Addressing health literacy through improved patient-practitioner communication

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The North Carolina Institute ofMedicineIn1983 theNorthCarolinaGeneralAssemblychartered theNorthCarolina InstituteofMedicineasan independent,

nonprofit organization to serve as a nonpolitical source of analysis and advice on issues of relevance to the health ofNorth Carolina’s population.The Institute is a convenor of persons and organizations with health-relevant expertise,aprovider of carefully conducted studies of complex andoften controversial health andhealth care issues,and a sourceofadvice regardingavailableoptions forproblemsolution.Theprincipalmodeofaddressingsuch issues is throughtheconvening of task forces consisting of some of the state’s leading professionals, policy makers, and interest grouprepresentatives to undertake detailed analyses of the various dimensions of such issues and to identify a range ofpossible options for addressing them.

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NC Med J September/October 2007, Volume 68, Number 5298

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The North CarolinaMedical Journal (ISSN 0029-2559) is published by the North Carolina Institute of MedicineandTheDuke Endowment under the direction of the Editorial Board.Copyright 2007©North Carolina Instituteof Medicine. Address manuscripts and communications regarding editorial matters to the Managing Editor.Address communications regarding advertising and reader services to the Assistant Managing Editor. Alladvertisements are accepted subject to the approval of the Editorial Board. The appearance of anadvertisement in the North Carolina Medical Journal does not constitute any endorsement of the subject orclaims of the advertisement.This publication is listed in PubMed.Managing Editor: Kristen L. Dubay, MPP, 919/401-6599, ext. 25 or kristen_dubay (at) nciom.org.Assistant Managing Editor: Phyllis A. Blackwell, 919/401-6599, ext. 27 or phyllis_blackwell (at)nciom.org.Graphic Design: Angie Dickinson, angiedesign (at) windstream.net. Printing: The Ovid BellPress, Inc, 1201-05 Bluff Street, Fulton, MO 65251, 800/835-8919. Annual Subscriptions (6 issues):Individual $42.80 ($40 plus 7% NC tax). Institutional: $64.20 ($60 plus 7% NC tax). Periodicals postagepaid at Durham, NC 27713 and at additional mailing offices. Postmaster: Send address changes to theNorth Carolina Medical Journal, 5501 Fortunes Ridge Drive, Suite E, Durham, NC 27713.

Editorial BoardWilliam B. Applegate,MD,MPH /Wake Forest University,Winston-SalemCynthia B. Archie, RN, EdD / Wayne Community College, GoldsboroWilliam K. Atkinson II, PhD,MPH /WakeMed, RaleighJames A. Bryan II, MD / University of North Carolina, Chapel HillJ. Steven Cline, DDS,MPH / Division of Public Health / NC DHHS, RaleighFred M. Eckel, MS / NC Association of Pharmacists, Chapel HillE. Harvey Estes Jr, MD / Duke University, DurhamHerbert G. Garrison,MD,MPH / East Carolina University, GreenvilleTedW.Goins Jr / Lutheran Services for the Aging, Inc, SalisburyBeth A. Griffin,MHP, PA-C / StellaBlaine Paxton Hall, PA-C / Duke University Medical Center, DurhamMargaret N. Harker,MD / Morehead CityRobert T. Harris, MD / RaleighOlson Huff, MD / Action for Children North Carolina, AshevilleThomas G. Irons,MD / East Carolina University, GreenvilleRichard D. Jordan, DDS / ArdenJulienne K. Kirk, PharmD /Wake Forest University,Winston-SalemRicky L. Langley,MD,MPH / Division of Public Health / NC DHHS, RaleighMark Massing,MD, PhD / The Carolinas Center for Medical Excellence, CaryJane B. Neese, RN, PhD / University of North Carolina, CharlotteM. Alec Parker, DMD / NC Dental Society, FletcherDeborah Porterfield,MD,MPH / Division of Public Health / NC DHHS, RaleighSenator William R. Purcell, MD / NC General Assembly, LaurinburgDennis R. Sherrod, RN, EdD / Winston-Salem State University,Winston-SalemPolly GodwinWelsh, RN-C / NC Health Care Facilities Association, RaleighW.T.Williams Jr,MD / DavidsonDavid R.Work, JD / NC Board of Pharmacy, Chapel HillJoyce M.Young,MD,MPH / IBM Corporation, Research Triangle Park

Publisher Pam C. Silberman, JD, DrPH / NC Institute of Medicine, DurhamPublisher EugeneW. Cochrane Jr / The Duke Endowment, CharlotteEditor-In-Chief Thomas C. Ricketts III, PhD,MPH / University of North Carolina, Chapel HillScientific Editor JohnW.Williams Jr,MD,MHS / Duke University Medical Center, DurhamEditor Emeritus Gordon H.DeFriese, PhD / University of North Carolina, Chapel HillEditor Emeritus Francis A. Neelon,MD / Duke University, DurhamAssociate Editor Dana D. Copeland,MD, PhD / WakeMed, RaleighAssociate EditorMark Holmes, PhD / NC Institute of Medicine, DurhamAssociate EditorMary L. Piepenbring / The Duke Endowment, CharlotteAssociate Editor Charles F.Willson,MD / East Carolina University, GreenvilleSection Editor, Running the Numbers Paul A. Buescher, PhD / NC DHHS, RaleighManaging Editor Kristen L. Dubay,MPP / NC Institute of Medicine, DurhamAssistant Managing Editor Phyllis Blackwell / NC Institute of Medicine, DurhamBusiness Manager Adrienne R. Parker / NC Institute of Medicine, Durham

NC Med J September/October 2007, Volume 68, Number 5 299

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301NC Med J September/October 2007, Volume 68, Number 5

September/October 2007,Volume 68,Number 5 Publishedby theNorth Carolina Institute ofMedicine andTheDuke Endowment

ARTICLES305 Knowledge and Practice of Foodborne Disease

Clinical Specimen Testing and Reporting inNorth Carolina, 2004Pia D.M.MacDonald, PhD,MPH;Michelle R.Torok, PhD,MPH; Jean-Marie Maillard,MD,MSc; Martha Salyers,MD,MPH; Leslie A.Wolf, PhD; Amy L.Nelson, PhD,MPH

312 Urgent Medical Decision Making Regarding aJehovah’sWitness Minor: A Case Report andDiscussionPaul R. Brezina,MD,MBA; John C.Moskop, PhD

POLICY FORUMEffective Patient-PractitionerCommunication318 Introduction

Thomas C.Ricketts III,PhD,MPH;Kristen L.Dubay,MPP

319 Issue Brief: Addressing Health Literacy ThroughImproved Patient-Practitioner CommunicationMark Holmes, PhD; Thomas J. Bacon,DrPH; L. AllenDobson,MD, FAAFP; E. Kiernan McGorty, JD, PhD; PamSilberman, JD,DrPH

COMMENTARIES327 Low Health Literacy: Epidemiology and

InterventionsDarren A.DeWalt,MD,MPH

331 Chasing the MonsterToni Cordell

333 Lay Health Educators' Roles in ImprovingPatient EducationSusan Auger,MSW; Sarah Verbiest,MSW,MPH

336 Incorporating Health Literacy Into Adult BasicEducation: From Life Skills to Life SavingSandra J.Diehl,MPH

340 Improving Prescription Drug LabelingMichael S.Wolf, PhD,MPH; Stacy Cooper Bailey,MPH

343 Medication Instruction by Pharmacists:MakingGood on an OfferMichael D.Murray, PharmD,MPH

346 Increasing the Public's Awareness:TheImportance of Patient-PractitionerCommunicationMarcus Plescia,MD,MPH;Mike Newton-Ward,MSW,MPH

349 Effective Practitioner-Patient Communication inLong-Term CareDennisW. Streets,MPH,MAT, LNHA

352 Developing an Informed Consent ProcessWithPatient Understanding in MindMary Ann Abrams,MD,MPH; Barb Earles, RN,MHA,CPHRM

356 Cultivating Patient-Centered CommunicationSkills Training Across the Medical EducationContinuum:A Model for PracticeGail S.Marion, PA-C, PhD; Sonia J. Crandall, PhD; FrankCelestino,MD;WilliamMcCann, PsyD; Julienne Kirk,PharmD

359 Communicating Health Information to Englishas a Second Language PatientsH.Nolo Martinez,MS, PhD

362 Identifying and Addressing CommunicationFailures as a Means of Reducing UnnecessaryMalpractice ClaimsGerald B.Hickson,MD; A.Dale Jenkins

365 A Perspective on Doctor-PatientCommunication in the Dental OfficeM.Alec Parker, DMD

368 Health Professions Education to Promote HealthLiteracy: Leverage Points and NewOpportunitiesKaren D. Stallings, RN,MEd; Thomas J. Bacon,DrPH

372 A Failure to CommunicateTimothyW. Lane,MD; J. Carson Rounds,MD

DEPARTMENTS302 Tarheel Footprints in Health Care

374 Spotlight on the Safety Net

376 Philanthropy Profiles

377 Running the Numbers

379 Readers’ Forum

383 Classified Advertising

384 Index of Advertisers

Tarheel Footprints in Health CareRecognizing unusual and often unsung contributions of individual citizens who havemade

health care for North Carolinians more accessible and of higher quality

Paula Nobles,RN,BSNPediatric CaseManager,Washington Pediatrics – AccessCare

AccessCare is a network of primary care physicians committed to providing the highestquality medical care for North Carolina’s Medicaid population. AccessCare is the largest of 14local networks of primary care providers that contract with the North Carolina Departmentof Health and Human Services to develop disease management and case managementinitiatives and coordinate prevention, treatment,and other services.This system of networks,coordinated by Community Care of North Carolina, enhances the Carolina ACCESS Medicaidprogram by developing physician-led community partnerships to improve care and reducecosts by connecting Medicaid enrollees with a medical home.

Within AccessCare, patient educators and case managers play a special role in helpingpatients understand their conditions and options along with managing their often complicated diseases.Paula Nobles, RN, BSN, is definitely an invisible hero in the world of case management for the enrollees ofBeaufort County. A 1997 Magna Cum Laude graduate of the East Carolina University School of Nursing, MsNobles formerly worked as a staff nurse in obstetrics,pediatrics, and the newborn nurseries at Beaufort CountyHospital and Pitt County Memorial Hospital. She joined AccessCare in June 2004 as a pediatric case managerwithWashington Pediatrics.Her supervisors say that Ms Nobles has used her solid nursing education to cohesivelymesh the worlds of hospital nursing and community case management.

Ms Nobles’ current areas of specialty include asthma and pediatric obesity. She coordinates the monthly asthmaand weight reduction clinics and has received further training in childhood hearing, chronic obstructivepulmonary disease, and smoking cessation. She is a referral resource for the provider staff of WashingtonPediatrics, Beaufort County Health Department,Beaufort County Department of Social Services, and Children’sDevelopmental Services Agencies. In addition she assists school nurses and other community health careproviders and always graciously accepts assignments to orient new staff at AccessCare as well as staff fromother North CarolinaMedicaid networks.Ms Nobles also has volunteered to assist staff in other counties assesshigh-risk patients that may be in need of case management services.

Ms Nobles, who once described herself as being quiet and meticulously organized, has quietly yet dramaticallyevolved into one of the best community case manager leaders in her county. A typical work week for MsNobles may consist of conducting patient-practitioner education, coordinating and directing the Asthma andWeight Reduction Clinics, planning and implementing patient care plans for various disease processes,electronically documenting all case management duties in the NC Medicaid Case Management InformationSystem, attending local and statewide meetings, and effectively serving the providers and case managing theenrollees ofWashington Pediatrics.Her work helps to improve quality of care while implementing cost savings.At the 2005 North Carolina Pediatric Society meeting, one eastern North Carolina pediatrician was quotedsaying,“I heard about the case manager at Washington Pediatrics, and I want a case manager in our office thatmirrors exactly what Dr Ainsworth’s case manager does for their office. I hear she is excellent!”

In addition to serving as an advocate for the Carolina ACCESS enrollees of Beaufort County, Ms Nobles isinvolved in other health-related community activities. She serves as a preceptor for ECU School of Nursingbachelor of science in nursing students, provides asthma education to students at Beaufort CommunityCollege,and has written articles on pediatric obesity for theWashingtonDaily News. She serves on the BeaufortCounty Task Force on sudden infant death syndrome and codirects the Weight Reduction Summer Camp inBeaufort County with pediatrician Dr Debbie Ainsworth.

For her efforts and accomplishments in case management and support services for the pediatric Accesspatients in Beaufort County, the editors of the North Carolina Medical Journal are pleased to recognize PaulaNobles, RN, BSN, and all case managers and patient educators across the state for their contribution to thehealth and well-being of all North Carolinians.

302 NC Med J September/October 2007, Volume 68, Number 5

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Abstract

Background: Detection of foodborne disease outbreaks relies on health care practitioners (HCPs), infection control practitioners(ICPs), and clinical laboratorians to report notifiable diseases to state or local health departments.

Methods: To examine knowledge and practices about notifiable foodborne disease reporting among HCPs and ICPs in western NorthCarolina and among clinical laboratorians statewide, participants responded to a self-administered questionnaire about foodbornepathogen testing and reporting, referencing Campylobacter, shiga-toxin producing Escherichia coli, and other organisms.

Results: Three hundred seventy-two of 1442 health care providers participated in this survey. Of 372 study participants, fewer than 20%knew that both the clinician and the laboratorian were legally responsible for reporting the study pathogens. Most laboratorians identified theICP (57%) as responsible for reporting. There was a lack of understanding about which infections and test results were reportable.

Limitations: The response rate was very low, particularly among HCPs; participants may have been biased towards those with aparticular interest in foodborne disease or surveillance. This descriptive study cannot be used to determine rates of reporting among themedical community.

Conclusions: Although not legally obliged to report, ICPs were found to play a significant role in disease reporting. Dissemination ofsurveillance information and training through the established network of North Carolina ICPs may be ideal for improving foodbornedisease surveillance in this state.

Key words: Foodborne disease, surveillance, reporting

Knowledge and Practice of Foodborne Disease ClinicalSpecimen Testing and Reporting in North Carolina, 2004

Pia D.M.MacDonald, PhD,MPH;Michelle R.Torok, PhD,MPH; Jean-Marie Maillard,MD,MSc;Martha Salyers,MD,MPH; Leslie A.Wolf, PhD; Amy L.Nelson, PhD,MPH

ARTICLE

Pia D. M. MacDonald, PhD, MPH, is a research assistant professor in the Department of Epidemiology and director of the NorthCarolina Center for Public Health Preparedness at the University of North Carolina at Chapel Hill. She can be reached at pia (at)email.unc.edu or Campus Box 8165, Chapel Hill, NC 27599-8165.

Michelle R. Torok, PhD,MPH, is an epidemiologist at the North Carolina Center for Public Health Preparedness at the University ofNorth Carolina at Chapel Hill.

Jean-Marie Maillard, MD, MSc, is head of Prevention, Investigation, and Surveillance in the Epidemiology Section of the NorthCarolina Division of Public Health.

Martha Salyers,MD,MPH, is leader of the Public Health Regional Surveillance Team Six at the Buncombe County Health Center.

Leslie A.Wolf, PhD, is director of the North Carolina State Laboratory of Public Health.

Amy L.Nelson,PhD,MPH, is an epidemiologist at the North Carolina Center for Public Health Preparedness at the University of NorthCarolina at Chapel Hill.

oodborne pathogens are responsible for an estimated 76million illnesses, 325 000 hospitalizations, and 5200

deaths annually in the United States.1 Reporting of foodbornedisease by physicians and laboratories (passive surveillance) isthe backbone of outbreak detection; local health departmentsalso identify outbreaks by those affected in the community.Passive surveillance in the US has been shown to be inadequatefor many foodborne diseases when compared to other sourcesof data.2-8

Additionally, the US food supply has been targeted in atleast two successful deliberate releases of biological agents.9,10

Enhancement of disease surveillance, laboratory identification,and outbreak detection and control are needed to prepare forbioterrorist acts involving the food supply.11 Therefore, thefoodborne disease reporting system in North Carolina shouldbe described and evaluated in order to identify areas to improvefoodborne disease reporting and better protect North Carolinacitizens.

F



In North Carolina all clinical laboratory facilities andphysicians are required by state law to report certain diseases/organisms to the state or the local health department. While notlegally mandated to report communicable diseases, infectioncontrol practitioners (ICPs) also may play an important role in thepassive surveillance system. Clinical surveillance for foodborneillness in North Carolina is conducted through clinician reportsto the local health department via a mail-in card reporting system,which should be preceded by a phone report for diseasesreportable within 24 hours. Most laboratory-based diagnosesare reported at the state level to the General CommunicableDisease Control Branch of the Epidemiology Section via mail,phone, fax, or Internet. Foodborne diseases that are currentlynotifiable in North Carolina include Campylobacter, Escherichiacoli (E. coli) O157:H7 (Shiga-toxin producing E coli, STEC),foodborne Clostridium perfringens, Listeria monocytogenes,Staphylococcus aureus, Salmonella, Shigella, Vibrio vulnificus,Vibrio other, and the category “foodborne other or unknown.”12

The NC State Laboratory of Public Health accepts clinicalspecimens for the isolation of enteric microorganisms frompublic health care providers. Fecal specimens are examined forthe presence of enteric pathogens including Salmonellaserotypes, Shigella, Campylobacter, Yersinia, and E. coli0157:H7. Reference isolates are accepted from public and privatehealth care providers for identification and/or serotyping. TheState Laboratory of Public Health also participates in theCenters for Disease Control and Prevention PulseNet System,13

which permits detection of foodborne outbreaks within a stateor widespread and diffuse outbreaks across states or countries.14

Although passive surveillance systems are relativelyincomplete,2 consistent disease reporting is thought to provideenough information to discern important occurrences of excessdisease. However, it is important to ensure that these passivecomponents of the notifiable disease reporting system areoperating efficiently to detect outbreaks, bioterrorist incidents,and emerging infectious diseases. In this study, we describe theknowledge and practices of foodborne disease reporting andscreening as well as diagnostic testing among North Carolinahealth care practitioners (HCPs), ICPs, and laboratorians.

METHODS

SurveyofHealthCareand InfectionControl PractitionersinWesternNorth Carolina

Health care practitioners and ICPs were surveyed in 2004.Contact information for HCPs in western North Carolinacame from a database compiled by the Cecil G. Sheps Centerfor Health Services Research at the University of NorthCarolina at Chapel Hill (UNC-Chapel Hill) and maintainedby the NC Medical Board. All medical and osteopathic doctors(excluding residents), physician assistants, and nurse practitionerswhose professional status was “active” were included. Healthcare practitioners with at least 8 hours per week of directpatient care and a business address in 1 of the 19 counties inwestern North Carolina were included in the study. A list ofICPs in hospitals located in western North Carolina was

obtained from the Statewide Program for Infection Control andEpidemiology at UNC-Chapel Hill. Surveys, an introductoryletter, and an Institutional Review Board fact sheet were mailedto HCPs and ICPs in western North Carolina. Nonrespondingindividuals were mailed another survey package 4 weeks afterthe original mailing. Nonresponders to the second mailingwere sent an identical mailing 8 weeks after the original, for atotal of 3 mailings. Health care practitioners included in theanalysis practiced in internal medicine, pediatrics, familypractice, general practice, obstetrics/gynecology, and emergencydepartment specialties.

Survey of Laboratories in North CarolinaLaboratories statewide were contacted in 2004 through NC

Micronet, a database designed for rapid dissemination ofemergency information to clinical microbiologists in NorthCarolina. Laboratories were included in the study if they hadfecal specimens submitted for bacterial screening in 2003. Thesurvey was posted on a secure server/Web site at the StateLaboratory of Public Health, and the contact person on the NCMicronet list at each laboratory was e-mailed survey information,an introductory letter, and an Institutional Review Board factsheet and was asked to participate. Contacts who did notcomplete the survey within 2 weeks received a reminder e-mail,and contacts who did not complete the survey within 4 weeks ofthe initial e-mail were contacted by telephone. Because laboratorysurveys were sent electronically, the resources existed to surveylaboratories statewide.

Survey Content and Data AnalysisThis survey was modeled closely after the Centers for

Disease Control and Prevention’s FoodNet surveys.15 All studyparticipants were asked questions about the diagnostic testingand reporting requirements of Campylobacter, Shiga-toxinproducing E coli, Salmonella, Shigella, and infection with Vibriospecies. Some questions also included L monocytogenes andYersinia infection.

The major domains of the survey included practice information(specialty, setting, location); foodborne disease experience(number of patients seen with acute diarrheal illness in past 30days, clinical history of last patient seen with acute diarrhealillness, factors relating to requesting/not requesting a stoolspecimen, location of bacterial stool culture testing); andreporting practices (who in the facility reports positive testresults to the local and state health departments). Questions aboutfoodborne illness and prevention patient education, confidence indiagnosing, and treating foodborne illness as well as confidencein the local health department’s ability to investigate diseaseoutbreaks also were asked. The survey contained both closedand open-ended questions as well as a 5-point Likert scale.

Data from HCP and ICP surveys were manually entered into aCenters for Disease Control and Prevention EpiInfo database andreviewed for accuracy and completeness. Laboratorian surveyswere downloaded into a Microsoft Access database. Datafrequencies and proportions were examined.

All participants provided informed consent for the survey.


This study was approved by the University of North Carolinaat Chapel Hill’s Biomedical Institutional Review Board.

RESULTS

SurveyofHealthCareand InfectionControl PractitionersinWesternNorth Carolina

Surveys were sent to 1442 HCPs in western NorthCarolina. There were 319 respondents who fit the inclusioncriteria; 53 respondents worked less than 8 hours per week andwere excluded from the analyses (response rate: 319 of 1389,23%). Respondents included physicians (228 of 319, 72%),nurse practitioners (55 of 319, 17%), and physician assistants(36 of 319, 11%). Among physicians, 38% were in familypractice (87 of 228), 16% were in internal medicine (36 of

228) or a subspecialty (7%, 16 of 228), 13% each were in theemergency department and pediatrics (30 and 29 of 228,respectively), and the remainder were in obstetrics/gynecology(10%) or pediatric subspecialties (3%). Medical specialties for18 participants were unknown.

Surveys were sent to ICPs at 21 facilities in western NorthCarolina and 11 responded. Seven of the responding ICPsworked in a hospital while the remaining 3 worked in morethan one setting (eg, a hospital and long term care facility).

