to quality information is trust. Much of the confusion surrounding the pandemic resulted from a lack of adequate information, but other qualms were deeply rooted in well-founded mistrust of the healthcare system. Building public trust is essential in mounting an effective response to this global crisis. Likewise, our patients may be more willing to share their lack of understanding and ask questions when the patient-physician relationship is founded on trust. It is well worth our while to dedicate a few minutes to listening to patients, addressing any gaps in understanding, and engaging in patient-centered communication.
Best Practices for Communication
Quality communication is important for both patient care decisions in the ED and patient self-care after discharge. Emergency physicians are often pressed for time, and may not have the ability to engage in lengthy conversations with patients or review discharge instructions in great detail. But practicing simple communication skills that promote health literacy is an efficient and effective way to demonstrate empathy, increase patient understanding, and improve patient outcomes. Best practices for communication include avoiding medical jargon, demonstrating concepts when possible, distilling information into key points, writing clear instructions, utilizing the teach-back method, and inviting patient questions.
Plain language is terminology that anyone can understand upon first use, which requires avoidance of medical jargon. Even terms that seem simple, such as "contraceptives," can be confusing for patients and should be replaced with clearer alternatives like “birth control.” Discussion of self-care measures can also be simplified through the use of demonstration. Instead of using words or written instructions to describe how to use an inhaler, demonstrate proper technique.
Another method of maximizing the amount of information patients walk away with is distilling material into a limited number of high-importance points. The sheer volume of new information often relayed to patients during a hospital visit can be overwhelming beyond the point of comprehension. Focusing on 3-5 key concepts and next steps increases the likelihood of retention. It is helpful to highlight these in discharge instructions as well, which should be written in clear and concise language.
Use of the teach-back method and an invitation for questions are ideal ways to close a patient encounter. The teach-back model is a means of ensuring patient understanding. It employs a cycle of relaying information to the patient, asking her to repeat back what she understood, and clarifying any missed points until mutual understanding is achieved. It should be emphasized that teach-back is used to ensure clear communication by the provider, not to measure patient intelligence. This can be illustrated to the patient by introducing the concept with an opening along the lines of, "To make sure that I have done a good job explaining everything to you, can you tell me what you understand about…" Nursing staff typically receive more education on teach-back than physicians, and may be able to assist with this.
Finally, questions should be elicited from patients in an open-ended and judgement-free manner. Instead of the potentially intimidating "Do you have any questions?", try "I know that you've been through a lot today; what questions do you have for me?" This demonstrates the expectation for questions and makes patients feel more comfortable asking them.
We can now apply some of these communication principles to our patient in bed 7. When talking with her, we can avoid jargon and explain her condition in simple terms. Instead of asking about her cardiologist, we can use the term “heart doctor.” We can end the encounter with emphasizing the key 3 things she needs to do to manage her condition, and use teach-back to ensure her understanding. Our discharge instructions should provide easily digestible information, as well as resources when available. Questions should be elicited in an inviting manner and fully addressed. Our patient will leave the ED with a better understanding of her disease and how to manage it thanks to our patient-centered communication that promoted health literacy.
Care that does not prioritize patient understanding is suboptimal care. We cannot place the onus solely on our patients to understand everything we spent years in school learning. It is our responsibility to communicate clearly in a manner that promotes comprehension and addresses patient questions and needs. We do our patients a disservice when we do not take the time to properly explain a diagnosis or appropriate management strategies.
On the flip side, we have the ability to use simple communication techniques to make a real impact on patient understanding. Use some proven practices:
- Avoid jargon
- Distill information
- Use teach-back
- Invite questions
Promoting health literacy not only reduces healthcare costs and otherwise avoidable overutilization of the ED, but also empowers patients and improves health outcomes. Knowledge is power, and health literacy is a vehicle for patient empowerment that allows individuals to play a more active role in their own health.
Ensuring understanding is one simple way emergency physicians can work toward quality care and health equity for all.
- Healthy People 2010: Understanding and Improving Health. US Department of Health and Human Services. Washington, DC: US Government Printing Office; 2000.
- The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. National Center for Education and Statistics. Updated on Sept 6, 2006. Available from: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483.
- Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107.
- Eichler, K., Wieser, S. & Brugger, U. The costs of limited health literacy: a systematic review. International Journal of Public Health. 2009; 54(5):313–324.
- Ku, I. & Matani, S. Left out: immigrants ′access to health care and insurance. Health Affairs. 2001; 20:247–256.
- Groene, R.O. & Rudd, R.E. Results of a feasibility study to assess the health literacy environment: navigation, written, and oral communication in 10 hospitals in Catalonia, Spain. Journal of Communication in Healthcare. 2011; 4, 227–237.
- Office of Disease Prevention and Health Promotion. Healthy People 2030: Social determinants of health. U.S. Department of Health and Human Services (n.d.).