Health Literacy Month: How Miscommunication Can Impact Health

October is Health Literacy Month. Health literacy refers to how well patients understand medical information from doctors. It plays a critical role in whether or not a patient receives the right care for them. 

While low health literacy is related to having problems with other types of reading and understanding, most of us have most likely had a confusing interaction at the doctor's office. With so many forms to fill out, and typically fifteen minutes or less with the doctor, it's easy for information to slip through the cracks for anyone. But health literacy isn't just critical at the doctor's office. Statistics show that 80% of internet users search for health information online, making it more important than ever that content creators share meaningful, accurate, and patient-friendly health information. 

E Hanh Le, MD, Senior Director, Medical Affairs at Healthline, has seen the impact of low health literacy first-hand as a refugee and then as a primary care physician. Today, she leads the medical strategy for content at Healthline, one of the top destinations for health content online. In our conversation, she shares her perspective on why health literacy is so important and how patients can better find and understand the critical information they need. 

Antidote: In your experience, what are some ways that health literacy can impact patient health?

E Hanh Le, MD: To start, health literacy is super important to me. It's something I've lived with my whole life. As a refugee, my family had lots of issues with health literacy. From the time I was eight years old, I was pulled into my mom's appointments, translating and trying to understand the health implications of the things she was having to make decisions on. 

With health literacy, what we find is that it's needed in every encounter that patients have with the healthcare system, even from the very beginning. When patients enter the healthcare system, they're given intake forms and have to figure out how to fill those out and how to engage with the systems. For instance, what does diagnosis mean? What is a diagnosis? Do you have a family history of something? What medications are you on? They don't necessarily remember the name of the medication, so they'll just say, I've got a blood pressure pill. That ability to identify yourself and clarify who you are and what your needs are from the get go is very difficult. Also, your average person doesn't understand how the body works. So then you enter the healthcare system, and you're engaging with the clinician right off the bat. The clinician really depends on that conversation between patient and physician. But again, most people don't really understand how the body works, so they don't necessarily know how best to articulate their symptoms, what's normal and what's not normal. For example, when people say dizzy, or lightheaded, or the room is spinning – what do they really mean by that? And that difficulty in terms of articulating what their ailments are, their issues and complaints, can actually dramatically delay an accurate diagnosis or treatment. Every time a clinician is listening to those symptoms, they're formulating a differential diagnosis in their mind. When someone gives you a symptom that is a red herring, it can send a clinician on the wrong path from the get go.

And then from there, the physician or any care provider starts to formulate that communication plan back to the patient. When I was in clinical practice, I was seeing about 30 patients a day with 15 minute windows, so you have literally five minutes to tell someone who potentially has a very complicated condition, based on the story you've given me and the exam that I've performed, this is the list of things that we need to do in sequential order, with some of this stuff happening in parallel. Patients need to understand what they need to do — and why.

Antidote: What makes the "why" so important?

E Hanh Le, MD: People talk about compliance. Patients didn't take their medication, or they didn't go to the lab. They didn't do their blood pressure readings at home and send it in to me like I asked them to. Perhaps there were too many instructions given to them all at once. Maybe they didn't understand the order in which things needed to be done. Or perhaps they didn't understand the significance; they didn't understand the context of why it was being done. For example, "I needed your at-home blood pressure readings to make sure the high blood pressure I saw in the office wasn't just a white coat syndrome situation, and those home readings really are significant and would drive my decision in terms of putting you on a blood pressure medication or not." 

All of this is under tremendous time pressure. To have a meaningful conversation between both patient and provider, there has to be a lot of time and patience to tease out the symptoms, to make sure you understand the clinical picture really well, to arrive at the correct diagnosis and treatment plan, and then to articulate back the what, the when, the how, and the why. And that is really hard to do. And so if you have any kind of impediment to health literacy, whether it's a language barrier or an educational barrier, or just a lack of insight, it really does set up for things being missed, or parts of a diagnostic or treatment plan falling through the cracks. And then there's frustration between both parties because something didn't get done, or it wasn't done correctly. 

I think one of the big things is there's a false assumption that even if we do speak the same language, that we think the same way. I have a funny story that I think about all the time because it really literally stopped me in my tracks. I had a patient who had fairly run-of-the-mill allergic rhinitis, and the first line of treatment is nasal steroids. When you pull it up in the EMR, it has standard prescribing instructions: Two puffs per nostril. The next time she came in to follow up with me, she said, "Dr. Le, I didn't know what to do with my nasal spray." I said, what do you mean? She says, "Do I go one-two [in the same nostril] or do I go one, then two, one, then two [alternating nostrils]?" It never even occurred to me that someone might be anxious about the order of the two puffs per nostril. And it really highlighted to me how something as basic as two puffs per nostril, which seems on the surface so straightforward, really floored this intelligent, native English speaker. 