Diagnostic Testing Knowledge and PracticeThe majority of HCPs noted that stool samples were tested

at their hospital laboratory (74%, 227 of 306); 21% reportedthat screens were performed at independent laboratories (65 of306); and 5% (14 of 306) did not know. Thirteen participants

Table 1.North Carolina Laboratories and Health Care and Infection Control Practitioners inWestern NorthCarolinaWho Report That the Laboratory Screens for These Pathogens

Enteric Bacterial Laboratories Health Care Infection Control

Pathogen No. (%) Practitioners No. (%) Practitioners No. (%)(N=42) (N=319) (N=11)

SalmonellaYes 39 (100) 270 (90) 11 (100)No 0 1 (<1) 0Don’t know … 26 (9) 0

ShigellaYes 40 (100) 266 (89) 11 (100)No 0 1 (<1) 0Don’t know … 31 (10) 0

CampylobacterYes 34 (87) 239 (81) 7 (78)No 5 (13) 7 (2) 2 (22)Don’t know … 48 (16) 0

E coli O157/STECYes 22 (60) 143 (53) 5 (50)No 15 (40) 51 (19) 4 (40)Don’t know … 76 (28) 1 (10)

VibrioYes 11 (35) 60 (23) 4 (44)No 20 (65) 66 (25) 4 (44)Don’t know … 137 (52) 1 (11)

YersiniaYes 16 (43) 4† …No 21 (57)Don’t know …

L monocytogenesYes 3 (10) … …No 26 (90)Don’t know …

† Noted as part of an“other” response, percentage not calculable


failed to respond to this question.In general, HCP respondents identified the same pathogens

as part of a routine screen. (See Table 1.) About half thought Ecoli O157:H7 was tested for routinely. Fewer thought Vibriospecies were included in the routine screen, and many respondentswere unsure about Vibrio and E coli O157:H7. Two individualsnoted that E coli O157:H7 was screened for in cases withbloody stool. In an open-ended response, 4 individuals saidYersinia and 4 said Giardia testing were part of the screen.

Most ICPs (10 of 13) noted that stool samples were testedroutinely at their hospital laboratory while several (3 of 13)indicated that the samples were tested by independent laboratories.According to most (8 of 9) of the ICPs, hospital laboratoriesconducted all stool screens, and 1 ICP reported 90% of culturesbeing conducted there. An additional ICP reported that allroutine cultures were performed at a commercial laboratory.

Knowledge of Reporting RequirementsAmong HCPs, 45% to 57% incorrectly thought that only

clinicians were responsible for reporting, depending on thepathogen (Figure 1), while 13% incorrectly thought that onlythe laboratorian was responsible for reporting these diseases(range, 12% to 14%). On average, 5% to 7% of HCPs correctlynoted that both clinicians and laboratorians were legallyresponsible for notifying the health department of thesepathogens. An additional 21% to 31% did not know whoshould report the study pathogens. Eight percent of HCPs (24of 296) incorrectly identified Campylobacter as nonreportable,8% (22 of 289) correctly identified Yersinia as nonreportable,and 1% to 3% of HCPs incorrectly identified the remainingdiseases as nonreportable.

Among ICPs, almost half (4 of 11) incorrectly thought that

only the clinician was responsible for reporting infections withthe study pathogens; a few (2 of 11) incorrectly thought thatonly the laboratorian was responsible for reporting thesepathogens; the same proportion (2 of 11) correctly thoughtthat both the clinician and the laboratorian were responsible forreporting; and some (4 of 11) thought some other person wasresponsible for reporting. Yersinia infection was correctlyidentified as nonreportable by 1 ICP. No ICP identifiedCampylobacter, STEC, L monocytogenes, Salmonellosis, Shigellosis,or Vibrio as “not reportable.”

Reporting PracticesWhen asked who in the facility completes the state’s

communicable disease report card, HCPs reported that thephysician (38%, 121 of 315), nurse (14%, 45 of 315), nursepractitioner (6%, 19 of 315), physician assistant (3%, 9 of 315),or another provider who saw the patient (3%, 10 of 315)completed the disease report card. However, 15% of respondents(48 of 315) did not know who completed the card in theiroffice. Another 29 HCPs (9%) said that ICPs, the laboratory(8%, 24), or the office manager or other administrative personnel(<2%, 6) completed the card.

Infection control practitioners may report notifiable diseases tothe health department, but they are not legally required to do so.Nevertheless, most of the Infection control practitioners (8 of 11)noted they completed the disease report card; 2 reported that thephysician and 1 reported that the laboratorian completed the card.

Survey of Laboratories in North CarolinaE-mails giving the Web site for the survey were sent to 108

clinical diagnostic laboratories in North Carolina. Forty-eightlaboratories responded and 42 fit laboratory inclusion criteria,

Figure 1.Percent ofWestern North Carolina Health Care PractitionersWhoThink Clinicians and/orLaboratorians Are Legally Responsible for Reporting Campylobacter,E coliO157/STEC,L monocytogenes,Salmonella,Shigella, and Vibrio Species, and Yersinia to the Health Department.


for a response rate of 41% (42 of 102). The participatinglaboratories were primarily hospital or medical-center basedlaboratories (39 of 42), but 2 were independent commerciallaboratories, and 1 was a military base laboratory.

Diagnostic Testing Knowledge and PracticeWe asked laboratorians about pathogens included in their

routine enteric screen and most reported including Salmonella,Shigella, and Campylobacter. Fewer included E coli O157:H7,Yersinia, and Vibrio. Routine screening for L monocytogenes wasrare. (See Table 1.)

When a positive result was determined for a foodbornepathogen, more than half of laboratorians (25 of 40) forwardedisolates to the State Laboratory of Public Health within 24 hours.Several (3 of 40) forwarded isolates weekly while others (4 of 40)never sent isolates, and the remaining respondents forwardedisolates monthly, yearly, within some other time frame, orwhenever needed. Some sent isolates to the county healthdepartment (n=8), presumably to forward to the StateLaboratory of Public Health.

Knowledge of Reporting RequirementsFor Campylobacter, L monocytogenes, Shiga-toxin producing

E coli, Shigella, and Salmonella, 36% to 41% of 39 respondentsfrom clinical diagnostic laboratories incorrectly thought that onlythe laboratorian was responsible for reporting (Figure 2); 26% to32% incorrectly thought only the clinician was responsible forreporting; and 5% incorrectly thought L monocytogenes wasnonreportable. For Vibrio, 33% of laboratorians thought onlylaboratories were responsible for reporting, 33% thought onlyclinicians were responsible, and 3% thought Vibrio wasnonreportable. For Yersinia, 28% said only the laboratorian wasresponsible for reporting, and 31% said only the clinician wasresponsible; 10% correctly thought Yersinia was nonreportable.For all study pathogens, an average of 27% (range, 23% to

28%) of respondents (n = 9-11) identified both clinician andlaboratorian as responsible for reporting.

Reporting PracticesThe majority of laboratorians (21 of 38) reported notifiable

test results to the health department by mail. Some (10 of 38)used a fax, 1 individual each reported using the telephone andthe Internet, and some (5 of 38) did not know how data wasreported. When asked who in their laboratory actually reportednotifiable results, most laboratorians (23 of 41) said the ICPwas responsible while others (15 of 41) said the microbiologistwas responsible. One each said the laboratory manager wasresponsible, automated computer reporting was used, or he/shenotified an epidemiology clinic.

DISCUSSION

This survey of participants in the North Carolinacommunicable disease reporting system identified gaps inknowledge of foodborne disease testing and deficiencies infoodborne disease reporting practices. All of the pathogensincluded in this survey are part of the routine bacterial stoolculture screen at the State Laboratory of Public Health, buthospital and independent laboratories may include differentpathogens. Survey results indicate HCPs and ICPs were uncertainabout the pathogens included in a routine screen at the laboratoriesused by their office or facility. Lack of knowledge about theroutine panel at their reference laboratory could result in significantunderdiagnosis and underreporting of foodborne pathogens ifclinicians assume diagnostic tests will be performed on stoolsamples because they are considered “routine,” when they are notactually part of the routine screen at their particular referencelaboratory.

The routine screening practices of laboratories to identifythe pathogens in the survey are comparable to those of the

Figure 2.Percent of North Carolina LaboratoriansWhoThink Clinicians and/or Laboratorians Are LegallyResponsible for Reporting Campylobacter,E coliO157/STEC,L monocytogenes,Salmonella,Shigella,and Vibrio Species, and Yersinia to the Health Department.

national foodborne surveillance sites of FoodNet, where mostlaboratories routinely culture for Salmonella, Shigella, andCampylobacter species, but fewer routinely culture for E coliO157:H7 (57%) and Y. entercolitica (50%). Fifty percent ofFoodNet sites routinely test for Vibrio species,16 which is morethan among the North Carolina laboratories surveyed. In astudy of laboratories in Gulf Coast states, only 22% of stoolspecimens submitted to laboratories with Vibrio culturingcapability were screened for Vibrio species, and only 24% of thelaboratory directors in these facilities knew that the organismwas reportable in their state.17 There may be a potential forunderdiagnosis of this infection in North Carolina and otherUS states due to lack of testing. The costs in materials and laborof testing stool samples may continue to be one barrier toreporting.17

A limitation of the present study was the low response rateamong HCPs (22%) and laboratorians (39%) and the smallnumber of ICPs (n=11). Since respondents may have moreinterest and knowledge in foodborne illness testing and reportingcompared to other clinicians and laboratorians, the data presentedhere may overestimate the knowledge and practices aroundfoodborne disease testing and reporting. Data on the workplacesetting of nonresponders was not available.

Participants seemed aware of the most frequently testedfoodborne pathogens but they were deficient in knowledge ofreporting requirements. All pathogens included in the surveyare reportable in North Carolina except Yersinia. Eight percentof HCPs, 1 ICP, and 10% of laboratorians correctly thoughtYersinia was not a reportable diagnosis. Three percent to 5% oflaboratorians incorrectly thought L monocytogenes and Vibriospecies were not reportable, and 8% of HCPs incorrectlythought Campylobacter was not reportable. L monocytogenes wasadded to the North Carolina notifiable disease list in 2001.

An average of 57% of HCPs knew the clinician was responsiblefor reporting notifiable diseases to the health departmentwhereas an average of 64% of laboratorians knew that reportingthe study pathogens was their responsibility. Health carepractitioners may be expected to report confirmed cases lessoften than laboratories because there is a delay in obtainingdiagnostic confirmation from the laboratory and patients mayno longer be under the clinician’s treatment. Only 6% of HCPsand 25% of laboratorians recognized that both clinicians andlaboratorians were required to report notifiable diseases.Schramm,18 who assessed the origins of confirmed case reports inVermont in the late 1980s, found that 71% of case reports werefrom laboratories, 10% from nurses including ICPs, 10% fromphysicians’ offices, and 9% from elsewhere. Thus, recognition bylaboratorians of their responsibility to report may be key in thepassive surveillance system. In North Carolina physicians arerequired to report “after the disease or condition is reasonablysuspected to exist.”12 In many circumstances, reasonable suspicionof a foodborne acute diarrheal illness may be difficult to definewithout laboratory confirmation.

Most laboratories forward foodborne pathogen isolates tothe State Laboratory of Public Health within 24 hours, butsome forward them less frequently or never. As part of the Centers

for Disease Control and Prevention PulseNet system, the StateLaboratory of Public Health serotypes some foodbornepathogens. Thus, especially in the context of a foodbornedisease outbreak, timely forwarding of isolates by laboratoriesshould be encouraged.

Limited knowledge among laboratories about the legalresponsibility for reporting notifiable results may reflect the factthat many hospital laboratories depend on ICPs to reportlaboratory results under surveillance. Nevertheless, sincereporting is the legal responsibility of the clinical laboratory,our findings indicate a need to educate laboratorians on thecommunicable disease reporting process and requirements.

The study also points to a need to increase awareness andknowledge among HCPs. The vital role played by cliniciansin state surveillance systems is undisputed.19-21 The HCP’sinteraction with the patient is the front line of disease surveillance.Studies in the US and elsewhere have found that knowledge ofthe reporting system is deficient among physicians with low ratesof reporting notifiable disease,3,22 suggesting that increasedcommunication with physicians could enhance passive reporting.22

This survey is the first study to examine notifiable diseasetesting and reporting awareness in North Carolina. To ourknowledge it is also the first assessment of awareness of reportingrequirements among participants in the disease reporting systemthrough which foodborne illness due to a biological attack maybe likely to first appear: ICPs, clinical diagnostic laboratorians,and primary care physicians and health care professionals.

The study results indicate that ICPs play a significant role inreporting diseases though they are not currently legally obligatedto report in North Carolina. Infection control practitionerswere identified by 9% of HCPs, 73% of ICPs, and 57% oflaboratorians as being the persons who actually submittedreports of disease to the health department. Many ICPs activelymonitor their institution’s laboratory and clinical data to identifyreportable cases. Dissemination of surveillance informationand training opportunities through the well-established networkof ICPs may offer opportunities to improve foodborne diseasesurveillance in North Carolina. Formally incorporating ICPsinto the disease reporting structure also may enhance the passivesurveillance system. Reaching HCPs who do not have contactwith an ICP is an issue that needs further exploration. Efforts tofacilitate disease reporting for HCPs also should be considered.For example, a printed statement on laboratory test resultscould serve to remind laboratorians and HCPs whichpathogens are included in a routine stool culture screen andincrease indirect communication between the laboratory andHCPs. Laboratory results for reportable positive pathogensalso could include a reporting reminder to the HCP or, forcomputerized laboratory results, could provide an Internet linkfor web-based reporting. NCMJ

Acknowledgements:The authors would like to thank the membersof the State Laboratory of Public Health Bioterrorism andEmerging Pathogens Unit for helping with follow-up phone calls,all survey respondents for taking time to complete surveys, andAndrew C. Voetsch for his assistance in conceptualizing the study


and reviewing the manuscript. This publication was supported bythe Association of Schools of Public Health (ASPH) ProjectA1011-21/21, Centers for Disease Control and Prevention (CDC)Cooperative Agreement Number U90/CCU424255-01, and

Contract Number 01559-04 from the NC Division of PublicHealth. Its contents are solely the responsibility of the authors anddo not necessarily represent the official views of ASPH, CDC, orNC Division of Public Health.


REFERENCES

1 Mead PS, Slutsker L, Dietz V, et al. Food-related illness anddeath in the United States. Emerg Infect Dis. 1999;5(5):607-625.

2 Doyle TJ, Glynn MK, Groseclose SL. Completeness of notifiableinfectious disease reporting in the United States: an analyticalliterature review. Am J Epidemiol. 2002;155(9):866-874.

3 Konowitz PM, Petrossian GA, Rose DN. The underreportingof disease and physicians’ knowledge of reporting requirements.Public Health Rep. 1984;99(1):31-35.

4 Kimball AM, Thacker SB, Levy ME. Shigella surveillance in alarge metropolitan area: assessment of a passive reporting system.Am J Public Health. 1980;70(2):164-166.

5 Harkess JR, Gildon BA, Archer PW, Istre GR. Is passivesurveillance always insensitive? An evaluation of shigellosissurveillance in Oklahoma. Am J Epidemiol. 1988;128(4):878-881.

6 Campos-Outcalt D, England R, Porter B. Reporting ofcommunicable diseases by university physicians. Public HealthRep. 1991;106(5):579-583.

7 Effler P, Ching-Lee M, Bogard A, Ieong MC, Nekomoto T,Jernigan D. Statewide system of electronic notifiable diseasereporting from clinical laboratories: comparing automatedreporting with conventional methods. JAMA.1999;282(19):1845-1850.

8 Vogt RL, Clark SW, Kappel S. Evaluation of the state surveillancesystem using hospital discharge diagnoses, 1982-1983. Am JEpidemiol. 1986;123(1):197-198.

9 Torok TJ, Tauxe RV, Wise RP, et al. A large communityoutbreak of salmonellosis caused by intentional contaminationof restaurant salad bars. JAMA. 1997;278(5):389-395.

10 Kolavic SA, Kimura A, Simons SL, Slutsker L, Barth S, HaleyCE. An outbreak of Shigella dysenteriae type 2 amonglaboratory workers due to intentional food contamination.JAMA. 1997;278(5):396-398.

11 Sobel J, Khan AS, Swerdlow DL. Threat of a biological terroristattack on the US food supply: the CDC perspective. Lancet.2002;359(9309):874-880.

12 N.C. Gen. Stat. § 15A-19A (1988)13 Swaminathan B, Barrett TJ, Hunter SB, Tauxe RV, CDC

PulseNet Task Force. PulseNet: the molecular subtypingnetwork for foodborne bacterial disease surveillance, UnitedStates. Emerg Infect Dis. 2001;7(3):382-389.

14 Bender JB, Hedberg CW, Besser JM, Boxrud DJ, MacDonaldKL, Osterholm MT. Surveillance by molecular subtype forEscherichia coli O157:H7 infections in Minnesota by molecularsubtyping. N Engl J Med. 1997;337(6):388-394.

15 Scallen, E. Activities, achievements, and lessons learned duringthe first 10 years of the Foodborne Diseases Active SurveillanceNetwork: 1996-2005. Clin Infect Dis. 2007;44(5):718-725.

16 Voetsch AC, Angulo FJ, Rabatsky-Ehr T, et al. Laboratorypractices for stool-specimen culture for bacterial pathogens,including Escherichia coli O157:H7, in the FoodNet sites,1995-2000. Clin Infect Dis. 2004; 38 Suppl 3: S190-197.

17 Marano NN, Daniels NA, Easton AN, et al. A survey of stoolculturing practices for vibrio species at clinical laboratories inGulf Coast states. J Clin Microbiol. 2000;38(6):2267-2270.

18 Schramm MM, Vogt RL, Mamolen M. The surveillance ofcommunicable disease in Vermont: who reports? Public HealthRep. 1991;106(1):95-97.

19 Danila RN, Lexau C, Lynfield R, Moore KA, Osterholm MT.Addressing emerging infections. The partnership betweenpublic health and primary care physicians. Postgrad Med.1999;106(2):90-105, vi.

20 Bednarczyk M, Lu S, Tan CG, Bresnitz EA. Communicable-disease surveillance in New Jersey. N J Med. 2004;101(9Suppl):45-50.

21 Ashford DA, Kaiser RM, Bales ME, et al. Planning againstbiological terrorism: lessons from outbreak investigations.Emerg Infect Dis. 2003; 9(5):515-519.

22 Krause G, Ropers G, Stark K. Notifiable disease surveillance andpracticing physicians. Emerg Infect Dis. 2005;11(3):442-445.

Abstract

Background: Physicians strive to respect the autonomy of patients. The emergent care of Jehovah’s Witnesses, however, leaves healthcare providers struggling with ethical and legal questions. These are further compounded when the patient in question is a minor.

Case: A girl aged 15 years presented with anemia, a large ovarian mass, massive hemoperitoneum, and parents who were devoutJehovah’s Witnesses who refused administration of blood products. Following discussion of the patient’s condition and treatment optionswith the patient, her family, members of the treatment team, and consultants, the patient was transferred to a hospital that offered a bloodconservation program for surgical patients. The patient received surgical management without the need for blood transfusion. Hersurgeons, however, reserved the legal right to give blood if an emergent need arose despite the lack of parental consent.

Conclusion: Society grants considerable legal latitude in dealing with Jehovah’s Witness minors, and physicians must be aware of thelegal and ethical parameters surrounding the care of such patients.

Urgent Medical Decision Making Regarding aJehovah’s Witness Minor:A Case Report and Discussion

Paul R. Brezina,MD,MBA; John C.Moskop, PhD

ARTICLE

Paul R. Brezina, MD,MBA, is a resident physician in the Department of Obstetrics/Gynecology and Internal Medicine at the BrodySchool of Medicine, East Carolina University.He can be reached at BREZINAP (at) ecu.edu or 600 Moye Blvd., Greenville,NC 27834.

John C.Moskop, PhD, is a professor of Medical Humanities at the Brody School of Medicine, East Carolina University, and director ofthe Bioethics Center of University Health Systems of Eastern Carolina.

he right of competent adults to make decisions regardingtheir medical care is well established in US law and ethics

and widely recognized throughout the medical community.1

Jehovah’s Witnesses’ refusal of blood products is a commonlyreferenced example of this right.2 Whether minors also have aright to make such decisions regarding care, however, is muchless clear.3 Legal and ethical standards regarding the autonomyand rights of minors have evolved over time. Due to thisevolution, confusion exists within the medical communityregarding the appropriate response to a minor whose parentsrefuse medically necessary treatment.

We present a patient who is a female minor with anemia, anurgent surgical need, and parents who are devout Jehovah’sWitnesses who refuse administration of blood products. Thefollowing article describes this case, reviews the beliefs ofJehovah’s Witnesses regarding blood products, discusses legalstandards for medical treatment of minors, and offers practicalguidelines for physicians in these situations.

Case Description

A girl aged 15 years presented to the emergency departmentof a tertiary care hospital with the chief complaint of 2 weeks ofincreased abdominal girth and constipation. These symptomshad previously been evaluated by primary care doctors whoinstructed the patient to come to the emergency departmentafter failed outpatient treatments for constipation. On exam,the abdomen was tensely distended with no guarding orrebound, and the remainder of the physical exam was normal.There was mild tachycardia of approximately 105 beats perminute but otherwise normal vital signs. The rest of the reviewof systems was negative.

The patient stated she had no prior medical, obstetric, orsurgical history, had never used any alcohol, tobacco, or drugs,had no significant family history, no history of sexual activity,and no known drug allergies. She noted normal monthlymenses since age 11. Her last menstrual period began 1 weekprior to presentation. The patient’s family was present at alltimes in her care and stated they were devout Jehovah’sWitnesses. The parents, upon meeting the medical team,expressed their intention to remain at the patient’s bedside at all

T



times during her hospitalization. This was not challenged by themedical staff. The parents stated that under no circumstancewould they accept a transfusion as a part of their daughter’streatment even if it meant the death of their daughter. Whenquestioned directly, the patient also refused blood productseven if this could save her life. The hospital ethics team wasconsulted and risk management was notified.

Laboratory results showed a negative urine pregnancy testand hematocrit of 32.5%. A computed tomography scanshowed a right adnexal mass, likely ovarian in origin, withmixed solid and cystic components, measuring 10 x 10.6 cmand with massive ascites. There was no evidence of peritonealseeding. The liver, spleen, adrenals, appendix, pancreas, andkidneys were normal. No adenopathy or osseous lesions wereseen. Ultrasound-guided paracentesis was performed, removing3 liters of fluid. Analysis showed a large amount of blood andan albumin level consistent with an exudative process.

The patient was given intravenous hydration, and a repeatcomplete blood count showed a drastic drop in her hematocrit to20.9% with worsening tachycardia. Intravenous iron and Procrit®

were begun, and interval monitoring of the patient’s blood levelswas changed to every 6 hours. An urgent consultation meetingwith the patient and her family, the medical team, and the ethicsteam was conducted. Also present were several elders from herchurch. The parents stated their refusal to permit the use ofblood products. In response to an option suggested by theethics consultants, they requested transfer to a facility “morecomfortable with bloodless surgery.”

