Coverage of Plenary Presentation at the 10th Annual Institute for Healthcare Advancement’s Health Literacy Conference. May 4-6, 2011
Cliff Coleman, MD
By Tina Beychok
One of the largest group of people who don’t understand the need for health literacy may well be the group that needs to understand it the most; medical doctors. The need for clear communication may seem to be self-evident. However, according to Dr. Cliff Coleman, the exact opposite holds true. He explained, “Most of the health literacy effort has gone into the patient side of things. We’ve made very little effort to turn the lens back onto ourselves and ask why this is important.”
As part of his efforts to make doctors, particularly medical students, aware of the need for health literacy, Coleman directs the health literacy curriculum for the Oregon Health Sciences University School of Medicine in Portland. He admitted that it can be an uphill battle at times because doctors get very little health literacy training in medical school. He added, “Medical school makes doctors even worse communicators than they were before.”
Among the barriers to providing quality health literacy education to medical students:
* Health professions students not necessarily selected for communication skills
* Medical students learn about 16,000 new words
* Hidden nature of low health literacy
* Crowded curricula
* Barriers to continuing education
* Fast-paced health care encounters
“Clear communication is not valued in our current health care system,” Coleman stated. “Doctors are not penalized for bad communication, and they certainly are not rewarded for clear communication.”
On top of that, doctors come out of medical school without any health literacy knowledge or skills. Coleman showed results from some of his own research. He had asked a group of doctors, nurses and other healthcare workers several questions about their attitude toward health literacy.
In terms of skills, Coleman cited a 2003 study in the Archives of Internal Medicine by conference keynote speaker Dean Schillinger. The study looked at how often 38 primary care doctors used the teach-back method with 74 low literacy patients who had diabetes. The results showed that only 20% of the doctors used teach-back with their patients. Furthermore, those patients who received teach-back education had better glycemic control than those patients who did not receive teach-back. The full text of Schillinger’s study can be found at http://archinte.ama-assn.org/cgi/content/full/163/1/83.
Clearly, doctors are not properly prepared to understand the issue of low health literacy. This raises the question of just how much training is being done and how it is being done. Coleman conducted a survey of 133 medical school deans in 2010. He found that out of the 63 who responded to the survey, almost three-fourths (72%) reported including some health literacy instruction in their curriculum.
Coleman noted that while this number may seem impressive, “it only added up to three hours worth of instruction. Furthermore, most of it was done during the first and second years, rather than through the course of students’ time in medical school.” As one might expect, most of the instruction on health literacy in schools that had such a program was done in a lecture format (84%). By comparison, only 25% of schools used experiences with adult low literacy patients as a means of teaching.
This led Coleman into looking at how schools can improve their health literacy curriculum. He identified three types of teaching methods that are used:
* Stand-alone: A health literacy course is taught only one time during the student’s career
* Episodic: Several stand-alone courses are interspersed throughout the student’s career
* Integrated: Health literacy is infused into every topic throughout the student’s career
In terms of easy tools that both physicians and medical students can learn to incorporate, Coleman suggested using plain language, slowing down when speaking to patients and using the teach-back method to ensure they understand instructions.
Some examples of how these methods can be incorporated into integrated learning might be role playing, video review of patient encounters, simulated encounters with actors, and interaction with adults who have low literacy. One example that Coleman likes to use with his own medical students is having them listen to each other talk to patients. Over time, they learn to identify when they are using jargon and can provide feedback on how to improve.
Ultimately, Coleman feels that it is the duty of physicians to use health literacy to better communicate with their patients: “If patients aren’t coming away with the information they need, it’s not their fault. It’s our fault for not properly communicating.”