There are moments like that that we need to remember - that patients don't necessarily think the same way doctors do. And what's clear as day to you is not clear to everyone. 

Antidote: It sounds like doctors having more time with patients is a solution to improving conversations. Since that's not always possible, what other approaches can doctors take to having better conversations? 

E Hanh Le, MD: When I was in clinical practice, I always sought out great patient education materials. I was always looking for patient education materials that were very highly credible but were very clear and simple to read. That's a surprisingly tall order. Because a lot of patient education that you see in the clinics come in big paragraphs, whether it's a pamphlet you hand out or a prefab body of text that you can paste into your EMR after-visit summary, which you print out and hand to the person. It tends to be a dense body of text that no human would find engaging. 

In fact, what I was always looking for was some content that was just very easy — like bulleted lists. People understand checklists, and they understand, to a degree, roadmaps. They understand this is where I am today. What about next week? What about in two weeks? What about in six months? They need a plan visualized in an easy-to understand way. 

It's also helpful to give people bite-sized pieces of information, at the point when they are ready for it. If someone just got diagnosed with hypertension, I don't want the patient education to be, "You're at risk for heart attack and stroke!" Maybe start out with hypertension, what it is, don't go into the science of it, but talk about lifestyle changes. Get people to the table to have deeper conversations later. But don't vomit all that information right off the bat because I think people get overwhelmed when they're not ready for it. Humans are humans. You need to engage them where they are and where they're ready to be.

Antidote: Speaking of creating patient-friendly content, tell me a bit about yourself and how you got into your work today at Healthline. 

E Hanh Le, MD: I worked in clinical practice up until 2007. I was a primary care doctor. I had a very large patient practice working as a primary care physician in the adult medicine clinic at Kaiser Permanente in Walnut Creek, CA. I enjoyed it, but what I recognized living in the Bay Area was that there are a lot of opportunities to leverage my skills as kind of a quarterback, navigating between a lot of different people with different backgrounds. People who come from different levels of health literacy. So it occurred to me that perhaps these skills could be applied in different ways. When I left clinical medicine, I started out at a company called Epocrates, which is an industry leader for drug and disease references, and I started off on the content management side; then I moved over to product management. 

Where I live at Healthline is really at the nexus of content and product management, driving a greater understanding of what our readers need. And here at Healthline, these strategies that we talked about, these are the strategies that we employ in our content. Our audience needs to understand a lot of information, but how can we provide it to them in a way that's understandable and actionable? One of the things that we do with our content is that we start out with a beginning, a starter list. A lot of our content starts out saying at the high level, these are the things we're going to cover, so that you can see it, so you can then jump to the section you're interested in. But it provides a scoping, a mental map for you to know at a high level what it is. Then we make a point at the end of the article to really drive through key takeaways. So that you as the reader know: This is the most important information. If you don't have time, or the literacy level to read all of that, you get the most important points. We create content at a literacy level so the average reader can read it — we aim for eighth to tenth grade reading level. But grade level, that's really a rough, crude guide. It's more about making sure it's really understandable and clear. 

Antidote: Has health literacy awareness improved among healthcare professionals in recent years, so that people are more aware that it's something they should keep in mind? 

E Hanh Le, MD: No! I think providers are at the point that they're so burned out that they're just trying to get through their day. I think they do wonder why their patient conversations and their patient relationships aren't better. I think a lot of times, they blame it on the EMR. When I was in clinical practice, I often felt like I was a glorified court reporter. My best bet to really faithfully capture a patient's chief complaints and come up with the best treatment plan was to capture it in the moment. As I'm doing that, this EMR is this third player in the equation. So as I'm trying to keep my high-level brain trying to think of what's right for you, I might take shortcuts in my speech. Speaking in an empathetic, inclusive, truly clear way ends up being sacrificed, and I might not even know it. I'm just trying to get you what you need so you can walk out the door, go to the pharmacy, and get that medication, which is waiting for you. It's not intentional; it's just because you have to do what you have to do in a short amount of time. A lot of clinicians don't realize there is a communication breakdown; they think it's the other barriers. It is the demand on their time, the demand in the room, the demand on the documentation. It's all those things together. 

Antidote: What advice do you have for patients who struggle with health literacy, but feel intimidated by doctors? 

E Hanh Le, MD: When you talk to the doctor, and they're saying a lot of things at you that you don't necessarily understand, ask the doctor, "Would you recommend this for your mom or dad?" Reframing it puts them into the position of asking themselves whether this is something they would recommend for a loved one and how they would discuss it with a family member. Would you be talking to your parents about this using the same words you're using with me? How I talk to my mom is not how I talk to my patients. To me that's a tactic that I think people might employ.