Following this meeting with the ethics consultants and family,the treatment team began aggressive efforts to accommodatethe request for transfer. Hospital attorneys made preliminarycontact with a local judge in case a court hearing was deemednecessary. Six hours later the hematocrit remained stable at22%. Another tertiary care center in the state that offered a“blood conservation program” accepted the patient, and within24 hours the patient was transferred in stable condition.

The patient was taken to surgery at that institution 2 dayslater with a hematocrit of 25%. The parents were told thatblood would be given if needed, and the parents signed an“acknowledgement statement” detailing their understandingthat emergency transfusion would not be withheld from aminor regardless of parental refusal. In surgery, a rightsalpingo-oophorectomy was performed as was removal of a 10cm right ovarian mass and 5 liters of bloody ascites. Blood lossduring the procedure was reported to be 25 cc. Pathology of themass revealed a granulosa cell tumor, juvenile type. No bloodwas given and the patient was discharged in stable condition.

The Religious Context: Jehovah’sWitnesses

Jehovah’s Witnesses are members of an international religiouscommunity who adopt a literal interpretation of the Bible andassert that their faith is a restoration of early Christianity.4

Jehovah’s Witnesses comprise a small proportion of the populationin both North Carolina and the nation. In 2001 approximately0.6% of the US population and less than 0.5% of North

Carolina residents identified themselves as Jehovah’sWitnesses.5 Jehovah’sWitnesses cite the following biblical passagesfrom the King James Bible to support their belief that acceptingblood products is a serious sin:6,7

� Genesis 9:4 “Blood ye shall not eat.”� Leviticus 17:12-14 “No soul of you shall eat blood…

whosoever eateth it shall be cut off.”� Acts 15:29 “That ye abstain…from blood.”� Acts 21:25 “Gentiles…[should] keep themselves from

things offered to idols and from blood.”

This sin is considered so grave by the faith that any directpartaking of blood results in the “loss of eternal life.”3

Therefore, it is common for Jehovah’s Witnesses in critical needof blood transfusions to choose death over acceptance of bloodproducts. The right of adults to make this decision is wellaccepted in the medical and bioethics literature and widelyrespected in medical practice.3 The ability of minors, however,to comprehend the gravity of such a decision or to make anautonomous decision independent of the wishes of their parentsis much less clear.

The Legal Context:Treatment of Minors

The legal limits of Jehovah’s Witness parents to dictate theactivity of their children were first addressed in the 1944 USSupreme Court case Prince v. Commonwealth of Massachusetts.8

This case involved a girl aged 9 years named Sarah Prince whowas instructed by her Jehovah’s Witness guardian to sell religiousliterature on public streets in Brockton, Massachusetts. Thisprompted discontent in the community, and the child and herguardian were convicted of violating a child labor law that read,“No boy under twelve and no girl under eighteen shall sell,expose, or offer for sale any newspapers, magazines, periodicalsor any other articles of merchandise of any description.”

The case was appealed to the US Supreme Court whichupheld the conviction. The Court concluded that there existsan “interest of society to protect the welfare of children” andsupported the “State’s assertion of authority to that end.”Furthermore, the Court established that “Parents may be freeto become martyrs themselves. But it does not follow they arefree, in identical circumstances, to make martyrs of their childrenbefore they have reached the age of full and legal discretionwhen they can make that choice for themselves.”8

This decision established the right of the state to supersedeparental authority, and it has shaped current legal opinionregarding the administration of emergency blood transfusionsand other medical care to minors. Indeed, legal protection ofminors from abuse and neglect is now well established in bothfederal and state law. The federal Child Abuse Prevention andTreatment Act defines child abuse or neglect as any act orfailure to act by a parent or caretaker of a child, usually underthe age of 18 years, “resulting in imminent risk of serious harm,death, serious physical or emotional harm, sexual abuse, orexploitation.”9


Although federal law provides a general framework forand funding support of child protection activities, each stateestablishes its own specific child abuse and neglect policies andenforcement programs. The case described above took place inNorth Carolina which has a clearly defined policy regarding thestate’s authority to supersede the wishes of parents or guardians.The North Carolina “Treatment of Minors Act” of 2005includes the following passage:

It shall be lawful for any physician licensed to practice medicine inNorth Carolina to render treatment to any minor without first obtainingthe consent and approval of either the father or mother of said child . . .where the parents refuse to consent to a procedure, and the necessity forimmediate treatment is so apparent that the delay required to obtaina court order would endanger the life or seriously worsen the physicalcondition of the child. No treatment shall be administered to a childover the parent’s objection as herein authorized unless the physicianshall first obtain the opinion of another physician licensed to practicemedicine in the state of North Carolina that such a procedure is necessaryto prevent immediate harm to a child.10

This statute gives physicians the authority to provideemergency medical care to minors including blood transfusionswithout parental consent or a court order, provided that theyobtain a second physician’s opinion that there is an immediateneed for treatment. The statute also provides an account ofwhen treatment constitutes an emergency, namely, “when thedelay required to obtain a court order would endanger the lifeor seriously worsen the physical condition of the child.”

Hospitals have an ethical obligation to delineate expressly tothe guardians of minors the parameters of the law and howmedical care will be administered. The institution operatingthe “blood conservation program” in the above case routinelyutilizes acknowledgement statements in circumstances involvingthe medical care of minors whose parents seek to refuse bloodtransfusions.11 These statements serve as a tool ensuring anddocumenting that clear and complete disclosure of the hospital’sintentions are conveyed to the patient’s guardians. Similarstatements may be viewed at http://www.noblood.com. Failureof the parents to sign such a document would not alter the careadministered to the minor under North Carolina law in the eventa life saving transfusion is required. From a legal and ethicalstandpoint, the statement serves to document formally that aclear dialogue was conducted between the hospital and the parentsregarding the emergent administration of blood products.

It is important to note that North Carolina’s minor treatmentstatute also provides legal protection to physicians who choosenot to override parental refusal of treatment for a minor child.The minor treatment statute cited above goes on to state:

“Provided, however, that the refusal of a physician to use, perform orrender treatment to a minor without the consent of the minor’s parent,guardian, or person standing in the position of loco parentis, inaccordance with this Article, shall not constitute grounds for a civilaction or criminal proceedings against such physician.”10

North Carolina law thus gives legal protection and discretionto physicians to make a considered decision, based on the moralarguments and the specific circumstances of the case at hand,either to honor or to override parents’ refusal of treatment fortheir minor child. To make this decision, physicians mustidentify and weigh a constellation of values including familyintegrity, religious freedom, the wishes of the parents and ofthe minor patient, and the life and health of the minor patient.

It is also worth noting that North Carolina is one of a smallminority of states that does not grant to parents an exemptionfrom charges of child neglect if they withhold medical treatmentfrom their child as a result of their religious beliefs.12 At least 41states provide such a religious exemption from child abuse andneglect laws, although many of these states permit courts toorder necessary treatment for children even when parents areprotected by religious exemption laws from conviction forcriminal abuse or neglect.13

In addition to the emergency treatment exception notedabove, North Carolina law allows treatment of minors withoutparental or guardian consent in several other particularcircumstances. By statute, minors can consent to treatment forthe following specific medical conditions: sexually transmittedand other reportable diseases; pregnancy (but not abortion);abuse of controlled substances or alcohol; and emotionaldisturbance.14 Emancipated minors can consent to their ownmedical treatment.15 In North Carolina, minors aged 16 and17 years may petition the court for a judicial decree ofemancipation. Minors who are married or members of thearmed forces of the United States are also emancipated underNorth Carolina law. In nonemergency situations, theDepartment of Social Services may, after investigation, assumecustody for a minor when it determines that the minor needstreatment that parents are unwilling to provide.16 Finally,although some states permit older or “mature” minors to makeat least some of their own medical treatment decisions, NorthCarolina law does not recognize this “mature minor rule.”16

The Case Revisited: Practical Guidelines

In the United States, adult patients with decision-makingcapacity have wide-ranging authority to accept or refuse medicaltreatment recommendations. Parents also have significantresponsibility and authority to choose the medical care of theirchildren, but that authority is circumscribed by certain legaland moral limits. Conflicts between the medical treatmentchoices of parents for their minor children and the treatmentrecommendations of physicians often resist easy resolutionbecause they pit deeply held principles of professional ethics,such as respect for the wishes of parents and minor patients andthe duty to protect the life and health of patients, against oneanother. The case described above offers a widely recognizedexample of this type of conflict. When such conflicts occur,physicians should be able to recognize their causes and pursueoptions for conflict resolution. In the concluding section of thisarticle, we offer several practical guidelines for addressing thesesituations.

When a patient or the patient’s representative refuses arecommended treatment, it is important to elicit and acknowledgethe reasons for that refusal. In the case we describe here, boththe parents and the adolescent patient clearly expressed theirrefusal of blood products and cited their religious beliefs asJehovah’s Witnesses as the reason for that refusal. In open andrespectful discussion with members of the treatment team, thepatient and her parents demonstrated that they had an adequateunderstanding of the patient’s medical condition, the potentialneed for blood products to treat that condition, and the potentialconsequences of forgoing this treatment. The team could thusestablish that the refusal of blood products was not based on amisunderstanding about the nature or seriousness of thepatient’s condition or about the rationale for this treatment.

In most situations, we suggest that health care professionalsdiscuss treatment options with adolescent patients both withand apart from their parents or others to ensure that the patientis able to express wishes or concerns that he or she is unable orunwilling to express to family members. In the case discussed,the family chose to remain with the patient, presumably toprevent administration of unwanted treatment without theirknowledge or consent. The patient appeared to understand thesituation and clearly expressed a refusal of blood products.There was no indication that she disagreed in any way with herparent’s views or wished to speak privately with her physicians, sothe treatment team decided not to insist on a private discussionwith the patient.

By acknowledging a family’s religious beliefs and values asthe reason for their refusal of treatment, members of the healthcare team can demonstrate that they have listened to andunderstood that reason and that they respect the importance ofthose beliefs and values. We hold that it is important to do this asa sign of respect for the patient and parents as moral agents. Forsimilar reasons, it is important for the health care professionals toarticulate the reasons for their treatment recommendation. Inthis way, the health care professionals make clear the values thatunderlie that recommendation and commend those values to thepatient and family. By offering reasons for their recommendation,the health care professionals also make clear that they too aremoral agents responsible for their actions.

When professionals, patients, and parents express theiropinions, beliefs, and guiding values, they can begin to seekcommon ground. Recognizing the value of respecting familywishes and religious freedom, for example, physicians mightpledge to the patient and family that they will not pursue bloodtransfusions or will not do so unless the patient’s life is inimminent danger. Recognizing the value of life, the patient andparents might express a willingness to accept blood products ifabsolutely necessary to save the patient’s life, although they didnot do so in this situation. This search for common ground can

identify shared beliefs and values and can sometimes lead to aresolution of conflict.

We recommend that health care professionals seek assistancefrom others when they encounter conflicts with patients andfamilies regarding treatment choices. In the case we describe, thetreatment team sought advice from both the hospital’s ethicsconsultation and risk management services. Risk managersoffered advice on the legal options available to the team. Ethicsconsultants suggested an option unavailable in the hospital,namely, a surgery program better prepared to accommodate thefamily’s wishes. As described above, the family expressed interestin this option and a transfer to a hospital with such a programwas accomplished with a successful outcome for the patient.

When conflict about treatment for a minor patient is rootedin incompatible and deeply held values, it may proveintractable. In this case, the parents and the patient might haverefused transfer, but also persisted in their refusal of bloodproducts. The patient’s condition might have deteriorated, andthe need for a blood transfusion might have become more urgentor emergent. As described above, North Carolina law permits 2physicians to administer emergency medical treatment over thepatient’s and parent’s objections, but it also protects physiciansfrom liability if they choose to honor the parent’s refusal oftreatment. Thus, law does not dictate the physician’s action, andthe physician’s decision is ultimately a moral one. Physiciansshould exercise this important moral responsibility with carefulreflection on the relevant moral principles and values and on theparticular circumstances of the case at hand. NCMJ

Table 1.Practical Guidelines for Addressing Refusal ofTreatment for Minor Patients

(1) Elicit the reasons for the refusal.

(2) Clarify any misunderstandings about the patient’scondition, prognosis, or treatment options.

(3) Seek a private discussion with adolescentpatients.

(4) Acknowledge beliefs and values informing therefusal.

(5) Articulate the reasons for the treatmentrecommendation.

(6) Seek common ground.

(7) Enlist assistance in identifying and evaluatingoptions.

(8) If conflict is intractable,make a considered moraljudgment.


REFERENCES

1 Berg JW, Appelbaum PS, Lidz CW, Parker LS. InformedConsent: Legal Theory and Clinical Practice. 2nd ed. New York:Oxford University Press; 2001.

2 Dixon JL, Smalley MG. Jehovah’s Witnesses: the surgical/ethicalchallenge. JAMA. 1981;246(21):2471-2472.

3 Sheldon M. Ethical issues in the forced transfusion of Jehovah’sWitness children. J Emerg Med. 1996;14(2):251-257.

4 “Jehovah’s Witnesses,” Wikipedia.http://en.wikipedia.org/wiki/Jehovah%27s_Witnesses. AccessedJune 12, 2007.

5 Kosmin BA, Mayer E, Keysar A. American religious identificationsurvey 2001. The Graduate Center, City University of New York.http://www.gc.cuny.edu/faculty/research_briefs/aris.pdf. AccessedJune 12, 2007.

6 Vercillo AP, Duprey SV. Jehovah’s Witnesses and the transfusionof blood products. NY State Med J. 1988;88:493-494.

7 How Can Blood Save Your Life? Brooklyn, NY: Watch TowerBible and Tract Society of New York; 1990.

8 Prince v. Commonwealth of Massachusetts, 321 US 158 (1944).

9 Child Abuse Prevention and Treatment Act (CAPTA) (2003version), 42 U.S.C. 5101, et seq.

10 NC Gen. Stat. § 90-21.1.11 Personal communication, Dr. Stephen Hill, director, Duke

University blood conservation program, June 2007.12 Janofsky M. Colorado’s children’s deaths rekindle debate on

religion. New York Times. 2001 (February 21):A10.13 Stanfield J. Faith healing and religious treatment exemptions to

child-endangerment laws: Should parents be allowed to refusenecessary medical treatment for their children based on theirreligious beliefs? Hamline J Pub Law Policy. 2000(1);22:45-86.

14 NC Gen. Stat. § 90-21.5.15 Crill J. Consent to medical treatment. In Feezor L, ed. North

Carolina Patient & Provider Rights Guide. Cary, NC: NorthCarolina Hospital Association, 2003: 3.1-3.7.

16 Dellinger A, Davis AM. Health Care for Pregnant Adolescents: ALegal Guide for Healthcare Providers. Chapel Hill, NC: Instituteof Government, University of North Carolina at Chapel Hill,2001:1-2.


JohnW.Williams Jr,MD,MHSScientific Editor,North Carolina Medical Journal

North Carolina is blessed with some of the finest medical research institutions in the world. The work of themedical scientists that labor in our research facilities becomes complete (in many ways) and public when it ispublished in peer-reviewed journals.

While medical researchers in North Carolina have many journals to which they can submit their manuscripts,wewant them to consider keeping their work here at home.To bemore specific,we invite the authors of our stateto submit their papers to the North CarolinaMedical Journal.

The Journal seeks papers that convey the results of original research.We are especially interested in publishingresearch papers that have relevance to the health of the people of our state.

An editor reviews all papers received and those of sufficient quality are peer-reviewed. As with any journal ofmerit, only papers of high quality will be published. Papers printed in the Journal are indexed in the NationalLibrary of Medicine’s MEDLINE public database.

Wegenerally accept twotypesofmanuscripts for review:(1)original clinicalorhealth services researchcontributionsand (2) systematic reviews (both regardless of specific topic).

The North CarolinaMedical Journal is published six times a year. It is distributed free of charge to the membersof the North Carolina Medical Society, the North Carolina Hospital Association, the North Carolina College ofInternal Medicine, the North Carolina Board of Pharmacy, the North Carolina Association of Pharmacists, the NorthCarolina Division of Public Health, the North Carolina Dental Society, the North Carolina Health Care FacilitiesAssociation, and The Carolinas Center for Medical Excellence.The Journal is available by subscription to others.

For guidance on manuscript preparation, authors should consult the“Author Guidelines,”which can be foundat www.ncmedicaljournal.com.

Call for Papers


IntroductionThomas C.Ricketts III,PhD,MPH;Kristen L.Dubay,MPP

Issue Brief: Addressing Health LiteracyThrough Improved Patient-PractitionerCommunicationMark Holmes, PhD; Thomas J. Bacon,DrPH; L. AllenDobson,MD, FAAFP; E. Kiernan McGorty, JD, PhD; PamSilberman, JD,DrPH

COMMENTARIESLow Health Literacy: Epidemiology andInterventionsDarren A.DeWalt,MD,MPH

Chasing the MonsterToni Cordell

Lay Health Educators' Roles in ImprovingPatient EducationSusan Auger,MSW; Sarah Verbiest,MSW,MPH

Incorporating Health Literacy Into Adult BasicEducation: From Life Skills to Life SavingSandra J.Diehl,MPH

Improving Prescription Drug LabelingMichael S.Wolf, PhD,MPH; Stacy Cooper Bailey,MPH

Medication Instruction by Pharmacists:MakingGood on an OfferMichael D.Murray, PharmD,MPH

Increasing the Public's Awareness:TheImportance of Patient-PractitionerCommunicationMarcus Plescia,MD,MPH;Mike Newton-Ward,MSW,MPH

Effective Practitioner-Patient Communicationin Long-Term CareDennisW. Streets,MPH,MAT, LNHA

Developing an Informed Consent ProcessWithPatient Understanding in MindMary Ann Abrams,MD,MPH; Barb Earles, RN,MHA,CPHRM

Cultivating Patient-Centered CommunicationSkills Training Across the Medical EducationContinuum:A Model for PracticeGail S.Marion, PA-C, PhD; Sonia J. Crandall, PhD; FrankCelestino,MD;WilliamMcCann, PsyD; Julienne Kirk,PharmD

Communicating Health Information to Englishas a Second Language PatientsH.Nolo Martinez,MS, PhD

Identifying and Addressing CommunicationFailures as a Means of Reducing UnnecessaryMalpractice ClaimsGerald B.Hickson,MD; A.Dale Jenkins

A Perspective on Doctor-PatientCommunication in the Dental OfficeM.Alec Parker, DMD

Health Professions Education to PromoteHealth Literacy: Leverage Points and NewOpportunitiesKaren D. Stallings, RN,MEd; Thomas J. Bacon,DrPH

A Failure to CommunicateTimothyW. Lane,MD; J. Carson Rounds,MD

“Patient-centerednessrequires a fundamentalredesign of clinicalcommunication fromspeaking the languageand syntax of healthcare professionals tothe plain language allpeople understand.”

POLICY FORUMEffective Patient-Practitioner

Communication

INTRODUCTION

Policy Forum:Effective Patient-Practitioner Communication

The Institute of Medicine of the National Academies released its report, Health Literacy: APrescription to End Confusion, in April 2004. The report made clear that low health literacy affects theeducated and wealthy as well as the uneducated and poor, touching the lives of countless individuals.Miscommunication affects every facet of our lives. It occurs for many different reasons includingsomeone not listening closely, people misinterpreting what they hear, or someone not understanding.Regardless of how miscommunication occurs, it can lead to inappropriate action, inaction, frustration,or anger. When miscommunication happens in a relationship, it can be hurtful or confusing. Whenmiscommunication occurs within the patient-practitioner relationship in a health care setting, it canlead to illness, inappropriate procedures, slow or no recovery, and even death.

The potential for such serious consequences prompted the North Carolina Division of PublicHealth and North Carolina Institute of Medicine to form a task force on health literacy. The task forcewas supported with funding from the Heart Disease and Stroke Prevention Branch in the ChronicDisease and Injury Section of the Division of Public Health via a US Centers for Disease Control andPrevention grant and with additional support from the NC Division of Medical Assistance. The taskforce found that low health literacy is a major, perhaps the most important, contributor to poorpatient-practitioner communication. The health care system is very complex, medical terminologytakes years of training to master, and the stress of illness can make the simplest things difficult.Communication between practitioner and patient can be impaired by these and other things includingdifferences in language and cultural perceptions of disease and health care.

This issue of the North Carolina Medical Journal explores many facets of the patient-providercommunication process. We draw on national and state-level work on health literacy and communicationto highlight problems that occur and to suggest improvements to make our health care system safer andmore effective. North Carolina is fortunate to have some of the nation’s foremost researchers in the areaof health literacy, and we are pleased that Darren DeWalt, MD, has shared some of his research on theepidemiology of low health literacy as well as naming possible interventions. Strategies are explored forimproving practitioner-patient communication in physician and dentist offices, pharmacies, long-termcare facilities, and hospitals. We also focus on the role of lay health educators and advisors whose useand effectiveness in North Carolina has been demonstrated. We present the perspectives of individualswith low literacy and English as a second langue and offer ideas for implementing communicationsstrategies for practitioners and low literacy adults through education and public marketing.

One-third of the nation’s population may have difficulty understanding basic health information. It isimperative that we take a closer look at health communication, improving individuals’ understanding oftheir health and how to appropriately manage illness when it occurs.

Thomas C. Ricketts, III, PhD, MPH Kristen L. Dubay, MPPEditor-in-Chief Managing Editor


ur health care system relies increasingly on thepatient to exercise clinical decisions, perform

self-management, and navigate the complex health caresystem. In 2003, the Institute of Medicine of the NationalAcademies of Science released a report on the quality ofthe United States health care delivery system and includedpatient-centeredness among the 6 dimensions of quality.1

Recent developments in the US health care systemembrace this fundamental shift in health care deliveryincluding increased use of self-management for chronicdiseases, consumerism (eg, higher deductible healthplans and cost and quality transparency initiatives), andpatient activation (eg, Web sites and patient-orientedelectronic medical records). All these developments helptransform our system to one that holds the patient,rather than the provider, at the center of the system.

However, all these policy and market developmentsrely on the ability of patients to act effectively as stewardsof their own health. In actuality, people vary widelyin their capability to understand and analyze healthinformation and to make informed decisions. Apatient’s ability to make informed decisions is dependenton his ability to process and synthesize information. Patientsmay have difficulty understanding clinical information,treatment regimens, or how the health system works. If patientshave difficulty compiling, processing, understanding, and actingon the information necessary to make informed decisionsconsistent with their desires, then the central assumptionsunderpinning the movement toward patient-centeredness areunfulfilled.

