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Seven steps to better health literacy with diverse patients

Consider the following real-life example of a patient in a medical practice:

The patient is pregnant and is also an immigrant who speaks a language for which no interpreter can be easily found. She also speaks a little Spanish.

In her 38th week, her health care providers decide a Cesarean section is warranted, primarily for the sake of the baby’s health, but also her own. However, the patient’s mother objects. In the patient’s culture, a mother’s opinions are revered, and she persuades her daughter to decline.

Fearing the worst, the hospital obtains a court order to perform the procedure involuntarily, as a life-saving measure.

But before that order is carried out, using a Spanish interpreter, the providers again attempt to sway the patient to consent. They fail, but try again the following day, using the fetal monitoring strips to demonstrate the imminent danger the baby faces.

Ultimately, she consents. A healthy child is born.

While this story has a happy ending, the providers experienced anxiety and incurred legal fees that potentially could have been averted if, earlier in the pregnancy, the patient and her mother had been better counseled about the possibility of a C-section, said Boston medical malpractice defense attorney Barbara Hayes Buell of Smith Duggan Buell & Rufo.

This example demonstrates the need to promote health literacy among patients from diverse backgrounds.

The U.S. Department of Health and Human Services defines health literacy as “the degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness.”

The 2003 National Assessment of Adult Literacy measured health literacy among 19,000 participants from every state, concluding that 36 percent had “basic” or “below basic” health literacy.

White and Asian/Pacific Islander adults had higher average health literacy than Black, Hispanic, American Indian/Alaska Native and multiracial adults. Also, adults who spoke only English before starting school had higher average health literacy than adults who spoke other languages alone or other languages and English.

In 2004, the Institute of Medicine released its influential report, “Health Literacy: a Prescription to End Confusion,” according to Joseph Betancourt, M.D., a Boston primary care practitioner and associate professor at Harvard Medical School. It found that nearly a third of all Americans – 90 million – have difficulty understanding and using health information.

“The average person in the U.S. reads at an eighth grade level, and many read more poorly than that,” said Rosemary Gafner, Ed.D, president of MedRisk in Houston. “That statistic often comes as a shock to many people, especially physicians, who typically have 20 years of education.”

A low literacy level, in any language, is just one of six factors that lead to poor health literacy, along with age, disability and fear, said Helen Osborne, M.Ed., OTR/L of Health Literacy Consulting in Natick, Mass.

Cultural beliefs, including a tendency to refrain from asking questions of authority figures, often play a role. They are frequently coupled with language issues: As the U.S. becomes more diverse, there are more people who don’t speak English as their primary language, and more languages spoken than ever before.

“As we as a nation become increasingly diverse, we as physicians will face these issues more commonly,” Betancourt said. “And there’s a lot of research that demonstrates that when health care providers aren’t sensitive and skilled at understanding patients’ expectations and perspectives, lower quality care, poor communication and poor outcomes result.”

Here are seven steps experts advise medical professionals to take in order to improve patient care and reduce risk when dealing with patients’ health literacy issues:

Step One:  Recognize the issue.

“You can’t be expected to know and understand the cultural differences among all peoples of the world,” Gafner said. “But it is important to understand that not everybody sees the world as you do. And if you have a patient who dresses nontraditionally or speaks with an accent, that person might have some beliefs that are not aligned with yours.”

Educate yourself – but make sure you choose a quality educational experience.

“A lot of health care providers have been exposed to very bad cultural competence training, with political correctness and a lot of sensitivity, but not skills,” Betancourt said. “But done well, where people learn skills to apply in the clinical encounter, they’re a lot more amenable to learning and applying the concepts.”

Step Two:  Keep it simple.

Daniel Oates, M.D., a primary care physician and assistant professor at Boston University School of Medicine, advised avoiding medical jargon and instead using simple language with patients.

Be cognizant that some words can be easily misunderstood because of popular usage, he noted. When using the term “diet,” for example, a patient with limited English proficiency might think he or she is being told to lose weight.

