Editor's Spotlight/Take 5: Patients With Limited Health Literacy Ask Fewer Questions During Office Visits With Hand Surgeons

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Shared decision-making, clinical decision-support tools, and patient-centered care can be practice-transforming, or they can be entirely unhelpful if the patient doesn't speak the language. Sometimes the language barrier is obvious—imagine a Farsi-speaking patient who knows not a lick of English. We know what to do for that patient; a professional interpreter makes all the difference. But what if a patient speaks perfect English, but doesn't “speak the language” of healthcare?
Good evidence suggests that this scenario is both common [9], and a problem [7]. If the physician fails to identify a patient's incomprehension (or incomplete comprehension) in the office, key recommendations will be misunderstood, the patient will be unable to make an informed decision about the risks and tradeoffs involved, and (s)he may not partner fully with the physician, decreasing the likelihood that treatment goals will be achieved [3, 10].
In the local argot, patients who engage in their care—perhaps by asking probing questions of their providers—are “activated” patients, and activated patients get more out of their encounters with the healthcare system [8]. But patients who don't speak the language of healthcare lack the tools to ask good questions. They are at risk.
For that reason, whether or not you are a hand surgeon, I urge you to read the study by Menendez and colleagues in this month's Clinical Orthopaedics and Related Research®. The authors analyzed more than 80 recorded office visits by Dr. Menendez's group at Harvard University. They learned that patients with lower levels of health literacy do not engage nearly as actively as other patients, and because of that, those patients miss opportunities to learn more about their conditions, potential treatment options, and how the therapies involved might work for them. With such fundamental gaps, no wonder that less-activated patients do not fare as well under the care of orthopaedic surgeons [2, 13].
Who are these patients, how can we identify them in practice, and—most importantly—how can we better serve them? For answers to those questions and others, I hope you will join me for the Take-5 interview that follows with Dr. Menendez, first author of this fascinating study.
Take Five Interview with Mariano E. Menendez MD, first author of “Patients With Limited Health Literacy Ask Fewer Questions During Office Visits With Hand Surgeons”
Seth S. Leopold MD:Congratulations on surfacing a critically important, but underappreciated topic. For the surgeon, perhaps the first step in addressing health literacy is to identify patients who are having difficulty understanding key elements of their visit. In your article, you suggest that physicians might assume “that patients do not understand unless proven otherwise.” How might the thoughtful provider “prove otherwise” in the course of a busy day at the office?
Mariano E. Menendez MD: One option is to formally assess health literacy using an available instrument (such as the Newest Vital Sign [11]) prior to the visit. Other factors that give us a sense of a person's health literacy include that person's ability to complete registration forms, give a coherent sequential medical history, list prior treatments and imaging tests, name his or her medications, know what musculoskeletal structure is affected, and ask questions about recovery time. Alternatively, everyone has difficulty comprehending health information when receiving an unexpected or unnerving diagnosis. We recommend taking “universal precautions” to confirm that expressed preferences are not based on misconceptions. There are simple things one can do. For instance, “Do you have any questions?” is a question that may be interpreted as the end, rather than the beginning, of a conversation. Instead, try: “Tell me your questions?” or “How does that fit with what you were thinking?”
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