Researchers have long understood high quality patient-provider

communication is a key determinant of a patient’s health.2,3

Effective communication has multiple dimensions, but attentionhas recently turned to the concept of health literacy. Healthliteracy can be defined as the degree to which individuals havethe capacity to obtain, process, and understand the basic healthinformation and services needed to make appropriate healthdecisions. Note that the concept of health literacy differs fromthat of literacy. Health literacy entails a broader set of skills andabilities than basic reading and writing. Health literacy requires

Addressing Health Literacy Through ImprovedPatient-Practitioner Communication

Mark Holmes, PhD; Thomas J. Bacon,DrPH; L. Allen Dobson,MD, FAAFP; E. Kiernan McGorty, JD, PhD;Pam Silberman, JD,DrPH

ISSUE BRIEF

Mark Holmes,PhD, is vice president of the North Carolina Institute of Medicine.He can be reached at mark_holmes (at) nciom.org or5501 Fortunes Ridge Drive, Suite E,Durham,NC 27713.

Thomas J. Bacon,DrPH, is executive associate dean of The University of North Carolina at Chapel Hill School of Medicine, director ofthe NC Area Health Education Centers Program, and cochair of the NC Institute of Medicine Task Force on Health Literacy.

L. Allen Dobson,MD, FAAFP, is former assistant secretary for health policy and medical assistance of the NC Department of Healthand Human Services and cochair of the NC Institute of Medicine Task Force on Health Literacy.

E.KiernanMcGorty, JD,PhD, is project director at the North Carolina Institute of Medicine.

Pam Silberman, JD,DrPH, is president and CEO of the North Carolina Institute of Medicine and publisher of the NCMedical Journal.

O “If patients have difficultycompiling, processing,

understanding, and actingon the information necessaryto make informed decisionsconsistent with their desires,then the central assumptionsunderpinning the movementtoward patient-centeredness

are unfulfilled.”


some reading skills but also the abilities to understand oralcommunication, use numbers and math skills, and understand thehealth system on a basic level. Health literacy also encompasses theability to communicate with health care providers and theirstaffs.

In the summer of 2006, the Chronic Disease and InjurySection of the NC Division of Public Health (NC DPH) askedthe NC Institute of Medicine (NC IOM) to convene a TaskForce on Health Literacy. The task force was a collaborativeeffort between the NC IOM, the NC Department of Healthand Human Services (NC DHHS), and the NC Area HealthEducation Centers (NC AHEC). The task force was funded bythe Chronic Disease and Injury Section in the Heart Diseaseand Stroke Prevention Branch of NC DPH through a Centersfor Disease Control and Prevention grant and the NC Divisionof Medical Assistance. Cochairs of the task force were ThomasJ. Bacon, DrPH, executive associate dean of The University ofNorth Carolina at Chapel Hill (UNC) School of Medicine anddirector of NC AHEC, and L. Allen Dobson, MD, FAAFP,assistant secretary for health policy and medical assistance ofthe NC Department of Health and Human Services. The taskforce consisted of 49 other members representing providers andstate medical associations, patient and consumer advocates, stategovernment, adult literacy organizations, and other interestedparties. The task force met 7 times over 9 months and made 14recommendations which are discussed below.a

Health literacy plays a central role in the patient-practitioner

exchange and improving this type of communication can helpaddress the adverse impacts of low health literacy. Patients withlow health literacy may have difficulty reading a bus scheduleor interpreting a simple bar graph.The prevalence of low healthliteracy is remarkably high; nearly one-half of US adults functionat marginal or limited health literacy.b Although everyone is atrisk for low health literacy, especially during times of considerablestress (eg, immediately following an unexpected diagnosis), lowhealth literacy is more common in some populations. Older, lesseducated, lower income, and uninsured and publicly insuredadults, along with racial and ethnic minorities, are more likelyto have low health literacy. Using the known prevalence rates oflow health literacy by demographic group, along with populationdata for each North Carolina county, prevalence estimates oflow literacy can be computed for most North Carolina counties.(See Figure 1.) As with many health conditions, poverty-strickenareas tend to have higher prevalence of low health literacy.

Those who primarily speak a language other than Englishtend to have lower health literacy, even when literacy is assessedin their native language. Cultural issues, in addition tolanguage issues per se, may inhibit effective patient-practitionercommunication. For example, practitioners treating patientsfrom Mexico may interpret mal de ojo (the evil eye) literally asconjunctivitis without appreciating the patient’s culturalperspective. These cultural misunderstandings greatly inhibiteffective patient-practitioner communication and hence areimportant to consider. In this issue, H. Nolo Martinez, MS, PhD,


a For brevity, the recommendations are simplified and shortened here.The full recommendations are contained in the report available onthe NC Institute of MedicineWeb site at http://www.nciom.org.

b Most assessments of health literacy are of literacy per se.Although some instruments specifically designed to assess health literacy havebeen developed, they are relatively recent and have not been used widely.

Figure 1Percent of Adults with Low Literacy

Source: Reder, Stephen.The State of Literacy in America.http://www.nifl.gov/reders/reder.htm.Map Produced by North Carolina Institute of Medicine. Estimates not available for counties with population below 5000.

expands on communication issues particular to nonnativeEnglish speakers in his commentary “Communicating HealthInformation to English as a Second Language Patients.”

Low health literacy affects many measures of health in anegative way. In fact, there is no one factor more important inpredicting an individual’s overall health status than literacy ability.Low health literacy is associated with poorer outcomes in generalhealth status, depression, asthma, diabetes control, and HIVcontrol. Low literacy leads to higher rates of hospitalization andlate stage prostate cancer on detection and lower rates ofmammography, Pap smear, pneumococcal immunization,influenza immunization, and sexually transmitted diseasescreening. Furthermore, low literacy patients have higher averagemedical costs.4 Low health literacy affects the health of childrenas well. Asthmatic children of low health literacy parents aremore than twice as likely to miss school and more than 3 timesas likely to be hospitalized as asthmatic children of adults withhigher health literacy.5 Darren DeWalt, MD, MPH, a nationalexpert in health literacy, discusses the epidemiology of healthliteracy in greater detail in his article “Low Health Literacy:Epidemiology and Interventions” later in this issue of the journal.

Although research demonstrating the negative health effectsof low health literacy is well developed, few interventionsdesigned to improve understanding, knowledge, and other keyfactors leading to improved health outcomes have been shownto be specifically effective for low health literacy populations. DrDeWalt and other researchers in North Carolina are developingnational expertise in this area. However, translating research intopractice remains a challenge; despite efforts across the nation tospeed the translation of research from “bench to bedside,” thereremains a considerable time gap between when research ispublished and the point at which that knowledge is incorporatedinto widespread practice. The task force recognized this factand recommended that state foundations should leveragethe research expertise existing in the state and fund a Centerfor Health Literacy Excellence charged with increasingprovider awareness of low health literacy, enhancing the capacityof adult literacy professionals to address problems of low healthliteracy, developing a library of health information and bestpractices, and increasing the skills of providers in treatingpatients with low health literacy.

Some of the most promising research on improving patientunderstanding and ability to self-manage is associated withchronic disease. For example, UNC researchers have identifiedeffective strategies to improve outcomes for diabetes patientswith low health literacy, and a pilot study on heart failurepatients demonstrated strong evidence of improved outcomes(eg, a 30% reduction in hospitalization and death).6 Becausechronic diseases account for such a large portion of medicalspending7 and for diminished quality of life,8 strategies toimprove outcomes for patients with low health literacy canyield tremendous results.

In addition to the evidence-based models shown to beeffective, there are some models currently existing in NorthCarolina that appear to be promising. Two such models areoutlined in “Lay Health Educators’ Roles in Improving PatientEducation” by Susan Auger, MSW, and Sarah Verbiest, MSW,MPH. These models appear to improve the ability of patientswith low health literacy to understand and act on healthinformation. For example, Ms. Auger helped develop Teachwith Stories. This method uses narratives and photonovellas,which are illustrated brief stories popular in Spanish-speakingsocieties, to frame and personalize a particular health issue,allowing the patient/client to more effectively identify with andinternalize the conveyed information.

Communication also can be hindered when practitionersare unaware of the low health literacy levels of their patientsand, thus, use medical terminology that is too technical.Unfortunately, national studies have found practitioner awarenessof limited health literacy to be low. One study presented medicalresidents with case studies and histories suggesting limitedhealth literacy as a cause of an adverse outcome, yet less than25% of the residents identified it as a cause.9 Another studythat assessed the health literacy knowledge of graduatingnursing students found less than half correctly identified theage group with the highest risk of low health literacy, and only15% correctly identified health literacy—not socioeconomicstatus—as the more important predictor of health status.10

Furthermore, practitioners underestimate the prevalence of lowhealth literacy in their patient panel.11 One of the reasonspractitioners underestimate the prevalence of low health literacymay be that many patients have learned how to mask theirliteracy problems. Clues are often subtle. Patients may dismissconveyed written information by stating they left their glasses athome and will read it later, or they may seem to be unengagedin a discussion about their health or therapy. Medical historiesand other forms filled out by patients may be missing keyinformation. In short, it is incumbent on practitioners to be awareof the subtleties that suggest a patient has low health literacy.When practitioners miss these cues, the results may be dramatic.Toni Cordell powerfully outlines her experience with theseproblems in “Chasing the Monster.”c Although every patienthas a different experience, one of Ms Cordell’s central points isthat patients need to feel sufficiently empowered to let theirproviders know when they do not understand the plan developedfor them.

Because low literacy may be difficult to perceive, someexperts advocate for universal precautions and treatment of allpatients as if they have low literacy. Other experts have developedscreening tools that are useful in identifying patients who mayhave low literacy. One example is a 6-question screen that presentsthe patient with a nutrition label from an ice cream box andtakes 3 minutes to administer.12 Timothy W. Lane, MD, and J.Carson Rounds, MD, discuss the practitioner’s view of health


c Ms Cordell, along with many others who have experienced the adverse effects of poor health communication, chronicles her experiencein a video available on-line from the AMA Foundation at http://www.ama-assn.org/ama/pub/category/8115.html.

literacy in “A Failure to Communicate.” Medical practitionersaren’t the only health care professionals who are faced with theproblem of low literacy and poor communication, M. AlecParker, DMD, outlines the issues existing in dental settings in hiscommentary, “A Perspective on Doctor-Patient Communicationin the Dentist’s Office.”

There are best practices designed to maximize communicationeffectiveness with patients with low health literacy. For example,the teach-back method—querying patients with phrases suchas “OK, I just gave you a lot of information. Let me make sureyou got it all. How often are you going to take this medicine?”—allows practitioners to assess patient understanding. Thismethod has been shown to increase patient recall from 61% to84%.13 As an additional example, the Partnership for ClearHealth Communication has identified the Principles for ClearHealth Communication14 that should be used when developingwritten health information:

(1)Use easy to follow layouts and simple pictures.(2)Write information at an appropriate level.(3)Replace complicated medical words with plain language.(4)Use pictures and diagrams.(5)Focus on desired behavior instead of medical facts.(6)Make information culturally sensitive and personally

relevant.

Although these principles are somewhat obvious, they may beviolated in daily practice. For example, medical histories may askpatients whether they have ever had hypertension, but manypatients may only know they have “high blood pressure.”Patient-centeredness requires a fundamental redesign of clinicalcommunication from speaking the language and syntax of healthcare professionals to the plain language all people understand.

Health professions certification and licensing boards recognizethe value of effective communication and require evidence ofeffective communication for maintenance of certification.Nonetheless, most practitioners receive little to no training oncommunication techniques during their formal training.Although recent trainees may be more aware of literacy issues,other strategies will be necessary to increase awareness amongcurrent practitioners. Karen D. Stallings, RN, MEd, andThomas J. Bacon, DrPH, outline strategies the NC Area HealthEducation Centers program can utilize in their commentary“Health Professions Education to Promote Health Literacy:Leverage Points and New Opportunities.” The task forcerecognized the barrier of low awareness among practitioners andendorsed a systemwide effort to combat this knowledge gap. Thetask force recommended that institutions and organizationsthat train health professionals incorporate health literacytraining into their curricula. Medical and health professionalschools, community colleges, the NC Area Health EducationCenters program, professional associations, and organizationsoffering practice support should ensure their curricula aredesigned to increase the understanding of health literacyamong all practitioners. Gail S. Marion, PA-C, PhD, Sonia J.Crandall, PhD, Frank Celestino, MD, William McCann,

PsyD, and Julienne K. Kirk, PharmD, describe how WakeForest University School of Medicine is integrating effectivecommunication pedagogy into curricula for its healthprofessional training programs in “Cultivating Patient-CenteredCommunication Skills Training Across the Medical EducationContinuum: A Model for Practice.”

Of course, the list of changes practitioners are being askedto incorporate into their daily practice pattern is ever increasing.One study found that primary care physicians would spend, onaverage, 7.4 hours a day delivering evidence-based preventivecare guidelines to a typical patient panel—allowing no time forthe acute needs for which many patients seek care.15 Effectivecommunication strategies are but one of many practice changesdemanded of practitioners. Changes will be more effectiveand permanent if the practitioner internalizes the issue andunderstands the importance of the improvement and the valueof the change. Although health care practitioners are committedto delivering high quality health care to their patients, changesin reimbursement policy could encourage providers to practiceeffective communication—such as the teach-back method.Thetask force recommended that reimbursement policy canencourage more effective communication. Furthermore, somepromising practices—such as group visits—are not reimbursedby all payers. Therefore, the task force adopted somerecommendations related to reimbursement policy. For example,NC Medicaid should pilot reimbursement models thatteach patient self-management, and other payers shouldconsider reimbursing for existing billing codes for individualand group self-management visits.

Disease and case management, which focus on chronicconditions, are excellent candidates for achieving qualityimprovement in patients with low health literacy. Disease andcase management often include components that attempt toincrease a patient’s knowledge and ability to manage her ownhealth. The task force recommended that the NCDepartment of Health and Human Services, CommunityCare of North Carolina, NC Division of Public Health,and payers incorporate best practices into disease and casemanagement initiatives and explore the use of nonprintinformation to enhance the understanding of patients withlow health literacy.

Although there are many promising practices for enhancingthe effectiveness of communication with patients with lowhealth literacy, some of these practices may not be sustainablein the current reimbursement environment. Cost savings andimprovement in quality of life for the patient (which often drivereimbursement design) might be evident only within a deliberatedemonstration project aimed at developing a sustainable newmodel of care. Traditionally, funding other than reimbursementrevenue is necessary to develop and refine such a model;providing funds for such projects has often been the domain offoundations. Therefore, the task force recommended thatfoundations fund demonstration projects that use promisingnew models of care that increase communication to patients,and payers should modify reimbursement policy to supportsuccessful models.


Enhancing patient-practitioner communication could notonly lead to better compliance, but it may also reduce therisk of malpractice claims. Research has shown a betterpatient-practitioner relationship reduces the risk of malpracticeclaims.16 Some malpractice carriers conduct risk managementworkshops for covered practitioners. As a result, the task forcerecommended that malpractice carriers incorporateinformation on health literacy into risk managementseminars. Gerald B. Hickson, MD, and A. Dale Jenkins discussthe relationship between communication and malpractice ingreater detail in their commentary “Identifying and AddressingCommunication Failures as a Means of Reducing UnnecessaryMalpractice Claims.”

Naturally, health care is often delivered in settings other thana medical office. Promising practices exist in these settings as well.For example, the Iowa Hospital System has prioritized addressinglow health literacy throughout its system of 24 hospitals and 430clinics. Individual hospitals choose specific initiatives aimed atimproving practitioner-patient communication. Mary AnnAbrams, MD, MPH, and Barbara Earles, RN, MHA, CPHRM,from the Iowa Health System explain how they redesigned theinformed consent process, typically one of the more complicatedforms patients are required to sign and digest, in “Developing anInformed Consent Process With Patient Understanding inMind.” The consent form signing process offers an importanttime for patient learning.

The task force recommended that all health careorganizations and institutions develop criteria and policiesto ensure best practices are followed for written information,Web sites, and other audio and visual media designed forclient and family use. Additionally, philanthropic foundationsshould give priority to those organizations and institutionsthat enact these changes. The task force recognized thatinsurers and payers may be limited by existing laws andregulations regarding consumer insurance information, sothe North Carolina Department of Insurance shouldseek changes in existing insurance laws that may inhibitunderstandability. The types of organizations charged in thisrecommendation include hospitals, health care systems, dentaloffices, and long-term care facilities.

Long-term care facilities face a multitude of challenges thatmight make the effects of low literacy more problematic inthose settings. These include lower patient cognition, moreacute health care needs, higher prevalence of chronic disease,and more reliance on medications. Yet, in these settings there isoften increased reliance on patient empowerment because thereare more opportunities for problems to arise due to a greaterneed for coordinating care among the facility staff and consultingclinicians. Dennis Streets, MPH, MAT, LNHA, outlinesissues particular to long-term care facilities in “EffectivePractitioner-Patient Communication in Long-Term Care.”

Just as health care is delivered by practitioners from manydisciplines and in settings other than the physician or dentist inan office, health is affected by entities other than health careproviders. The state has many disparate forms of interactionswith individuals which may affect their health directly or

indirectly. The NC Department of Health and HumanServices consists of many agencies providing direct services toNorth Carolinians such as public health, aging, and mentalhealth services. Because many of the department’s clients are athigher risk for having low health literacy and departmentactions affect so many people, creating a department-wide cultureto adopt practices known to be effective with low health literacypatients can lead to considerable improvement in communicationeffectiveness. The task force recommended that the NCDepartment of Health and Human Services develop criteriaand policies to ensure best practices are followed for writteninformation, Web sites, and other audio and visual mediadesigned for client and family use.

In addition, the task force recommended that agencieswithin the department, including but not limited toCommunity Care of North Carolina, the Division of PublicHealth, the Division of Mental Health, DevelopmentalDisabilities and Substance Abuse, and the Division of Aging,have staff at the local level trained in best practices for lowhealth literacy patients and charged with disseminating thatinformation to staff.

Today, patients receive health information from manysources in addition to their health care practitioner. For example,the Internet is a common source of information, and friends,family, and coworkers often volunteer or are consulted foradvice. Therefore, the task force recommended that the NCDepartment of Health and Human Services, health caresystems and providers, and payers explore and improveother ways of educating patients that may be more effectivefor patients with low health literacy. Examples include trainedlay health advisors and patient navigators, group educationsettings, and information dissemination in nontraditional forums(eg, religious institutions, community fairs, and barber shops).

The task force spent considerable time on the specialchallenges inherent in pharmaceuticals. Medication errors lead tohigh costs and adverse health effects (including preventable deaths)in our health care system. Research has found that patients withlower health literacy have poorer understanding of drug labels.Even patients who correctly explain the instructions may struggleto demonstrate how to correctly take the medication.17,18 Studieshave found that instructions such as “Take two pills twice a day”are more likely to be misinterpreted by patients with lower healthliteracy. Part of this confusion may be due to the design of the“average” medication bottle. A study of medication labels fromacross the country found that the types of elements mostpronounced on the label—such as the pharmacy name andprescription number—are not pertinent to helping the patienttake the medication correctly. Furthermore, warning stickerson labels are commonly misinterpreted, and patients withlower health literacy are more likely to misinterpret labels suchas “Take with food” or “Swallow whole: do not crush or chew.”Therefore, the task force recommended that the NC Boardof Pharmacy, in collaboration with other key stakeholders,develop requirements for consumer information andmedication labels making them more readily interpretableto those with low health literacy. Michael S. Wolf, PhD,



MPH, and Stacey Copper Bailey, MPH, explore this issue inmore detail in their commentary “Improving Prescription DrugLabeling.”

Likewise, the role of pharmacists as medication counselorscan be enhanced to improve patient understanding andcompliance.The Asheville Project, a program that intensively usedmedication therapy management to increase patients’ abilities toeffectively manage asthma and diabetes, demonstrated the costsavings associated with such interventions during and beyondthe intervention period.19,20 One barrier to enhancing the roleof pharmacists as medication counselors is the currentreimbursement environment. Pharmacists have experienced a56% increase in their workload filling prescriptions in the lastdecade.21 In light of such increased demands, it is difficult toexpect pharmacists to undertake more active medicationcounseling without a realignment of incentives. Although there issome evidence that these types of practice redesigns are effective,more studies are needed. Traditionally, foundations have beenwilling to fund pilot projects demonstrating the effectiveness ofnew models of care. Therefore, the task force recommendedthat North Carolina foundations fund demonstration projectsenhancing the role of pharmacists as medication counselorsand that payers reimburse successful models. Michael D.Murray, PharmD, MPH, discusses what North Carolina statelaw requires in terms of pharmacist counseling and highlightssuccessful pharmacy initiatives in “Medication Instruction byPharmacists: Making Good on an Offer.”

Of course, the most direct approach to limiting the adversehealth effects of low health literacy is to increase literacy skillsfor everyone. The task force believed initial efforts aimed atimproving consumers’ health literacy should be targeted at themost vulnerable populations. Adult education services andsystems, such as literacy councils and adult basic educationoffered by community colleges, provide an existing mechanismthrough which to achieve that goal. Although adult educationonly reaches a small segment of the population (ie, between 2and 3 million of the 94 million US adults with limited literacyskills), these individuals can bring the skills they learn back totheir families and communities. Adult education teachers, statedirectors of adult education, and basic skills program leaders allsee the benefits of using health issues to teach literacy. In a surveyof adult basic educators, over 90% of teachers viewed adulteducation as an appropriate setting to teach and learn abouthealth issues.22Teachers who used health to educate their studentsreported lessons based on health issues enhanced students’dialogue, discussion, vocabulary, reading, language development,and critical thinking. Teachers report students’ interests,participation, and motivations were greater when health wasthe topic of the educational exercise when compared to otherareas. A national survey of state directors of adult educationfound respondents believed health was an appropriate topicfor adult education both as a content area and as a skills area.23

The task force recommended that adult literacy programsincorporate health literacy concepts into curricula. Sandra J.Diehl, MPH, discusses her experience and possible approachesin adult education in “Incorporating Health Literacy Into

Adult Basic Education: From Life Skills to Life Saving.”Naturally, patients have a responsibility to do their part to

improve communication with their practitioner.The health careenvironment can be intimidating to the average consumer,and medical language can be confusing. The task force believedthat patient activation can be enhanced through adoption of asocial marketing campaign aimed at increasing awareness ofthe importance of asking questions when consumers do notunderstand health information. Again, there are some promisingpractices to guide these efforts. The Justus-Warren Task Forceand the Chronic Disease and Injury Section of the NCDivision of Public Health partnered on an award-winningcampaign called “Lost In Translation,”24 which targeted peoplewith cardiovascular disease. The campaign conveyed theimportance of having a dialogue with practitioners to ensureunderstanding of clinical information. Messages need not bedisease-specific. The Partnership for Clear HealthCommunication developed a campaign called Ask Me 3 whichdirects consumers to ask 3 questions at each health care visit:(1) What is my main problem? (2) What do I need to do? (3)Why is it important for me to do this?

This population-based message can lead to more effectivecommunication and hence better understanding and outcomes.The task force recommended that the NC Division ofPublic Health adopt a social marketing campaign, includingpartnerships with key organizations and stakeholders, toincrease awareness of the importance of effective patient-practitioner communication among all North Carolinians.Marcus Plescia, MD, MPH, and Mike Newton-Ward, MSW,MPH, discuss this issue further in “Increasing the Public’sAwareness: The Importance of Patient-PractitionerCommunication.”