Also, limit the amount of information offered. In primary care, most physicians have ongoing relationships with patients, Oates said, and when treating for chronic conditions, you don’t immediately need to cover every aspect. Prioritize, saving noncritical information for later.

Don’t follow your patient education with, “Do you understand?” advised Gafner, because that calls for a yes/no response. “Instead, try, ‘I know I’ve just given you a lot of information. You must have questions. What questions do you have?’ It’s the presumptive way of saying, ‘It’s okay to ask.’”

Step Three:  Try the Teach Back method.

Osborne described it as saying, “‘I want to make sure I explained this as clearly as I could. So when you go home, what will you tell your spouse?’ Ask them to paraphrase your key point. Listen to what they say. Then re-state your key point in another way, and test it again.”

Another approach, suggested Betancourt, is to ask, “How do you understand your diabetes?” to get a picture of the patient’s worldview.

Consider the patient’s social context:  Can he or she do what you want them to? For example, a physician can’t recommend more exercise to a patient who lives in an unsafe neighborhood.

Then “negotiate,” he said – reach a shared understanding of what the patient will do going forward.

Step Four: Use trained medical interpreters.

Don’t rely on the interpretation of well-meaning volunteers, or the friend, family member or especially the child who might be accompanying the patient, Osborne said.

If you’re not in a practice setting with ready access to trained interpreters, investigate other tools such as telephone interpretation.

Another excellent resource, according to Osborne, is Healthy Roads Media, a website created by Mary Alice Gillespie, M.D., in Bozeman, Mont., with health information resources available in 19 languages, on over 100 topics, and in six formats.

Step Five: Provide written instructions in the patient’s native language.

Again, use a trained medical translator to develop instructions in the patient’s language, Osborne suggested.

But remember that not all members of a particular culture can read their predominant language, and not all spoken languages are written.

Step Six: Document.

“We are saved by our documentation,” said Buell. Have a staff member available to witness the communication, and make certain that his or her presence is documented as well. Advise the patient to get a second opinion, and document that, too.

Attorney Martin Foster of Foster & Eldridge in Cambridge, Mass., who defends physicians in med-mal cases, advised doctors to document that they recognized a patient’s limited English proficiency and what they did to overcome it. If written materials were given to the patient, those should be scanned into the electronic records as well.

Step Seven: Talk to the patient’s family.

Buell said that in cases where things go terribly wrong, it typically won’t be the patient who sues, but family. The chances of that happening can be decreased by making them a part of the conversation as well, after obtaining the patient’s consent to involve them.

Follow this tip on a case-by-case basis, she advised, because sometimes family can be more hindrance than help.

Overcoming obstacles

A common observation from clinicians, Osborne said, is they don’t have time.

“But it’s really a matter of prioritizing. We all have a finite amount of time. So the question becomes, how can we use our time more efficiently, and how long does it really take? The recommendation from the American Medical Association, at least a few years ago, was to try it with your last patient of the day, one day a week.”

Another approach is to engage your team, including staff such as certified diabetes educators, nurses or patient advocates.

For his part, Betancourt said, “Just like any set of skills, you don’t need to use all of them at once; you use them on an as-needed basis.

“What we argue is, if you have patients who are confused, and you don’t understand their perspectives, it takes more time than if you’re able you’re able to cut through some of those mutual misperceptions and get at a mutual understanding. It actually helps save time. It’s an investment that yields very positive outcomes. And it doesn’t necessarily have to take more time.”

Money is another frequent obstacle. But consider the costs of misunderstandings, said Foster. While resources might be limited with regard to staff to witness conversations or interpret, it’s up to physicians to speak up when they’re clearly needed.

Foster said, “Not having resources is not the answer, because all you need is one lawsuit, and whatever resources were conserved are now squandered – and that’s not even to mention the emotional and professional trauma experienced by the provider who’s being sued.”

Questions or comments can be directed to the editor: reni.gertner@mamedicallaw.com

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