letters

Patient communication and health literacy

In "Have You Really Addressed Your Patient's Concerns?" [March 2008], the authors discuss a topic that deserves more attention than it is often given - patient-centered communication. While the article is excellent, I would like to raise an important issue that it did not address - the concept of health literacy, or the patient's ability to obtain, process and understand basic health information to make appropriate health decisions.

The article suggests that practices use written or online forms to help the patient prepare for the visit. Although these methods have been studied and have been found useful to some, they may not be useful to the 89 million Americans with limited health literacy.

I think the article would be more complete if it encouraged physicians to be aware of the prevalence of low health literacy by using simple terms that patients can understand, using visual aids, avoiding acronyms, creating a shame-free environment and using the "teach-back" method to verify a patient's understanding of the instructions given. The article appropriately points out that patients remember only half of the physician's recommendations, and other research suggests that half of what is remembered is actually incorrect. Clear communication is essential for better health outcomes, and health literacy is integral to patient-centered communication.

Oralia Bazaldua, PharmD, BCPS
San Antonio, Texas

Authors' response:

Health literacy is one of several important barriers to communication, which we have addressed in greater detail in a recent publication.1 We agree that the ability to read, write and understand basic health concepts is a major communication barrier. We would also suggest that cognitive impairment, cultural context, access to care, illness beliefs and representations, issues of power in the patient-physician relationship, assertiveness and primary language influence the likelihood that messages intended will correspond with messages received. In addition to the helpful suggestions provided by Dr. Bazaldua, use of interactive visual electronic media can provide individualized patient education and counseling. They, too, can enhance the efforts of clinicians in overcoming barriers to care imposed by disparities in health literacy.

Ronald M. Epstein, MD
Larry Mauksch, MEd
Jennifer Carroll, MD, MPH
Carlos Roberto Jaén, MD , PhD

1. Epstein RM, Street RL. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. Bethesda, MD: National Cancer Institute, NIH; 2007.

Tracking follow-up care

I would suggest a different answer to the question "Do we have a legal obligation to ensure that our patients receive necessary follow-up care?" that appeared in the April edition of the "Practice Pearls" department.

Failure to track and follow the events of care (monitoring results, taking appropriate action, etc.) is a common source of malpractice claims. When an injury is attributed to poor follow-up, blaming the patient is a typical defense, but a better strategy is a clear audit trail that documents the extensive steps taken - and the systems in place - to prevent errors of missed follow-up.

It is impossible to guarantee that every patient receives necessary follow-up care. But you can eliminate obvious gaps in your procedures for lab tracking, results reporting, etc. It is sometimes suggested that doctors ask their patients to sign a contract that acknowledges the need to follow medical recommendations. In a few specific cases (e.g., high-dose steroids or liver-threatening drugs), an informed consent form can be evidence of important communication. But as a general measure, asking patients to sign a contract agreeing to comply with everything the doctor says would be presumptuous, offensive and silly, and is unenforceable as a legal defense.

Two dangerous pitfalls to avoid writing or saying to your patients are "Follow up as needed" and "If you don't hear from us, everything is fine." Instead, include specific check boxes on your forms with messages such as "Call if you have not received results in ___ days" and "Please notify us of the date of your referral appointment."

To aid our process, I have pads of sticky notes printed to be used for writing follow-up prescriptions. At the end of every visit, I write a "prescription" for any follow-up care the patient needs and stick it in the chart. The medical assistant enters my instructions directly into our electronic tickler file before the chart is shelved.

Michael S. Victoroff, MD
Centennial, Colo.