Addressing health literacy through patient-practitionercommunication is certainly not a cost-free exercise.Practitioners will have to learn new skills, develop new tools,and train staff to be aware of the issue. Although health careproviders want to provide the best possible care to all patients,the American health care practitioner today is facing increasingdemands on her time in and out of practice. Many of thesedemands ask practitioners to do more—spend more time withpatients, order more tests, or educate oneself more on an issue.Among the myriad of issues the practitioner faces, health literacymay be easy to dismiss. However, in addition to negativelyaffecting patient health as outlined here, poor communicationwith patients may negatively affect practitioners’ livelihoods.Although the business case for addressing health literacy is stillcurrently unproven, many potential benefits exist. In theincreasingly competitive environment, providers compete dailyfor patients in the health care marketplace. Because patientsatisfaction tends to be higher for those practitioners utilizingbest practices, a commitment to addressing low health literacymay lead to increased market share. Increased communicationleads to a more satisfying work environment and can increasemorale and decrease staff turnover. As discussed above andelsewhere in this issue, malpractice liability may be reduced.Perhaps most importantly, the increasing number of initiatives

REFERENCES

1 Brach C, Fraser I, Paez K. Crossing the language chasm. HealthAff (Millwood). 2005;24(2):424-434.

2 Schillinger D, Bindman A, Wang F, Stewart A, Piette J.Functional health literacy and the quality of physician-patientcommunication among diabetes patients. Patient Educ Couns.2004;52(3):315-323.

3 Schillinger D, Piette J, Grumbach K, et al. Closing the loop:physician communication with diabetic patients who have lowhealth literacy. Arch Intern Med. 2003;163(1):83-90.

4 DeWalt DA, Berkman ND, Sheridan S, Lohr KN, PignoneMP. Literacy and health outcomes: a systematic review of theliterature. J Gen Intern Med. 2004;19(12):1228-1239.

5 DeWalt DA, Dilling MH, Rosenthal MS, Pignone MP. Lowparental literacy is associated with worse asthma care measuresin children. Ambul Pediatr. 2007;7(1):25-31.

6 DeWalt DA, Malone RM, Bryant ME, et al. A heart failureself-management program for patients of all literacy levels: arandomized, controlled trial [ISRCTN11535170]. BMC HealthServ Res. 2006;6:30.

7 Thorpe KE, Florence CS, Howard DH, Joski P. The risingprevalence of treated disease: effects on private health insurancespending. Health Aff (Millwood). 2005;10 (Websuppl):W5.317-W5.325. http://www.healthaffairs.org.

addressing health care quality presents additional leverage oninvestment in low health literacy mitigation strategies.Outcome measures—such as the percent of diabetics with mostrecent Hemoglobin A1c less than 7.0%—are affected bypatient understanding and compliance. Practitioners who valuetheir performance on these measures are given incentives todevelop strategies addressing their low health literacy patients.However, although many of the strategies outlined here maylead to cost savings, the toll on individual patients and theirfamilies adversely affected by poor understanding is perhaps themost important reason to improve communication. NCMJ

Acknowledgements: The task force was a collaborative effortbetween the North Carolina Institute of Medicine (NC IOM), theNorth Carolina Department of Health and Human Services (NCDHHS), and the North Carolina Area Health Education Centers(AHEC) Program. The work of the task force was funded by NCDHHS, Division of Public Health, Chronic Disease and InjurySection, Heart Disease and Stroke Prevention Branch through aCenters for Disease Control and Prevention (CDC) grant,Cooperative Agreement Number U50/CCU421315-05, and theDivision of Medical Assistance. The contents of this report are solelythe responsibility of the authors and do not necessarily represent theofficial views of the CDC.

The work of the task force would not have been possible withoutthe volunteer efforts of the task force and steering committee members:

Task force members: Thomas J. Bacon, DrPH, NC AreaHealth Education Centers (AHEC) Program, UNC School ofMedicine (cochair); L. Allen Dobson, MD, FAAFP, NCDepartment of Health and Human Services (cochair); SusanAuger, MSW, Auger Communications, Inc; Karen M. Brown, NCCommunity College System; Heather Burkhardt, MSW, NCDivision of Aging and Adult Services; Patricia C. Casper, MSW,LCSW, Orange County Health Department; Laura Coffee, MSW,Alamance Community College; Toni Cordell, Patient Advocate;The Honorable William A. Current, Sr, DDS, NC GeneralAssembly; Dominque Davis, Durham Literacy Center; Darren A.DeWalt, MD, MPH, University of North Carolina School ofMedicine; Sandy Diehl, MPH, University of North Carolina atChapel Hill; Carolyn Dunn, PhD, NC State University; ArtEccleston, PsyD, Division of Mental Health, DevelopmentalDisabilities and Substance Abuse Services; Chris Evans, JD,

MAEd, NC State Health Plan; Olivia Fleming, MA, UrbanMinistries of Wake County; Jane M. Foy, MD, Wake ForestUniversity Baptist Medical Center; Janice A. Freedman, MPH,NC Healthy Start Foundation; The Honorable Rick Glazier, NCGeneral Assembly; James J. Gooch, DrPH, North Carolina A&TState University; Francis N. Kateh, MD, MHA, Anson CountyHealth Department; Meera Kelley, MD, WakeMed Health andHospitals; Michael Lancaster, MD, Division of Mental Health,Developmental Disabilities and Substance Abuse Services; TimothyW. Lane, MD, Moses Cone Health System; Denise Levis Hewson,RN, BSN, MSPH, Community Care of North Carolina; H. NoloMartinez, MS, PhD, University of North Carolina at GreensboroCenter for New North Carolinians; Gerri Mattson, MD, Divisionof Public Health; Linda Mayne, PhD, East Carolina UniversitySchool of Nursing; Meg Molloy, DrPH, MPH, RD, NCPrevention Partners; Ben Money, MPH, NC Community HealthCare Association; Merry-K Moos, RN, FNP, MPH, FAAN,University of North Carolina at Chapel Hill; Michael D. Murray,PharmD, MPH, University of North Carolina at Chapel Hill;Mike Newton-Ward, MSW, MPH, NC Department of Healthand Human Services; Lloyd F. Novick, MD, MPH, The BrodySchool of Medicine; April Locklear Oxendine, MAEd, RobesonCounty Health Department; Marcus Plescia, MD, NC Division ofPublic Health; Ronald Plummer, EdD, UNC-TV; Elmira J.Powell, MEd, PA-C, Piedmont Healthcare for Women; LaHomaSmith Romocki, PhD, MPH, North Carolina Central University;J. Carson Rounds, MD, Village Family Care of Wake Forest; AliceJ. Schenall, MPH, CHES, RHEd, Area L AHEC; Jason M.Spangler, MD, MPH, Pfizer Global Pharmaceuticals; BrendaSparks, RN, CPUR, Carolina Collaborative Community Care,Inc.; Karen Stallings, RN, MEd, NC AHEC; AnnamarieStreilein, MHS, PA-C, Duke University Medical Center; JeffreyWeinstock, Blue Cross and Blue Shield of North Carolina; CynthiaWells, EdD, Wake AHEC; Susan D. Yaggy, MPA, DukeUniversity Medical Center

Steering Committee members: Thomas J. Bacon, DrPH;Darren DeWalt, MD, MPH; Barbara Moeykens, MS, NCDivision of Public Health; Marcus Plescia, MD, MPH; SarahVerbiest, MSW, MPH, UNC Center for Maternal and InfantHealth; Alexander White, JD, MPH, NC Division of PublicHealth


8 Alonso J, Ferrer M, Gandek B, et al. Health-related quality oflife associated with chronic conditions in eight countries: resultsfrom the international quality of life assessment (IQOLA)project. Qual Life Res. 2004;13(2):283-298.

9 Kirpalani S, Jacobson KL, Brown S, Manning K, Rask KJ,Jacobson TA. Development and implementation of a healthliteracy training program for medical residents. Med EducOnline. 2006;11(13):1-8.

10 Cormier CM. Health Literacy: The Knowledge and ExperiencesOf Senior Level Baccalaureate Nursing Students. [dissertation].Baton Rouge, Louisiana: Louisiana State University; 2006.

11 Bass PF, Wilson JF, Griffith CH, Barnett DR. Residents’ abilityto identify patients with poor literacy skills. Acad Med.2002;77(10):1039-1041.

12 Weiss BD, Mays MZ, Martz W, et al. Quick assessment ofliteracy in primary care: the newest vital sign. Ann Fam Med.2005;3(6):514-522.

13 Bertakis KD. The communication of information fromphysician to patient: a method for increasing patient retentionand satisfaction. J Fam Pract. 1977;5(2):217-222.

14 Pfizer Global Pharmaceuticals. Pfizer Clear HealthCommunication initiative. 2003-04.

15 Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M,Michener JL. Is there time for management of patients withchronic diseases in primary care? Ann Fam Med.2005;3(3):209-214.

16 Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM.Physician-patient communication. The relationship withmalpractice claims among primary care physicians and surgeons.JAMA. 1997;277(7):553-559.

17 Davis TC, Wolf MS, Bass PF, et al. Low literacy impairscomprehension of prescription drug warning labels. J GenIntern Med. 2006;21(8):847-851.

18 Davis TC, Wolf MS, Bass PF, et al. Literacy andmisunderstanding prescription drug labels. Ann Intern Med.2006;145(12):887-894.

19 Bunting BA, Cranor CW. The Asheville project: long-termclinical, humanistic, and economic outcomes of acommunity-based medication therapy management programfor asthma. J Am Pharm Assoc. 2006;46(2):133-147.

20 Cranor CW, Christensen DB. The Asheville project: short-termoutcomes of a community pharmacy diabetes care program.J Am Pharm Assoc. 2003;43(2):149-159.

21 Fraher E, Ricketts TC, King J, Gaul K, Hadley H, Holmes M.Trends in the primary care and specialist physician workforce inNorth Carolina. Presented at: Primary Care and SpecialtySupply Task Force Meeting; January 13, 2006; Durham, NC.http://www.nciom.org/projects/supply/Jan13_Fraher.pdf.Accessed August 6, 2007.

22 Rudd RE, Moeykens BA. Adult educators’ perceptions ofhealth issues and topics in adult basic education programs.NCSALL Rep. 1999;8:1.

23 Rudd RE, Zahner L, Banh M. Findings from a national surveyof state directors of adult education. NCSALL Rep. 1999;9:1-10.

24 Brogan and Partners. Brogan & Partners Start With Your HeartCampaign Wins 2005 Telly Award. http://www.brogan.com/press/newsworthy_hearttelly.shtml. Accessed January 29, 2007.


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ealth literacy entered the mainstream medical literaturein 1995 with an article published in the Journal of the

American Medical Association.1 Since that time, we havewitnessed the emergence of a field of research and advocacythat attempts to improve health communication so that allpeople can understand and act on health information. In thiscommentary, I will review the epidemiology of low healthliteracy, our understanding of the relationship between literacyand health outcomes, and emerging interventions to mitigatethe effects of low health literacy. As this field rapidly gains newinsights, we are beginning to learn how to address the problem.

Epidemiology of LowHealth Literacy

Health literacy, as defined byHealthy People 2010 and describedin the issue brief in this issue of theNorth Carolina Medical Journal, is aconstruct which has been elusive tomeasure as a single variable. Most ofthe research to date has focused onthe ability to read basic healthinformation. However, all of us canidentify a friend or colleague whohas excellent reading skills, but whohas low health literacy. This personhas trouble understanding and actingon health information. As such,describing the epidemiology of healthliteracy requires an explanation ofwhat has been traditionally measuredin these studies. To date, researchers have measured reading abilityas a proxy for health literacy. Measuring reading ability emphasizesthe role of understanding written health information and wouldlikely classify our colleague with excellent reading skills as having“high health literacy.” So, although measuring reading abilitydoes not give us the full picture of health literacy, understanding

the problems associated with not reading well can help us identifykey principles for addressing health literacy.

The most up-to-date portrait of reading ability in theUnited States was the 2003 National Assessment of AdultLiteracy (NAAL).2 The NAAL found that 43% of adults readat basic or below basic levels. Based on analysis by economistsand educators, people who read at these levels are not adequatelyskilled to compete in the current economy or to effectivelynegotiate much of the health care system.3 This current state ofaffairs is astounding and should call close attention to how weprovide health care. If close to half of the population we serve

is unable to accurately participate inhealth care, we need to fundamentallyrestructure how we operate. As wepursue patient-centered care, we mustconsider the information processingskills of those we serve and adjust ouractions to match the skill level.

Health Literacy and HealthOutcomes

The importance of health literacy isunderscored by its relationship to healthoutcomes. The research to date hasfocused on the relationship betweenreading ability and health outcomes,largely because reading ability is easierto measure than the broader conceptof health literacy. Regardless, if poorreading ability translates to poorhealth outcomes—after controlling

for variables like insurance, income, race, ethnicity, and diseaseseverity—then we are more confident that inability to understandhealth information is an important factor for health outcomes.In 2004, the Agency for Healthcare Research and Quality(AHRQ) released a report on the relationship between literacyand health outcomes.4,5 This report found that, across several

Low Health Literacy:Epidemiology and Interventions

Darren A.DeWalt,MD,MPH

COMMENTARY

Darren A. DeWalt, MD, MPH, is an assistant professor of medicine in the Division of General Internal Medicine at the University ofNorth Carolina School of Medicine.He can be reached at dewaltd (at) med.unc.edu or Campus Box 7110, Chapel Hill, NC 27599-7110.

H

“If close to halfof the populationwe serve is unable

to accuratelyparticipate in

health care, we needto fundamentallyrestructure how we

operate.”

areas of health and health care, low literacy was associated witha worse prognosis than higher literacy even after controlling forconfounding variables.

Since the publication of the systematic review, several newarticles have added to the evidence by evaluating new populationsand new outcomes. Two studies have documented that peoplewith lower literacy die at a faster rate than people with higherliteracy.6,7 Patients with low literacy are more likely tomisunderstand prescription medication instructions andwarning labels.8-10 Young children with asthma who haveparents with low literacy have more days of school missed andmore hospitalizations.11 The body of literature associating lowliteracy with worse health outcomes becomes more robust eachyear. Some studies are beginning to explore potential mediatingvariables such as self-efficacy,12,13 medication knowledge,10,14,15

and patient-physician communication.16 As we begin tounderstand the mediators between literacy and health outcomes,our intervention design will become more informed and effective.

Interventions toMitigate the Effects of LowHealth Literacy

Interventions to mitigate low health literacy usually fall intoone of 4 categories:

(1)Improve health literacy skills in the population(2)Improve written and multimedia communication(3)Improve patient-provider communication in health care

visits(4)Alter systems of care

No doubt, such a framework is an oversimplification, but itlays out what we need to think about when addressing healthliteracy at the state level. I will briefly review each category andthe current state of knowledge for each.

1. Improve Health Literacy Skills in the PopulationAlthough the most attractive solution, this may be the most

elusive. Improving the reading ability of an adult takes hours ofpersonalized instruction and self-motivation. With one year ofintense adult basic education, a person’s reading level increasesabout one or two grade levels. Such improvements, if targetinggermane topics, may improve function in the health careenvironment, but educating 90 million adults with suchspecificity and intensity is not feasible. No studies have beenpublished that demonstrate improved health literacy over time.As such, we do not know if specific health-related informationprocessing can be improved faster than general reading ability.

We have a small amount of evidence that literacy trainingprograms can improve depression outcomes, regardless of theimprovement in literacy. Two studies have enrolled people inadult literacy courses, and both showed an improvement indepression symptoms when compared to a control group.17,18

The mechanism of the effect may be related to self-confidenceand life skills improvement for people who have been strugglingto get by. Regardless of the mechanism, the outcome suggests

that further study in this area could be promising.What about the children? Unfortunately, approximately

one-third of our nation’s children do not graduate from highschool, a statistic that has not changed in 30 years.19 As such, Ianticipate that the problem of low health literacy will remainwith us in the foreseeable future. Expanding curricula in healthliteracy for primary and secondary education may help tofamiliarize students with the health care environment, butimproving graduation rates may be more important for theoverall health of the population.

2. ImproveWritten andMultimedia CommunicationMost of the research and advocacy related to health literacy

has focused on written and multimedia communication.Numerous studies have shown that the readability of healthinformation almost always exceeds the reading ability of itsintended audience. If we (health care professionals) were acommunications agency, we would be fired. Creating betterwritten messages and using other forms of media (audio orvideo) have been tested in clinical research and can improveknowledge.5 Written messages targeting specific illnesses canincrease the rate of physician-patient dialogue on a topic andincrease the receipt of clinical preventive services.20,21 Creatinghealth messages that are understandable by most of the intendedaudience is an imperative for any systematic approach towardaddressing low health literacy. Experts have developed guidesfor creating health messages,22 and more and more examples arepublished in the medical literature.23-25

Beyond improving specific patient education materials, weneed to consider broad-based campaigns to activate people toask questions and seek clarity. Such campaigns have been createdincluding the Justus-Warren Heart Disease and Stroke TaskForce message “Start with Your Heart”26 and the AHRQ fundedmessage “Questions Are the Answer: Get More Involved WithYour Health Care.”27 Although we do not know how mucheffect these messages have had, they normalize the behavior ofseeking clarity in the health care setting. Such social marketingapproaches may lead to more efficacious health care encounters.

3. Improve Oral Communication in Health CareVisitsHealth communication researchers have known for years

that patients remember about 50% of what they are told in avisit with a physician.28 Even that which is remembered is oftenremembered incorrectly.29 This is especially of concern whenmost health communication takes place orally in the health caresetting. Therefore, strategies that improve oral communicationmay lead to better health outcomes, particularly for those withlow health literacy.

People who have strong reading and information processingskills can get by in the current environment because they canseek more information after they leave the health care settingby looking on the Internet or in books. Unfortunately, a largepart of society cannot access information so easily and mustrely on good information transfer in the clinic or hospital.Although an important area of research, we do not have muchempirical evidence on what strategies work best.


The most promising strategy to facilitate understanding inthe office setting is the teach-back method. Using this method,the clinician explains a concept or behavior to a person, thenasks the person to explain it back in his or her own words. Thiscan give the clinician the opportunity to clarify any areas theperson did not adequately understand. This method is the onlyway a clinician can be certain that the patient or family under-stands the content. An added bonus to this method is that thepatient recall will be better because of having to communicateit to the clinician.

One published study has evaluated the use of the teach-backmethod by audiotaping visits between patients with diabetesand their physicians.30 The study found that the teach-backmethod was used with only 20% of the patients. However,those patients had 9 times the odds of having their blood sugarbelow the average (a lower blood sugar is good in this context).Although an observational study, it suggests this approach mayhave benefit. It was also noted that those visits which includedthe teach-back method were not longer. In addition to thisstudy, the teach-back method and its variants are tried and truepedagogic methods advocated by educators as far back asSocrates.31

Another strategy for improving oral communication is tolimit the number of topics communicated at one time. In thecontext of a health care encounter, the clinician often mentionsseveral different ideas, prescribes medications, and suggestsspecific self-care behaviors. Frequently, there is no summation ofthe main points, and the clinician is not aware of the elaboratecontent he or she has just imparted. People have a variety ofcapacities for remembering things, so the clinician must tailorthe amount of information to a given patient. I advocate thatclinicians try to limit the number of points they expect thepatient to remember to 3. Anything beyond that requiressupplementary methods to help the patient remember andreinforce the information.

4.Alter Systems of CareLastly, we must consider the role of our care systems in

making health care less effective for patients with low healthliteracy. Most current care systems rely on complex organizationsthat make lots of errors including problems in scheduling,prescriptions, administering medications, and receipt ofself-management support. In these systems, patients withhigher health literacy can often get by, but not easily. A patientwith low health literacy is left extremely vulnerable and likelyreceives substandard care. At the time of the 2004 AHRQsystematic review, no studies directly demonstrated whethersystem changes could mitigate the effects of low health literacy.

Making health care systems responsive to the needs of peoplewith low health literacy is not easy. In many quality improvementprograms, the provision of self-management support is thehardest improvement to implement with fidelity and efficacy.32

Fortunately, models are beginning to emerge,33 and some practiceshave shown improved health outcomes for patients with lowhealth literacy.

One system in North Carolina created a diabetes diseasemanagement program within the practice that included clinicalpharmacist practitioners, diabetes educators, and care assistantsto help educate and respond to the needs of the patients withdiabetes.34 This program focused mostly on the patient’sdesired behavior goals and used the teach-back method whencommunicating. However, the program also helped patientsnavigate the health system by teaching them how to get rides tothe clinic and how to register for pharmacy benefits when theforms were too complicated. Although patients of all literacylevels benefited from the program, those with low literacyreceived much greater benefit from the program.35 In essence,this program reduced disparities in outcomes for patients withlow literacy.

The same practice developed a heart failure self-managementtraining program targeted toward patients with low literacyskills.25 This program offered training for the patient with severalfollow-up phone calls to reinforce the education. Although thisprogram did not offer specialized medical care or ancillary helplike the diabetes program, it did reduce hospitalizations amongall patients.36 Patients with low literacy benefited as much ormore than those with higher literacy, but the study was not largeenough to explore whether the disparities in fact narrowed.

A large public hospital in California tested 2 forms of diabetessupport versus usual care.37 One of the intervention arms usedautomated telephone disease management (ATDM) to callpatients and gather information on how the patient was doing.If any concerns were elicited, the patient received a call from anurse educator. The other intervention arm used group visits toprovide self-management support. The study found that patientsin the ATDM had improved functional status, self-management,and mental health compared to patients in the group visits armand in the control arm.

System changes to provide more comprehensive care appearpromising for patients with low literacy. A system that does notrequire advanced literacy skills will likely improve care forpatients regardless of literacy level. Hence, health literacy meetsquality improvement. As we proceed with redesigning our caresystems, we should consider the role of the patient and how wecan reduce the navigation burden, eliminate clinical inertia,and provide tailored and effective self-management support toreach optimal health outcomes.

Conclusions

Understanding and addressing low health literacy willrequire further basic research but also implementation scienceand quality improvement. Basic research in the field is expandingrapidly and we will continue to identify best practices.Implementation has lagged behind because, until recently, wedid not have evidence-based methods to improve outcomes.The emergence in the past 3 years of evidence-based approachesshould lead to the next phase of implementation science to helpus provide health literacy sensitive care to patients in our clinics,hospitals, and public health venues. NCMJ



REFERENCES

1 Williams MV, Parker RM, Baker DW, et al. Inadequatefunctional health literacy among patients at two public hospitals.JAMA. Dec 6 1995;274(21):1677-1682.

2 Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacyof America’s Adults: Results from the 2003 National Assessment ofAdult Literacy. Washington, DC: National Center forEducation Statistics; September 2006. NCES 2006-483.

3 Comings J, Reder S, Sum A. Building a Level Playing Field: TheNeed to Expand and Improve the National and State AdultEducation and Literacy Systems. Cambridge, MA: National Centerfor the Study of Adult Learning and Literacy; December 2001.

4 DeWalt DA, Berkman ND, Sheridan SL, Lohr KN, PignoneM. Literacy and health outcomes: a systematic review of theliterature. J Gen Intern Med. 2004;19:1228-1239.

5 Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN.Interventions to improve health outcomes for patients with lowliteracy. A systematic review. J Gen Intern Med.2005;20(2):185-192.

6 Baker DW, Wolf MS, Feinglass J, Thompson JA, GazmararianJA, Huang J. Health literacy and mortality among elderly persons.Arch Intern Med. July 23, 2007;167(14):1503-1509.

7 Sudore RL, Yaffe K, Satterfield S, et al. Limited literacy isassociated with mortality in the elderly: the health, aging, andbody composition study. J Gen Intern Med. 2006;21(8):806-812.

8 Davis TC, Wolf MS, Bass PF, et al. Literacy and misunderstandingof prescription drug labels. Ann Intern Med. 2006 Dec19;145(12):887-894. Epub 2006 Nov 29.

9 Davis TC, Wolf MS, Bass PF, et al. Low literacy impairscomprehension of prescription drug warning labels. J GenIntern Med. 2006 Aug;21(8):847-851.

10 Kripalani S, Henderson LE, Chiu EY, Robertson R, Kolm P,Jacobson TA. Predictors of medication self-management skill ina low-literacy population. J Gen Intern Med. 2006Aug;21(8):852-856.

11 DeWalt DA, Dilling MH, Rosenthal MS, Pignone MP. Lowparental literacy is associated with worse asthma care measuresin children. Ambul Pediatr. 2007;7(1):25-31.

12 DeWalt DA, Boone RS, Pignone MP. Literacy and itsrelationship with self-efficacy, trust, and participation inmedical decision-making in patients with diabetes. Am J HealthBehav. 2007;In Press.

13 Wolf MS, Davis TC, Osborn CY, Skripkauskas S, Bennett CL,Makoul G. Literacy, self-efficacy, and HIV medication adherence.Patient Educ Couns. 2007;65(2):253-260.

14 Paasche-Orlow MK, Cheng DM, Palepu A, Meli S, Faber V,Samet JH. Health literacy, antiretroviral adherence, andHIV-RNA supression: a longitudinal perspective. J Gen InternMed. 2006 Aug;21(8):835-840.

15 Fang MC, Machtinger EL, Wang F, Schillinger D. Healthliteracy and anticoagulation-related outcomes among patientstaking warfarin. J Gen Intern Med. 2006 Aug;21(8):841-846.

16 Schillinger D, Bindman A, Wang F, Stewart A, Piette J.Functional health literacy and the quality of physician-patientcommunication among diabetes patients. Patient Educ Couns.Mar 2004;52(3):315-323.

17 Weiss BD, Francis L, Senf JH, Heist K, Hargraves R. Literacyeducation as treatment for depression in patients with limitedliteracy and depression: a randomized controlled trial. J GenIntern Med. Aug 2006;21(8):823-828.

18 Poresky RH, Daniels AM. Two-year comparison of income,education, and depression among parents participating inregular Head Start or supplementary Family Service CenterServices. Psychol Rep. 2001 Jun 2001;88(3 Pt 1):787-796.

19 Thornburgh N. Dropout nation. Time Magazine.2006;167:30-40.

20 Kripalani S, Sharma J, Justice E, et al. Low-literacy interventionsto promote discussion of prostate cancer: a randomized controlledtrial. Am J Prev Med. 2007;33(2):83-90.

21 Jacobson TA, Thomas DM, Morton FJ, Offutt G, Shevlin J,Ray S. Use of a low-literacy patient education tool to enhancepneumococcal vaccination rates. A randomized controlled trial.JAMA. Aug 18 1999;282(7):646-650.

22 Doak C, Doak L, Root J. Teaching patients with low literacyskills. 2nd ed. Philadelphia: JB Lippincott; 1996.

23 Seligman HK, Wallace AS, DeWalt DA, et al. Developinglow-literacy patient educational materials to facilitate behaviorchange. Am J Health Behav. 2007;In Press.

24 Kripalani S, Robertson R, Love-Ghaffari MH, et al.Development of an illustrated medication schedule as alow-literacy patient education tool. Patient Educ Couns.2007;66(3):368-377.

25 DeWalt DA, Pignone M, Malone R, et al. Development andpilot testing of a disease management program for low literacypatients with heart failure. Patient Educ Couns. 2004;55(1):78-86.

26 Justus-Warren Heart Disease and Stroke Prevention Task Force.Start with Your Heart; 2005.

27 Agency for Healthcare Research and Quality. Questions are theanswer: Get more involved with your health care; 2007.http://www.ahrq.gov/questionsaretheanswer/. AccessedSeptember 11, 2007.

28 Kessels RP. Patients’ memory for medical information. J R SocMed. May 2003;96(5):219-222.

29 Anderson JL, Dodman S, Kopelman M, Fleming A. Patientinformation recall in a rheumatology clinic. Rheumatology.February 1, 1979;18(1):18-22.

30 Schillinger D, Piette J, Grumbach K, et al. Closing the loop:physician communication with diabetic patients who have lowhealth literacy. Arch Intern Med. Jan 13 2003;163(1):83-90.

31 Blackburn S. The Oxford Dictionary of Philosophy. 2nd ed:Oxford University Press; 2007.

32 Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V,Wagner EH. Self-management aspects of the improvingchronic illness care breakthrough series: implementation withdiabetes and heart failure teams. Ann Behav Med. Spring2002;24(2):80-87.

33 Schillinger D. Improving the quality of chronic diseasemanagement for populations with low functional health literacy:a call to action. Disease Management. 2001;4(3):103-109.

34 Rothman RL, Malone R, Bryant B, et al. A randomized trial ofa primary care-based, disease management program to improvecardiovascular risk factors and glycated hemoglobin in patientswith diabetes. Am J Med. 2005;118(3):276-284.

35 Rothman R, DeWalt DA, Malone R, et al. The influence ofpatient literacy on the effectiveness of a primary-care baseddiabetes disease management program. JAMA. Oct. 132004;292(14):1711-1716.

36 Dewalt DA, Malone RM, Bryant ME, et al. A heart failureself-management program for patients of all literacy levels: Arandomized, controlled trial [ISRCTN11535170]. BMC HealthServ Res. Mar 13 2006;6(1):30.

37 Schillinger D, Handley M, Wang F, Hammer H. Effects ofself-management support on structure, process and outcomesamong vulnerable patients with diabetes: a 3-arm randomizedtrial [Abstract]. J Gen Intern Med. 2007;22(Supplement 1):19.

COMMENTARY

Chasing the Monster

Toni Cordell

hile attempting to do the task before her, a youngwoman stated in frustration, “I am only as good as the

information I am given.“ Communication offers an opportunityfor understanding and success or misunderstanding and failure.As we all know, the lack of crystal clear health communicationcan put lives in danger.

Medical professionals have extensive training and education.Face to face with the doctor, health issues can be talked throughif both the practitioner and the patient are on the same pagewhile communicating. But some patients also hope that thedoctor not only hears their words but also understands thefeelings associated with them when they have the courage toexpress them.That puts a great deal of responsibility on doctors,nurses, and other medical professionals.

About 30 years ago, I visitedthe gynecologist knowing therewas a problem (I later learned itwas a prolapsed uterus). Duringthe exam the physician said thatthe problem had “an easy repair.“I asked no questions. We just setthe surgical date, and I showed upat the hospital for that “easyrepair.”

I graduated from high schoolreading at the fifth grade readinglevel. When I was in school therewas no help for those of us withlearning problems. So, I’ve spentmy life facing challenge after challenge and attempting to gainenough knowledge so I can feel normal.

Because of my poor reading skills, I simply signed every paperpushed in front of me at the admissions desk before my surgery.This was not my first surgical procedure, and I knew I wasrequired to sign those papers in order to have the “easy repair”procedure. I didn’t read a single word. I didn’t even try because Isuspected the medical jargon would make the documents toodifficult to understand.

Looking back, it would have been so helpful if the documentsneeding my signature could have been mailed out ahead of

time. Then I could have gone over them at my own pace orasked my husband, an educated man with a high IQ, to checkthem out. Another option may have been to call ahead of timeand request the paperwork so I could familiarize myself with it.

The surgery was a successful “repair.” However, during the6-week follow–up appointment in the doctor’s office, the nursewalked into the examining room and cheerfully asked, “Toni,how are you doing since your hysterectomy?” Shocked andhumiliated, I behaved as normally on the outside as possible.However, it caused an emotional overload with my insidesscreaming at me for being so stupid. The word hysterectomymeant they cut something out. That is more than a “repair.”How could it happen that I did not know? I just realized partof my body was cut out, and I only thought it was a surgical

repair. Although I was not hopingfor more children, it was still atraumatic day for me.

Several years ago, after numeroussurgeries attempting to correct theorgans in my lower abdomen, Iwas sent to a urologist, Dr NiallGalloway, at Emory UniversityHospital in Atlanta. His nursetold me that he gets all the trainwrecks. Thankfully, he serves as anexcellent example of a very positiveexperience within the medicalcommunity.

Of course at the initialappointment I had to deal with the clipboard and the papersneeding my signature. By this point in my life I had been to anadult literacy program and my reading level had improved butI still loathed paperwork. I was led back into the examiningroom. Dr Galloway came in and sat chair to chair and face toface with me. We were both fully clothed. He asked lots ofquestions. Then as he left the room he instructed his nurse toprepare me for the physical exam.

When I was properly set on that horrible table and fullydraped, Dr Galloway returned. Before he laid a hand on me, hespoke with care letting me know what he was doing and even

“Communicationoffers an opportunityfor understandingand success or

misunderstandingand failure.”

Toni Cordell is a patient advocate. She can be reached at tcordell2 (at) yahoo.com.


W

a The Ask Me 3 campaign was developed by the Partnership for Clear Health Communication to improve communication betweenpractitioners and patients. It endeavors to teach patients to ask 3 questions of the practitioner during a health encounter:What is my main problem?What do I need to do?Why is it important for me to do this? For more information, visithttp://www.askme3.org/for_patients.asp.


warned me to expect the uncomfortable part. After DrGalloway left the room, the nurse helped me take time torecover and get up right, and she asked if I needed any help toget dressed. So, when Dr Galloway returned, once again I wasdressed. That tends to put physician and patient on more of apeer relationship. While in a paper or cloth drape one can feelvulnerable. Being dressed in street cloths takes some of that outof the encounter.

Dr Galloway clearly stated his evaluation and what hebelieved the treatment should be to correct the current problem.His Picasso-like hand drawings illustrated the places wherethere would be cuttings, stretching, and stitches. Although I amstill not as good at asking questions as I need to be, DrGalloway communicated so clearly that I went into that surgeryvery well informed of what to expect.

As a result of my interaction with the medical field andattending conferences on patient safety, I now know about theAsk Me 3 campaign.a Ask Me 3 gives a patient a place to startto become better informed and educated about his or her ownmedical needs. I never want to suggest that all of the responsi-bility for communication rests on the shoulders of the medicalprofessional. It needs to be a partnership in which the patientalso plays a role.

Many of us with low literacy skills or a poor education haveemotional baggage from the many years of feeling stupid. Afterall, many of us sat in high school classrooms alongside of you.I graduated from high school reading at the fifth grade readinglevel. I know I am not your academic equal. I have a highregard for all who have earned a college education and beyond.But now I have learned that I no longer have to just do as I amtold. I suspect one physician has written “noncompliant” onmy chart because I argued with him about depression andrefused antidepressant drugs. But it is my body and my life,thus it is my choice.

I have lived my life being attached to the stupid monsterthat is my lack of formal education. No, I am not suggesting Ithink there are really monsters around every corner waiting toget me. It is just that when I say or do something that reveals mylack of education I get slammed in the face with humiliation. Sowhen a staff member in your office gets frustrated with me, Iknow it and I tighten up.

Most of the time, I make an effort to be very honest aboutmy reading skill or lack thereof. After I sign the HIPAA papers,I hand the clipboard to the person at the desk and say, “I signedthese, but I don’t understand them.” Most of the time thatperson just looks at me. Sometimes they will joke that theydon’t either. I believe at that moment I have just put the ballback in your court, and if there is a problem you could be opento a legal suit. I am not sure, just a guess. I am not personallyinterested in suing anyone.

Not all patients lack the education to communicate withmedical professionals on a peer level. However, even those withadvanced educations may not be at peak performance whilevisiting the doctor. What happens to those with college degreeswhen their temperatures soar over 100 degrees? Are they able tounderstand and follow every bit of instructions coming at themwhen a flu bug has moved in with a bit of diarrhea and vomiting?Okay go one step further. If the word cancer has just come outof the doctor’s mouth, can you, at that moment, process allinstructions to deal with that life-threatening illness?

Health literacy is not just a problem for those of us with apoor education. No matter how difficult the task, all medicaldecisions need to be made in partnership with the medicalprofessional and the patient. That requires crystal clearcommunication with mutual respect. NCMJ

here is an urgent need to transform our health care systemto improve the quality of and access to care, more

efficiently use limited resources, and be more cost effective. Theconvergence of trends, many studied by the North CarolinaInstitute of Medicine, driving this need for transformationinclude the alarming increase in chronic diseases across the lifespan,persistent shortages of health care professionals and interpreters,the increasing uninsured population, and limitations of ourhealth care safety net to meet growing demands. Demographicchanges, environmental health risks, and health literacy issuesfurther compound these problems. All these factors contribute tohealth disparities and underscore the need for culturally relevantand linguistically appropriatehealth education and care. A keyto health care transformation isthe shift from a traditionalhierarchical, clinician-centeredapproach to a patient orrelationship-centered approachin interpersonal communicationand service delivery strategies.

Given the current milieu, itis time to take a fresh look at therole lay health educators (LHEs),also known as lay healthadvisors, community healthworkers, or promotoras, can playin improving communication,increasing access to quality care,and reducing costs. Research inhealth literacy has heightenedawareness that it is not enough, from a practical or ethicalstandpoint, to simply disseminate health information. It isproblematic when the information is laden with medical jargonand technical terms and written at too high a reading level. For

effective disease treatment and prevention and behaviormodification, individuals must be motivated and able to access,understand, and use health information in the context of theirdaily lives. Lay health educators are respected and trusted membersof a community who know most of the residents they educate.They help translate health information into culturally meaningful,understandable messages that their neighbors can criticallythink about and act on. The LHE model was first endorsed bythe federal government in the 1960s as a way to expand access tocare for underserved populations. These natural helpers buildbridges between systems of government, educational institutions,and medical and social services that might otherwise be out of

reach to individuals and their communities. Acting in a spirit ofcollaboration and mutuality, their work and use of “livingroom” language embody the principles and best practices ofhealth literacy and relationship-centered care.

“Lay health educators are respectedand trusted members of a communitywho know most of the residents theyeducate. They help translate health

information into culturally meaningful,understandable messages that their

neighbors can critically thinkabout and act on.”

Susan Auger,MSW, is president of Auger Communications, Inc. She can be reached at auger (at) augercommunications.com or POBox 51392,Durham,NC 27717.

Sarah Verbiest, MSW,MPH, is executive director of the Center for Maternal & Infant Health, School of Medicine, and a doctorate inpublic health candidate, School of Public Health, the University of North Carolina at Chapel Hill. She can be reached at sarah_verbiest(at) med.unc.edu or University of North Carolina at Chapel Hill, CB# 7181, Chapel Hill, NC 27599-7181.

COMMENTARY

Lay Health Educators’ Roles in Improving PatientEducation

Susan Auger,MSW; Sarah Verbiest,MSW,MPH


T


Although currently an underutilized service delivery strategy,the versatility and effectiveness of LHE programs make them anattractive and vital option in today’s health care environment.Lay health educator programs are typically used to accomplish 3interrelated goals: (1) strengthen the therapeutic alliance betweenhealth care professionals and community members; (2) improveappropriate health care utilization; and (3) reduce health risks.1

Diverse program structures and roles and responsibilities oflay health educators reflect the uniqueness of communitiesand their resources. Amidst this diversity, common programcomponents exist. For example, many programs includeoutreach to underserved communities through activities such asnetworking with neighbors, providing simple health screening,and staffing mobile units. Lay health educators often helpdevelop or select health materials for their peers based on theirknowledge of language as well as local cultural beliefs andpractices. Many LEH models have roots in Paolo Freire’s workin adult literacy and seek to empower community members toidentify their own needs and then develop and implement aplan that is right for them.2 Health advocacy, home visits, healthpromotion, support for lifestyle changes, and the provision oftransportation are other program components that are oftenpart of LHE outreach efforts.

Lay health educators’ primary allegiance is to their communitiesand social networks. This is a critical element and must be bothrespected and maintained by programs. The degree to whichLHE programs are integrated within the health system varies.On one end, LHEs are fully integrated into the health careteam as paid employees. On the other end, LHEs workautonomously in their community with no connection to thehealth care community and no compensation. Within theseextremes lie a wide variety of partnerships and structures. Thelevel of formal and informal linkages between LHEs and healthcare providers should be balanced based on the program’s focus.In some cases, strong ties with health care providers assist LHEsin their work and health promotion efforts. In other cases,particularly when reaching more isolated and difficultto access communities (such as those with HIV/AIDS), stronglinks to providers might create a sense of distrust withincommunities and undermine a LHE’s effectiveness. In othercircumstances, activities that are integrated with a health center’sclinical operations may facilitate better access to comprehensiveservices.3 For example, consistent contact between physicians,case managers, and LHE home visitors can help ensureappropriate referrals and more effective follow up. Lay healtheducator programs must consider ways to respect the contributionof time and expertise of LHEs as well as ways to keep themengaged over time. Cash compensation is one obvious incentive.Increased access to services, training opportunities, respectfrom their peers, and a deep sense of knowing they have helpedtheir community are other ways that LHEs benefit from theirlabors.

Programs that actively work with LHEs can build capacityat individual and system levels. Lay health educators commonlyreport an increased level of self-confidence, assertiveness, andability to speak their minds as a result of their role. Their increase

in knowledge and enhanced health and science literacy skillshelp increase the capacity of the entire community to takeaction on behalf of their members. Individuals and communitiesare empowered to get involved and stay connected with outsidesystems, a crucial function in times of health crises and naturaldisasters. Identifying motivated individuals in communitiesthrough LHE training can foster opportunities to recruit newtalent from underserved communities for possible careers inhealth care.

With appropriate training and supervision, LHEs can benefithealth care systems by providing a cost effective way to addresscultural and language differences and more effectively meet theneeds of an increasingly diverse patient population. One exampleof potential system efficiency is to use LHEs with groups ofmothers to provide prenatal education as a complement toshort physician visits. This can expand and heighten the culturalsensitivity of health care information received by women. Thepregnant mothers would also receive greater social support,which has been shown to improve birth outcomes.4 In addition,sharing the educational responsibilities with LHEs would allowhealth professionals and clinic interpreters an opportunity touse their time more effectively. In fact, nurse-supervised LHEsprovided group prenatal education to high-risk Latinas in arecent study to improve quality of care and reduce healthdisparities among Medicaid managed care enrollees. They usedphotonovellas (or “photo-stories”) and the Teach-With-StoriesMethod. This innovative approach, developed in NorthCarolina, is an internationally recognized best practice modelfor addressing prenatal care, empowerment, and health literacyneeds of women. Latinas who received the Teach-With-Storiesintervention had higher rates of optimal prenatal care(90.5% vs 64.7%) than the overall prenatal population atNeighborhood Health Plan of Rhode Island, the statewidehealth maintenance organization conducting the study.5

Lay educators have been used successfully with diversepopulations to address specific health problems such as cancer,HIV/AIDs, diet and nutrition, prenatal care, environmentalhealth issues, and health disparities within all these issues. Thelack of standardization in the program structures, roles, andresponsibilities described above as well as differences betweencommunity and research cultures pose evaluation challenges.While more research is needed, there are additional studies thatdemonstrate that LHE interventions can improve access tocare, increase client knowledge, and facilitate behaviorchanges.5,6,7 Research has also shown that LHEs can improvethe health status of individuals with chronic diseases such asdiabetes and high blood pressure.8 The studies available thatevaluate the financial impact of LHE programs provide evidencethat they are economically sustainable.9 One study, designedto assess the return on investment of LHEs working withunderserved men, examined service utilization, charges, andreimbursements. Primary and specialty care visits increasedwhile urgent care and inpatient and outpatient behavioralhealth care utilization decreased. Consequently, uncompensatedcosts decreased; the return on investment was $2.28 for every$1.00 in costs.9

REFERENCES

1 Nemcek MA, Sabatier R. State of evaluation: communityhealth workers. Public Health Nurs. 2003:20(4);260-270.

2 Freire P. Pedagogy of the oppressed. New York, NY: The SeaburyPress;1970.

3 Zuvekas A, Nolan L, Tumaylle C, Griffin L. Impact ofcommunity health workers on access, use of services, andpatient knowledge and behavior. J Ambul Care Manage.1999:22(4);33-44.

4 Feldman PJ, Dunkel-Schetter C, Sandman CA, Wadhwa, PD.Maternal social support predicts birth weight and fetal growthin human pregnancy. Psychosom Med. 2000:62;715-725.

5 Martin C. Reducing Racial and Ethnic Disparities: QualityImprovement in Medicaid Managed Care Toolkit. Hamilton, NJ:Center for Health Care Strategies, Inc.; 2007.

6 Thomas JC, Earp JA, Eng E. Evaluation and lessons learnedfrom a lay health advisor programme to prevent sexuallytransmitted diseases. Int J STD AIDS. 2000:11;812-818.

7 Kim S, Koniak-Griffin D, Flaskerud JH, Guarnero PA. Theimpact of lay health advisors on cardiovascular healthpromotion: using a community-based participatory approach.J Cardiovasc Nurs. 2004:19(3);192-199.

8 Levine DM, Becker DM, Bone LR. Narrowing the gap inhealth status of minority populations: a community-academicmedical center partnership. Am J Prev Med. 1992:8(5);319-323.

9 Whitely EM, Everhart RM, Wright RA. Measuring return oninvestment of outreach by community health workers. J HealthCare Poor Underserved. 2006:17;6-15.

Meaningful dialog and greater insight into the strengths andneeds of communities are needed to improve health literacy,increase access to quality health care, and use limited resourcesmore efficiently. This cannot be accomplished in isolation. Layhealth educators offer a unique opportunity to strengthen therelationships between health professionals and patients throughmore culturally sensitive communication. They are able toadapt and discuss health information with their neighbors in away that is understandable and encourages improved healthpromotion and risk reduction. With appropriate training andsupervision, these natural helpers can also give community

members practical support to navigate systems and makechanges in their lives. Despite mounting evidence of theirefficacy and cost-effectiveness, barriers exist to the use of LHEsand the sustainability of such programs. For example, while grantfunds may be available to start community-based programs,innovative ways to fund LHEs and maintain a program’sinfrastructure are needed. Also, data systems must be improvedto allow better tracking and assessment of LHE programs.Working together, health professionals, community members,researchers, and policy makers can make better use of lay healtheducators in North Carolina to the benefit of all. NCMJ


ur health care system increasingly encourages patientinvolvement in care, yet patients are often not

well-equipped to assume such a role. A contributing factor ishaving marginal health literacy skills. Health literacy does notjust refer to reading and writing skills but a much broader setof communication, cognitive, social, and inquiry skills thatallow individuals to meet personal health goals. Approximatelyhalf of North Carolina’s population has marginal literacy skills.1

Furthermore, almost aquarter of our state’spopulation has severelylimited skills. Theseindividuals can performtasks such as signingone’s name or locatingthe expiration date on adriver’s license butcannot perform moredifficult tasks such aslocating an intersectionon a map, identifying and entering background information on asocial security card application, or totaling the costs of a purchasefrom an order form.2 Adequate health literacy skills play anintegral role in preparing individuals to interact with our healthcare system. They also have important implications for healthpromotion, disease prevention, and disease management becausethey influence actions such as making informed decisions,following health advice and instructions, and seeking and usinghealth information and services.

The Role of Adult Education in ImprovingHealth Literacy

Skill building is a critical component of a multidimensionalapproach to addressing North Carolina’s health literacy concerns.Fortunately, we have a community college system that servesall 100 North Carolina counties and has enjoyed a long, stable

history of building basic skills among adults. Complementingthis system are the efforts of literacy councils and community-basedorganizations. Basic skills classes at the community college buildfunctional skills that lead to a stronger workforce, and many ofthese same skills translate to building a more health-literatepopulation. Between 136 000 and 153 000 North Carolinianstook part in basic skills classes annually from 2001-2006,according to community college data.4 Classes are offered free

of charge for studentsattending any of 4distinct programsunder the basic skillsumbrella.Two of theseprograms, English asa Second Language(ESL) and Adult BasicEducation (ABE) areespecially well-suitedfor teaching healthliteracy skills.

Adult Basic Education classes are designed for adults wholack proficiency in reading, writing, speaking, problem-solving,or computation at a level necessary to function in society, on ajob, or in the family.4 English as a Second Language classes aredesigned to help adults who are limited English proficientachieve competence in the English language.4 Language andcultural barriers contribute to special health literacy needsamong these students.

The adult education setting offers a compelling opportunityfor building health literacy skills because of the compatibilitybetween health literacy goals and adult education goals, theflexibility offered to ABE and ESL instructors in choosing acurriculum, teaching methods that are friendly to adult learners,and the potential to reach a high-risk population. Adult educationis rooted in a long tradition of encouraging social change andempowerment5,6 among vulnerable populations, and educatorsare often passionate advocates for their students. Instructors

Incorporating Health Literacy Into Adult Basic Education:From Life Skills to Life Saving

Sandra J.Diehl,MPH

COMMENTARY

Sandra J. Diehl, MPH, is a doctoral student in the Department of Health Behavior and Health Education at the University of NorthCarolina at Chapel Hill. She can be reached at diehl (at) email.unc.edu or the University of North Carolina at Chapel Hill, Campus Box7440, Chapel Hill, NC 27599.

O

“Adult education principlessuggest that learning occursbest when the material beingtaught is immediately relevantand useful to the student.”


serve as an invaluable resource to adult learners both as links toreliable health information as well as facilitators for buildinghealth-related skills.

Qualitative data from a series of recent statewide health literacyworkshops offer some insight into the literacy-associated challengesthat individuals face. Attendees, representing literacy, health,and human service organizations, named misunderstandingmedications, tuning out because a provider uses technicalterms, and trouble with paperwork as common concernsamong the people they serve. A reading center manager fromFayetteville said, “I work for an adult literacy program and seemany people who do not read…they talk about the stack ofpapers you get to fill out the minute you walk into the doctor’soffice.” A nurse gave another perspective saying, “As a telehealthnurse, I get calls from patients who do not understand the writteninstructions given to them by their doctor, the emergencydepartment, and/or discharge instructions after hospitalization.This may include how to take their medication or managechronic diseases such as diabetes or asthma.” An adult literacyinstructor from Charlotte offered, “Some students read andunderstand well enough to take meds, the right ones at theright times with (the) correct dosage. However, there are somethat do the exact opposite. It’s scary.” These communicationconcerns are best addressed through multiple channels such aspractice or policy changes to address systems issues and educationto strengthen individual skills. Adult education can helpcomplement those efforts not only by enhancing general literacyskills but by also focusing on specific needs such as understandingmedicine labels or modeling and practicing communicationtechniques that may lead to a mutually beneficial conversationamong patients and providers.

Classrooms offer a safe place for individuals who share commoneducational needs to learn new information, practice new skills,and receive feedback. Adult educators employ a variety of

teaching methods that appeal to individual learning styles.Furthermore, students usually enjoy a sustained educationalrelationship with their peers and instructor. This relationshipserves to enhance rapport and opportunities for informationsharing. Both ABE and ESL classes are guided by a set of nationalobjectives called Comprehensive Adult Student Assessment whichoutline skills that individuals need to successfully function ineveryday life.7

Strategies for Building Health Literacy Skillsin the Adult Education Setting

Integrating health information into adult education is not anew practice. The adult education arena already builds healthliteracy skills among adult basic skills learners, albeit framed in anoverlapping ‘life skills’ context. For example, “identify emergencynumbers and place emergency calls” is a life skills learning objective;it is also a health literacy skill. The Comprehensive AdultStudent Assessment system outlines many other competenciesthat would also fit under a health literacy rubric. Table 1 presentsa small sample of these competencies. Thus, teaching healthliteracy in classrooms is compatible with existing basic skillsstandards and helps programs meet progress goals. Becausethere is compatibility and growing awareness among educatorsof the importance of health literacy, specialized curricula havebeen used in adult education classrooms in North Carolina,and more are being developed to help build health literacyskills. Adult Basic Education and ESL classes don’t have a setcurriculum, thus instructors are able to respond to the needs oftheir learners and have flexibility to incorporate a variety oflearning experiences.

One notable statewide effort is the Expecting the Best projectwhich involved curriculum development and evaluation, aproject Web site, a multidisciplinary advisory board, and active

dissemination efforts. The goals ofthis project were to introduceteaching material into communitycollege and community-basedorganizations and facilitate theformation of ties between healthand literacy providers. Expecting theBest is a 14-lesson curriculum forESL students that teaches a varietyof health-related skills includingwhere to seek health services, howto make an appointment, how tounderstand medicine labels, andhow to understand nutritionlabels. It was developed withconsiderable input from ESLstudents and community collegeinstructors and administrators, andreviewed by health professionalsfor accuracy. An evaluation of14 community college classesrandomized to Expecting the Best


Table 1.Sample Comprehensive Adult Student Assessment CompetenciesRelated to Health and Literacy

Nutrition Competencies

� Select a balanced diet

� Interpret food packaging labels

� Interpret nutritional and relatedinformation on food labels

� Compute discounts

� Use coupons to purchase goodsand services

� Make comparisons, differentiatingamong, sorting, and classifyingitems, information, or ideas

Health Competencies

� Locate medical and healthfacilities in the community

� Complete a personal informationform

� Identify emergency numbers andplace emergency calls

� Describe symptoms of illness,including identifying parts of thebody and interpreting doctor’sdirections

� Use a telephone directory andrelated publications to locateinformation

� Fill out medical health history forms

or usual curriculum showed a significant increase in healthliteracy skills among female students.8 Other curricula forlow-literacy audiences are available on the web.a One popularweb resource is a series of picture stories for beginner ESLstudents that can be adapted for audiences of varied literacylevels to generate discussion and teaching moments (Figure 1).9

Furthermore, a consortium of 5 literacy programs in NorthCarolina is currently developing a health literacy tool kit thatcan be used by other programs in the future.

Adult education principles10 suggest that learning occursbest when the material being taught is immediately relevantand useful to the student. Adult educators are not limited onlyto specialized health skills curricula; they can also take advantage

of community resources to create a range of relevant and usefullearning experiences. The ideas are limitless, and a few aredescribed here to illustrate the possibilities. For example, healtheducators are often available to visit the classroom and speakabout a topic of interest to students.11 In one case, after a student’schild choked and they experienced a distressing trip to theemergency department, a Red Cross trainer visited the classroomand taught students First Aid basics, including rescue skills forchoking. This emergency also presented an opportunity for the

class to talk about medical bills andthe North Carolina Children’s HealthInsurance Program (NC SCHIP). Inanother case, at the students’ request, ahealth educator from the local healthdepartment visited a class to talkabout HIV prevention.

Encouraging civic engagement isoften a goal for adult learner programs;this can tie into health literacy efforts byactively involving students in educatingothers. One promising idea is toconsider recruiting lay health advisorsfrom adult education programs.Another idea that has been successfullyimplemented in an adult educationclassroom involves asking students toresearch and create health educationmaterials for their peers. In this program,students presented health informationon breast cancer and mammographyscreening to fellow students.12 Adulteducation students might also serve asa potential field testing audience forconsumer materials prior to release.

Field trips can be a fun way toteach information in a real-life setting.The Raleigh Farmer’s Market hasbeen a popular place to bring studentsto teach life skills such as makingnutritious choices and calculatingcorrect change from transactions.Arranging an introductory visit to alocal walk-in or sliding-scale healthcenter can promote health by creatinga familiarity with the setting before amedical visit is needed. A trip to thelocal library can help students buildconfidence and skills in learning how

to research health information.A key consideration when incorporating health literacy topics

into adult education classrooms is student interest. That is, it iscrucial to choose curricula, guest speakers, and other activities

a For example, see the Health and Literacy Special Collection atWorld Education’sWeb site, http://healthliteracy.worlded.org.

A Doctor's Appointment

Copyright 2001 Kate Singleton

Figure 1.


REFERENCES

1 Siedow MD. Literacy in North Carolina. NC LiteracyResource Center. April 2002. http://www.ncccs.cc.nc.us/Basic_Skills/docs/pdf_documents/LitNCApril2002.PDF. AccessedAugust 20, 2007.

2 Kirsch I, Jungeblut A, Jenkins L, et al. Adult Literacy inAmerica: A First Look at the Findings of the National AdultLiteracy Survey. 3rd ed. Washington, DC: National Center forEducation, US Department of Education; 2002.

3 Annual Unduplicated Headcount by Program Area and Total2001-02 through 2005-06. 2007 North Carolina CommunityCollege System Fact Book. North Carolina Community CollegeSystem Web site. http://www.ncccs.cc.nc.us/publications/docs/publications/fb2007.pdf. Accessed August 22, 2007.

4 Basic Skills. 2007 North Carolina Community College SystemFact Book. North Carolina Community College System Website. http://www.ncccs.cc.nc.us/publications/docs/publications/fb2007.pdf. Accessed August 22, 2007.

5 Freire P. Pedagogy of the Oppressed. New York: Seabury Press;1970.

6 Shor I. Empowering Education: Critical Teaching for SocialChange. Chicago: University of Chicago Press; 1992.

7 CASAS Competencies. Comprehensive Adult StudentAssessment Web site. https://www.casas.org. Accessed January 5,2006.

8 Hoeft KS, Bowling JM, Diehl SJ. Efficacy Evaluation of theExpecting the Best Health Literacy Curriculum: A Pilot Study(Abstract). American Public Health Association.http://apha.confex.com/apha/135am/techprogram/session_22376.htm. Accessed June 29, 2007.

9 Singleton K. Picture Stories for Adult ESL Health Literacy.Center for Applied Linguistics. http://www.cal.org/caela/esl_resources/Health/healthindex.html. Accessed 8/24/2007.

10 Lieb S. Principles of Adult Learning. http://honolulu.hawaii.edu/intranet/committees/FacDevCom/guidebk/teachtip/adults-2.htm.Accessed September 22, 2005.

11 Diehl SJ. Life Skills to Life Saving: Health Literacy in AdultEducation. Adult Learning. 2007;15(1/2).

12 Hohn MD. The Role of Adult Basic Education in DevelopingHealth Literacy. Literacy Across the Curriculumedia Focus.2004;17(2):12-15. http://www.centreforliteracy.qc.ca/publications/lacmf/vol17no2/vol17no2.pdf. Accessed August 24, 2007.

that are of interest to students. If students do not activelyparticipate in selecting what they learn, then it is unlikely theywill be engaged. Worse, the intent can be misinterpreted. Anadvocate in the Latino community explained, for instance, howstudents felt alienated when a health educator visited their ESLclassroom to talk about sexually transmitted infections. Whilethe intention was good, it ended up as a stigmatizing experiencebecause the students did not ask for this information nor didthey have any particular interest in it. Another suggestion,based on formative data from the Expecting the Best program, isto include health literacy skills as part of a diverse curriculumrather than creating a class that focuses only on improvinghealth skills.

Finally, instructors themselves must feel confident inincorporating health literacy skills into their classes.Understanding that health literacy is a part of general literacyand life skills can help, as can viewing themselves as a linkrather than a primary resource of health information.

Arranging meetings between health educators and literacyorganizations to share resources is mutually beneficial and canalso help acquaint educators with local health resources.Literacy workers can learn how to incorporate health materialsinto their classrooms, while health care workers can learn howto reach low-literacy groups and can refer patients to adulteducation classes. Making health literacy curricula widelyaccessible and easy to use, accompanied by teaching workshopsthat orient and encourage instructors to implement newmaterials and which include pointers on how to link withhealth resources, may be a useful dissemination strategy.

Adult education is a context where meaningful learningoccurs among individuals at high risk for low health literacy. Itis an easily accessible, positive environment to not only provideinformation but to practice and reinforce skills. Best of all, it isa stable system that offers a sustainable point for interventionand which serves to contribute to a diverse approach to meetingthe health literacy needs of North Carolinians. NCMJ


ccording to a 2006 report by the Institute of Medicine ofthe National Academies, Preventing Medication Error,

approximately 1.5 million preventable adverse drug eventsoccur each year.1 Attention to the root causes of medicationerrors leading to adverse events has most often been attributedto the provider’s or health care system’s contributing role in errorsduring the prescribing, ordering, dispensing or administering ofa medicine.2,3 The reason attention was focused on those causesmay be that most studies investigating medication error havebeen conducted in inpatient hospitals or nursing homes.4

However, more than one-third of adverse drug events take placein outpatient settings at a cost approaching $1 billion annually.1

It has been estimated that a large proportion of outpatientmedication errors occur as a result of patients themselves notadministering a medicine as intended.3 For ambulatory care, thepatient, rather than the provider, is ultimately responsible forcorrectly administering a medicine as prescribed. Therefore, theprocesses of quality control and monitoring of medication errorshift from provider to patient.

The current body of evidence detailing the incidence andcauses of outpatient medication error is limited. Yet problemsare likely to intensify as patients increasingly self-manage greaternumbers of prescription and over-the-counter medications.Chronically ill patients and the elderly are at greatest risk forexperiencing medication errors as they take more prescription

drugs annually than younger and healthier patients, and visual/cognitive impairments by age may limit reading ease andcomprehension.5-9 The risk for miscommunication and errormay be further compounded since the average older adult seesseveral different health care providers annually.10

Health Literacy as aMedication SafetyConcern

Limited health literacy is another significant risk factor thatcould account for outpatient medication errors that are theresult of improper dosing administration. Numerous studieshave found low health literacy to be significantly associatedwith a poorer understanding of medication names, indications,and instructions.11-14 More recently, health literacy skills havebeen linked to requisite knowledge for adherence to treatmentregimens.15 This current and well-publicized body of researchhas focused on the ability of patients to read, understand, anddemonstrate instructions on drug container labels. The line ofinquiry has been supported by parallel work in human factorsresearch.5,6 Davis and colleagues conducted a multisite studyamong adults receiving primary care at community healthcenters and found a high prevalence of patients, especiallythose with limited literacy, misunderstanding seemingly simpledose instructions provided on the primary label of medication

containers.11 In this study, 46% of adultsmisunderstood at least one prescription containerlabel they encountered. The problem extends to theauxiliary sticker labels that provide accompanyingwarnings and instructions for use of the medicine.Another study demonstrated over half (53%) ofpatients, especially those with limited literacy, haddifficulty interpreting text and icons commonlyused on these auxiliary warning instructions.12

Beyond the container, drug labeling alsoincludes accompanying medication informationmaterials that provide indications for use and

Improving Prescription Drug Labeling

Michael S.Wolf, PhD,MPH; Stacy Cooper Bailey,MPH

COMMENTARY

Michael S.Wolf,PhD,MPH, is assistant professor ofmedicine and director of the Health Literacy and Learning Program at the Institutefor Healthcare Studies in the Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University. He can bereached at mswolf (at) northwestern.edu or 750 N Lake Shore Drive, 10th Floor, Chicago, IL 60611.

Stacy Cooper Bailey,MPH, is program manager of the Health Literacy and Learning Program in the Institute for Healthcare Studiesin the Division of General Internal Medicine, Feinberg School of Medicine,Northwestern University.

A

“...the manner in which thecurrent health care system

delivers necessary medicationinformation to patients is

clearly inadequate.”


further detailed precautions that can not fit on the container dueto space constraints. Studies have found that these materials, aswith the container label, are not useful for a majority ofpatients, particularly those with limited health literacy.16 Thisincludes consumer Medication Guides (aka Med Guides) that arerequired by the Food and Drug Administration to be dispensedalong with certain prescribed medicines that have been identifiedas having serious public health concerns. Patients with limitedhealth literacy were significantly less likely to attend to thesematerials. These findings are supported by earlier research studiesthat suggest consumer medication materials are too difficult formost patients to read.17 As a result, the patient informationleaflets and Med Guides that accompany many prescriptionmedications may be ignored.

A System Failure

The 2004 Institute of Medicine of the National Academiesreport on health literacy, A Prescription to End Confusion, aptlyidentified the problem of health literacy as encompassing morethan limitations in individual abilities.13 Rather, the complexityof demands placed upon the individual by the health caresystem must clearly be addressed. While patients must haveadequate cognitive capacity and proficiency to read, understand,and act on medication label instructions to ensure proper andsafe use, the manner in which the current health care systemdelivers necessary medication information to patients is clearlyinadequate. Physicians, who are legally responsible for deliveringimportant drug information directly to patients, frequently missopportunities to adequately counsel their patients on how toself-administer their medicines.19 Pharmacists, next in line tocounsel patients, also frequently fail to verbally communicatedetailed information to patients at the point of dispensingmedicines.20

In light of these failures, patients must depend more on theprint drug labeling materials (ie, the container label, consumermedication information, Med Guides, patient informationleaflets) that are challenging for patients across all health literacylevels.17,18 With the exception of Med Guides and a very limitedset of similar patient package inserts that are available for only aselect number of drugs, no national standards or regulations existfor the development and oversight of consumer medicationinformation or container drug labels. Informational leaflets areindustry-generated, and state laws minimally govern content andformat on prescription container vials. This all leads to what canbest be described as a fragmented system of patient information.

Taking Action

Improving the readability and understanding of instructionsand supplementary information for prescription drugs iswarranted as it may ultimately stimulate appropriate and safemedication use among patients. Evidence is available nowsupporting the design of better drug labeling.21 This includesconsiderations for both the container label and accompanyingmaterials. Based on recent health literacy studies and work by

the American College of Physicians Foundation (ACPF) onprescription drug labeling, certain general recommendationscan be issued that espouse the importance of promoting healthliteracy as a medication safety issue.22

First, seemingly simple dosage instructions printed on thecontainer label should be written in the most clear and concisemanner. Previous research has found that patients have moredifficulty understanding vague medication directions ascompared to more explicit ones.23,24 The less a patient isrequired to make inferences, the more easily medication schedulescan be comprehended (ie, “take every 6 hours” vs “take at 8am,2pm and 8pm”). This is especially important for more complexdosing schedules, where patients may become easily confusedor more prone to errors if instructions are read in haste.

Second, Shrank and colleagues examined the variability incontent and format on prescription drug container labels.25 Theyfound that pharmacies consistently emphasized provider-directedcontent versus information most pertinent to the patient.The useof bolding, highlighting, and larger font should be directed solelyto label content that is most salient to the patient. Informationsuch as prescription number or the pharmacy logo should bede-emphasized and segregated from dosage instructions,warnings, or indications so as to not detract from the mostimportant label content detailing its appropriate use. Everyeffort should be made to organize the container label in themost patient-friendly manner. It likely will be the most tangiblesource of drug information repeatedly used by patients.

Third, accompanying materials should abide by core principlesupheld by adult literacy practitioners.17,26 Consumer medicationinformation should keep to simple language and avoid medicaljargon. The scope of information should be limited andsummaries more frequently used to highlight actionablemessages. Shrank and colleagues further describe the type ofcontent that is desired by patients to support appropriate use.21

Surveys have shown that patients want to know, in addition todosage instructions, the indications for use of a prescribedmedicine, any precautions, and the duration of treatment.Information on the benefits and side effects of drugs is alsosought after by patients, and providing this information hasbeen found to improve adherence.20

Finally, steps should be taken to ensure that these separateelements of drug labeling, the container label and accompanyingmaterials, are developed together as an integrated andcomplimentary set of information sources. Patients should beincluded in this process so materials are appropriately organized,and they accurately reflect the common schemas imposed bypatients of all literacy levels when seeking to understand how touse prescribed medicines.

Conclusion

System change is urgently needed to promote health literacyfor greater medication safety. Patients must be able to easilyunderstand how to use prescription drugs correctly.Standardizing and integrating drug labeling must be a centralgoal to ensure that best practices are implemented because


REFERENCES

1 Aspden P, Wolcott J, Bootman L, Cronenwett LR, eds.Preventing Medication Errors. Washington DC: Institute ofMedicine of the National Academies; 2006.

2 Gandhi TK, Weingart SN, Borus J, et al. Adverse drug eventsin ambulatory care. N Engl J Med. 2003;348(16):1556-1564.

3 Gurwitz JH, Field TS, Harrold LR, et al. Incidence andpreventability of adverse drug events among older persons inthe ambulatory setting. JAMA. 2003;289(9):1107-1116.

4 Poon EG, Cina JL, Churchill W, Patel N, Featherstone E,Rothschild JM. Medication dispensing errors and potentialadverse drug events before and after implementing bar codetechnology in the pharmacy. Ann Intern Med. 2006;145(6):426-434.

5 Morrell RW, Park DC, Poon LW. Effects of labeling techniqueson memory and comprehension of prescription information inyoung and old adults. J Gerontol. 1990;45(4):166-172.

6 Morrell RW, Park DC, Poon LW. Quality of instruction onprescription drug labels: effects on memory and comprehensionin young and old adults. J Gerontol. 1989;29(3):345-353.

7 Cline CM, Bjorck-Linne AK, Israelsson BY, Willwnheimer RB,Erhardt LR. Non-compliance and knowledge of prescribedmedication in elderly patients with heart failure. Eur J HeartFail. 1999;1(2):145-149.

8 Moisan J, Gaudet M, Gregoire JP, Bouchard R. Non-compliancewith drug treatment and reading difficulties with regard toprescription labeling among seniors. J Gerontol. 2002;48(1):44-51.

9 Phillips DP, Christenfeld N, Glynn LM. Increase in USmedication-error deaths between 1983 and 1993. Lancet.1998;351(9103):643-644.

10 Medical Expenditure Panel Survey. 2003. Agency for HealthcareResearch and Quality, US Dept of Health and Human Services.http://www.meps.ahrq.gov. Accessed January 3, 2007.

11 Davis TC, Wolf MS, Bass PF, Tilson H, Neuberger M, ParkerRM. Literacy and misunderstanding of prescription drug labels.Ann Intern Med. 2006;145(12):887-894.

12 Davis TC, Wolf MS, Bass PF, et al. Low literacy impairscomprehension of prescription drug warning labels. J GenIntern Med. 2006;21(8):847-851.

13 Nielsen-Bohlman L, Panzer A, Kindig DA, eds. Health Literacy:A Prescription to End Confusion. Washington, DC: Institute ofMedicine of the National Academies; 2004.

14 Wolf MS, Davis TC, Arozullah A, Penn R, Arnold C, BennettCL. Relationship between literacy and HIV treatmentknowledge among individuals enrolled in HAART regimens.AIDS Care. 2005;17(7):863-873.

15 Wolf MS, Davis TC, Cross JT, Marin E, Green KM, BennettCL. Health literacy and patient knowledge in a Southern U.S.HIV clinic. Int J STD AIDS. 2004;15(11):747-752.

16 Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, RaskK. Factors associated with medication refill adherence incardiovascular-related diseases: a focus on health literacy. J GenIntern Med. 2006;21(12):1215-1221.

17 Wolf MS, Davis TC, Shrank W, Neuberger M, Parker RM. Acritical review of FDA-approved Medication Guides. Pat EducCounsel. 2006;62(3):316-322.

18 Gustafsson J, Kalvemark S, Nilsson G, et al. Patientinformation leaflets: patients’ comprehension of informationabout interactions and contraindications. Pharm World Sci.2005;27(1):35-40.

19 Tarn DM, Heritage J, Paterniti DA, Hays RD, Kravitz RL,Wenger NS. Physician communication when prescribing newmedications. Arch Intern Med. 2006;166(17):1855-1862.

20 Morris LA, Tabak ER, Gondel K. Counseling patients aboutprescribed medications: 12-year trend. Med Care.1997;35(10):996-1007.

21 Shrank W, Avorn J, Rolon C, Shekelle P. Effect of content andformat of prescription drug labels on readability, understanding,and medication use: a systematic review. Ann Pharmacother.2007;41(5):783-801.

22 Wolf MS. Prescription medication labeling in the UnitedStates: can we confuse patients less? Paper presented at:American College of Physicians Foundation National HealthCommunication Conference; November 29, 2006;Washington, DC.

23 Swanson JM, Forrest K, Ledbetter C, et al. Readability ofcommercial and generic contraceptive instructions. Image JNurs Sch. 1990;22(2):96-100.

24 Ngoh LN, Shepherd MD. Design, development, andevaluation of visual aids for communicating prescription druginstructions to nonliterate patients in rural Cameroon. PatientEduc Couns. 1997;30(3):257-270.

25 Shrank WH, Agnew-Blais J, Choudhry N, et al. The variabilityand poor quality of medication container labels: a prescriptionfor confusion. Arch Intern Med. In press, 2007.

26 Doak CC, Doak LG, Root JH. Teaching Patients with LowLiteracy Skills. 2nd ed. Philadelphia, PA: Lippincott; 1996.


evidence is already available to target improvements. Thisshould be viewed as a short-term goal for policymakers, andsome states have already made progress to this end.

In the long term, additional challenges for drug labelinginclude efforts to seek labeling concordance in other languagesbecause not all prescription drug information and instructionsare currently available to non-English speakers. A formativeresponse to labeling problems would also extend to addressinghow health care providers communicate to patients the

information that is necessary to safely administer prescribedmedicines. More broadly, health technology used by an increasingnumber of providers at the point of writing the prescriptionshould be integrated with the software used by dispensingpharmacies to fill it and print out the labeling components.This would provide another layer of quality assurance thatcould minimize variability and the risk that instructionsbecome lost in translation. NCMJ

edications are often the most effective treatment alternativefor chronic diseases. Because most of the 3 billion

prescription medications are self-administered by patients intheir homes, appropriate use of medications requires carefulinstruction tailored to a patient’s level of health literacy andcomprehension. Unfortunately, many patients are not gettingsuch instruction, which increases their risk of treatment failureor otherwise preventable adverse medication events. There aremany reasons for this lack of instruction.However, the primary reason is that healthprofessionals lack sufficient time to communicateneeded instruction, and they are driven by theinertia of existing practice behaviors to the extentthat inadequate instruction of patients is largelyignored. Patients also have time constraints, andthey expect their prescriptions to be filled quicklyso they can dash to the next thing on their list.While pharmacists are legally bound to offermedication counseling to patients, little counselingis actually provided in most pharmacies. However,the general void in medication counselingpresents an important opportunity for pharmacists to play agreater role in patient care by reinforcing physician-to-patientmedication instructions and improving the effectiveness andsafety of self-administered medications. This commentaryreviews salient factors and recent research involving medicationinstruction by pharmacists.

Risks of InadequateMedication Instruction

Insufficient medication information carries a risk of harm tothe patient. This, in itself, must be considered as an impetus forbetter medication instruction. Patients who lack adequateinformation about their medications are more likely to experiencetreatment failures due to poor adherence, medication errors,and adverse events. Gandhi and colleagues1 conducted a

prospective cohort study of 661 outpatients responding to asurvey to determine the rates, severity, and preventability ofadverse drug events. Of the 661 participants, 25% (162)experienced adverse drug events of which 13% were seriousand 39% could have been made less severe or entirely prevented.Physician-patient communication about new somatic complaintswas a major factor in mitigating or preventing many of theseadverse events.

The results of the study by Gandhi et al are consistent witha study of spontaneous reports of medication errors occurring inthe home that were submitted to the United States Pharmacopeia’sMedMarx and Medication Errors Reporting programs.2 Of the802 reports submitted, 11% (87) were classified as severe andresulted in permanent harm in 3 cases, a life-threatening situationin 4 cases, and death in another 4 cases. The most frequent causesof the 802 errors were performance deficit in 34% (246), poorcommunication in 21% (151), knowledge deficit in 19%(135), and not appropriately following a medication-relatedprocedure or protocol in 13% (91). These results reinforce theimportance of good communication involving in-homeadministration of medications and remind us of the potentiallycatastrophic results of not providing sufficient education aboutmedications and not monitoring their use.

“While pharmacists are legallybound to offer medicationcounseling to patients, little

counseling is actually providedin most pharmacies.”

Michael D.Murray,PharmD,MPH, is a Mescal S. Ferguson Distinguished Professor and chair of Pharmaceutical Outcomes & Policy atthe University of North Carolina at Chapel Hill. He can be reached at mick (at) unc.edu or CB #7360 Kerr Hall, Chapel Hill, NC 27599.

COMMENTARY

Medication Instruction by Pharmacists:Making Good on an Offer

Michael D.Murray, PharmD,MPH


M


North Carolina State Counseling Rule

Pharmacists are required to offer, as opposed to actuallyprovide, medication counseling.

Patient Counseling shall mean the effective communicationof information, as defined in this Rule, to the patient orrepresentative in order to improve therapeutic outcomes bymaximizing proper use of prescription medications,devices, and medical equipment. An offer to counsel shallbe made on new or transfer prescriptions at the time theprescription is dispensed or delivered to the patient orrepresentative.3

While the offer to counsel may be made by nonpharmacistpersonnel, the counseling must be conducted by a pharmacist.The reality is that the amount of time spent by pharmacists (orothers) providing medication instruction or counseling isminimal.

Lack of Time

Physicians often provide to each patient a brief overview ofthe rationale and directions for each medication they prescribe.However, their time is limited due to the many other importantmatters that must be addressed during a visit including a reviewof the objective findings from the physical examination, adescription of the rationale for laboratory tests, interpretationof the results of previous laboratory tests, an outline of the nextsteps in the patient’s care, and consideration of new somaticcomplaints. Bodenheimer termed this a “tyranny of the urgent”whereby constant attention to acute needs leaves little time formatters pertinent to the patient’s chronic care planning.4 Giventhat the typical visit with the physician is approximately 15minutes (with multiple interruptions), time and attention arebarriers to more comprehensive medication instruction byphysicians.

Pharmacists are also pressed for time. The legal requirementto offer medication counseling prompts an all too familiar nearmonologue from a pharmacy assistant to the patient: “Do youhave any questions for the pharmacist? Please sign here. That’llbe $58.25 for today’s medications. Thank you.” An offer tocounsel made—check; legal requirements satisfied—check;business requirements satisfied—check; written informationabout the prescribed medications included on the bag containingthe medications—check; patient appropriately instructed onmedications—likely not.

Patients are also sometimes impatient when it comes totimely filling of their prescriptions and getting out the door of thepharmacy. Ironically, for many patients, their lack of adequatemedication counseling is often because they are too rushed.Additionally, pharmacies are confusing places. Patients who gettheir prescriptions filled at busy pharmacies often do not knowwhich person—among several wearing a white coat behind thecounter—is the pharmacist. Furthermore, the lack of a privatearea for counseling in many pharmacies is also an important

barrier to comprehensive instruction and communication.

Recent Studies

Recent studies suggest that spending more time with patientsat the pharmacy translates into important improvements intheir health status and in cost reductions. In North Carolina,the success of the Asheville Project has resulted in its imitationthroughout the country. The project was a prospective cohortstudy of workers from 2 large employers in Asheville, MissionHealth and Hospitals and the City of Asheville, who wereserviced by 12 pharmacies. The clinical protocol promotedintense self-care education, financial incentives to participantssuch as free medication copayments, and frequent follow-up bypharmacists and nurses. Specially trained pharmacists scheduledfree personal consultations to provide medication education,encourage adherence to the doctor’s prescription, and providetreatment monitoring. For example, pharmacists trainedpatients on the use of home glucose monitors (for patients withdiabetes) and measured peak flow (for patients with asthma).Patients were referred to physicians as needed.

Results of studies involving patients with diabetes5 andasthma6 indicated favorable changes. Patients with diabetes(n=85) had lower values of hemoglobin A1c over 7 to 9 months.While the costs of diabetes-specific services and medicationswere increased, the total costs considering all diagnoses werelower after implementation of the program. Furthermore,participants were quite satisfied with the program.5 Recentresults involving 207 Asheville Project participants with asthma(n=207) followed for up to 5 years suggested reductions inemergency department visits, hospital admissions, and totalhealth care costs of approximately $2000 per year.6 While theseresults are generally encouraging and have been embraced bythe broad pharmacy community, they must be considered inlight of limitations such as participant loss to follow-up andmissing data.

We recently reported a randomized controlled trial involving314 low-income participants with heart failure.7The interventioninvolved a pharmacist who had access to patient-centeredmaterials aimed at persons with low health literacy. We wereparticularly interested in whether more pharmacist time spentinstructing patients would lead to improved medicationadherence, which in turn could result in decreases in expensivehealth care utilization and associated costs.To measure adherenceto cardiovascular medications for heart failure, we used a specialprescription lid that contained a battery and computer chipthat recorded the time and date when the medication bottlewas opened and closed. Compared to the 192 participantsassigned to the usual care group, the 112 participants in theintervention group took more of their medications with lessday-to-day variability in the timing of their medication dosing.Intervention participants had fewer emergency department visitsor hospital admissions and approximately $3000 lower totaldirect annual health care costs. Study participants in theintervention group were satisfied with the information providedby the pharmacist and preferred the patient-centered materials

REFERENCES

1 Gandhi TK, Weingart SN, Borus J, et al. Adverse drug eventsin ambulatory care. N Engl J Med. 2003;348(16):1556-1564.

2 Camp SC, Hicks R. Examination of Medication ErrorsOccurring in the Patient’s Home Reported to USP’s MedicationError Reporting Programs. Rockville, MD: US Pharmacopeia.http://www.usp.org/hqi/patientSafety/resources/posters/posterPatientHome.html. Accessed August 26, 2007.

3 North Carolina Board of Pharmacy; Pharmacy Rules. 21NCAC 46.2504 Patient Counseling.http://www.ncbop.org/LawsRules/rules.2500.pdf. AccessedAugust 26, 2007.

4 Bodenheimer T, Wagner EH, Grumbach K. Improving primarycare for patients with chronic illness. JAMA.2002;288(14):1775-1779.

5 Cranor CW, Christensen DB. The Asheville Project: short-termoutcomes of a community pharmacy diabetes care program.J Am Pharm Assoc. 2003;43(2):149-159.

6 Bunting BA, Cranor CW. The Asheville Project: long-termclinical, humanistic, and economic outcomes of a community-based medication therapy management program for asthma.J Am Pharm Assoc. 2006;46(2):133-147.

7 Murray MD, Young J, Hoke S, et al. Pharmacist interventionto improve medication adherence in heart failure: a randomizedtrial. Ann Intern Med. 2007;146(10):714-725.

8 Morrow DG, Weiner M, Steinley D, et al. Patients’ healthliteracy and experience with instructions: influence preferencesfor heart failure medication instructions. J Aging Health.2007;19(4):575-593.

compared to the densely written medication information thatis provided by most pharmacies.8 In summary, we found thataddressing the heterogeneity in health literacy among patients isimportant: The one size fits all written medication informationfor patients is not appropriate for many patients, at least notwithout sufficient accompanying verbal instruction.

ImprovingMedication Instruction andImplementation

Pharmacy practice is undergoing a transformation that willfavorably influence medication instruction for patients. Theforces of change surrounding this transformation include thewidespread recognition that patients:

� Need more information about the potent drugs they areprescribed.

� Have more prescriptions filled than ever before.� Are serviced with faster, more sophisticated automation

and information systems.� Have access to pharmacists and pharmacy technicians

who are serving broader roles.

Implementation of any successful program to improvemedication instruction for patients will require more time andindividualized service from pharmacists. While time-consuming,pharmacists should consider a teach-back method for making

sure the patient can understand and explain instructions in theterms he or she comprehends.

In any profession or business, more time means moremoney. If the returns on investment of the aforementionedstudies are generalizable to broader health care settings, then itwould be more feasible to consider greater remuneration forcognitive services by pharmacists. Indeed, several NorthCarolina pharmacies have taken progressive steps to engage itspharmacists in nondispensing aspects of pharmaceutical care,have reconfigured many of their dispensing areas to includespace for private counseling, and have successfully receivedremuneration for nondispensing services. However, increasingcognitive services by pharmacists in the setting of increasedcompetition for the health care dollar will more likely require atransfer of some pharmacist dispensing activities to highlytrained technicians. For example, shifting the role of pharmacistwork functions (dispensing, checking, adjudicating insuranceclaims, etc) to the pharmacy technician could allow more timefor pharmacist counseling and other cognitive services. Such aredistribution of pharmacy workload between pharmacists andtechnicians would clearly require revision of the Board ofPharmacy’s pharmacy practice rules. Notwithstanding anydirect action by the Board on the medication counseling rule,the near hope would be that pharmacists will take it uponthemselves to make a more concerted effort to provide medicationcounseling to willing patients rather than simply making anoffer to do so. NCMJ


ffective communication among professionals, patients,and communities is a significant public health concern.

With up to one-third of individuals in some health care settingsstruggling with limited understanding of health issues andinstructions, health literacy has emerged as an important causeof health disparities and a significant public health issue.1

Effective communication to bring about behavior change requiresa focus on both communities and individuals. From a publichealth perspective, communication must capture the collectivenature of community health while recognizing individual healthliteracy issues. Successful communication within communitiesrequires community involvement, the use of nontraditionalapproaches, and a focus on social norms. In this commentarywe discuss specific public health approaches to working incommunities with low levels of health literacy and the use ofthe social marketing process to develop an array of interventionsthat can impact all the determinants of a health problem in apopulation.

The best strategy to increase effective communication andimprove health knowledge and skills is to increase health literacylevels overall. This requires significant time and resources. Inthe interim, the emphasis must be on working within existinglevels of health literacy to develop more effective prevention andself-management of acute and chronic illness. Best practices inthe medical setting have been described throughout this issue ofthe North Carolina Medical Journal. In the public health setting,promising community practices include the use of lay healthadvisors and engagement of important community institutions.

Lay Health Advisors as Community ChangeAgents

Since many causes of racial disparities have strong socialetiologies, the use of lay health advisors has emerged as a focusof many interventions, particularly those in racial and ethnicminority communities. Lay health advisor projects seek to

identify and recruit “natural helpers” in a community and providetraining and support for them to advise and assist their neighborsand peers with a variety of health issues. Lay health advisor modelsenhance empowerment and capacity building by promoting andsupporting individuals who assume responsibility for communityimprovement, seek new knowledge and skills, and activelyengage and recruit others. Lay health advisor programs havedemonstrated changes in the attitudes of community membersabout their control over health issues and their willingness toconsider behavioral changes.2,3

A number of lay health advisor and other natural helperprograms have been implemented in communities acrossNorth Carolina. The NC Office of Minority Health andHealth Disparities’ Community Health Ambassador Programworks with faith and community-based organizations across thestate to train trusted leaders and community volunteers to improvecommunication about access to care and self-management for

Increasing the Public’s Awareness:The Importance of Patient-Practitioner Communication

Marcus Plescia,MD,MPH;Mike Newton-Ward,MSW,MPH

COMMENTARY

MarcusPlescia,MD,MPH, is chief of the Chronic Disease and Injury Section of theDivision of Public Health,North CarolinaDepartmentof Health and Human Services.He can be reached at Marcus.Plescia (at) ncmail.net or1915 Mail Service Center, Raleigh,NC 27699.

Mike Newton-Ward,MSW,MPH, is a social marketing consultant in the Chronic Disease and Injury Section of the Division of PublicHealth,North Carolina Department of Health and Human Services.

E

“From a publichealth perspective,

communication mustcapture the collectivenature of community

health while recognizingindividual healthliteracy issues.”


diabetes and cancer prevention. Over the last 7 years, theCharlotte REACH 2010 project has maintained a cohort of 15to 20 lay health advisors who focus on diabetes and heartdisease among African Americans in the Northwest Corridorneighborhoods of Charlotte.4 Lay health advisors serve as aneffective source for health communication by acting as peer rolemodels, increasing community capacity, and forming newsocial support networks.

Community Settings to Promote HealthBehavior Change

The medical setting is a good venue for health-relatedcommunications. Health care professionals are credible, highlyrespected, and expected to provide advice and instruction onhealth issues. However, other community settings are equallyvaluable, particularly in communities with low health literacylevels.The faith community plays a central role in many culturesand is an important source of social capital and influence. Inmany communities, priests and ministers are highly influentialand have been effective communicators about important publichealth issues.5 Many interventions in the African-Americancommunity have focused on the faith setting because the churchis such an important source of social support and communityleadership, especially among older women.

Numerous programs in North Carolina have engaged the faithcommunity in effective health communication. Some of thesehave been highly effective. For example, the BlackChurchesUnitedfor Better Health project showed a significant improvement indaily servings of fruits and vegetables following a multicomponent,multichurch intervention in 10 rural counties.6 Project Direct, amultiyear diabetes demonstration project in southeast Raleigh, hascollaborated with multiple faith-based projects in North Carolinato create a manual for health communication in the faith setting.7

A Social Marketing Approach to HealthCommunication

The social marketing approach was first introduced in 1971 asa way to apply commercial marketing principles to improve socialissues. It has been applied to a range of health, environmental, andsocial issues including breastfeeding, family planning, and tobaccocontrol. The social marketing process provides a powerful toolto improve health and well-being at the population level. Itoffers a logical framework to link multiple interventions suchas those described above. Behavior change at the communitylevel requires more than increased knowledge and awareness,and individuals and populations frequently encounter barriersto engaging in desired behaviors. A consensus conference ofbehavioral scientists, sponsored by the National Institutes ofMental Health, identified a variety of external and internaldeterminants of health behavior ranging from access, policy,and cultural beliefs, to knowledge, perceived consequences,and self-efficacy.8 A social marketing approach augmentscommunication efforts by identifying and addressing thesedeterminants.

Social marketing is an evidence-based approach. Commercialmarketing research and planning processes are used to identifyall the determinants of a given behavior in a target audienceand then implement interventions that lower barriers orincrease facilitators for the desired behavior. Social marketing ischaracterized by an emphasis on voluntary behavior changeand attention to the costs and benefits of engaging in a behavior.A variety of interventions are customized for specific audiencesbased on an understanding of the target audience. The ultimategoal is to make a behavior “fun, easy and popular.”9 Such anapproach targets 3 important determinants of behavior: (1)rewards and consequences; (2) adequate skills and knowledge;and (3) impact of family, friends, and culture. Social marketingemploys the same intervention strategies as commercialmarketing: product, price, place, and promotion—referred toas the “marketing mix.” Product strategies include any tangibleservices or items that make the behavior easier and emphasizebenefits that are meaningful to the audience. Price interventionsinclude activities, outreach, policy changes, or messages thatdecrease barriers to the targeted behavior. Place strategiesinclude offering times and locations that are convenient oroccur where and when the audience is likely to be thinkingabout the issue. Promotion strategies are intended to persuadeor inform. These include public service announcements, newsstories, media advocacy, and word of mouth.

To illustrate how the social marketing process can integratemultiple communication strategies to impact a health problem,consider how a traditional media campaign could be enhancedwith other intervention activities. The Lost in Translationcampaign uses television public service announcements to raiseawareness among African Americans about the role hypertensionplays as a risk factor for heart disease and stroke. To augmentthe public service announcements, the campaign developedbrochures and revised its Web site to include a section withconsumer information on reducing heart attack and strokerisks. The campaign addresses two barriers to action identifiedin research with the target audience: lack of knowledge of one’sblood pressure numbers and lack of awareness of the connectionbetween high blood pressure and stroke.

A social marketing approach would expand this campaignbeyond increased knowledge and awareness—to health promotioninterventions. A social marketing approach might augment thepublic service announcements with a product interventionsuch as supplying free or low cost blood pressure cuffs andtraining family members how to use them. Place promotionswould expand interventions beyond the medical practice settingto churches; community centers, and African-American ownedbusinesses. Price interventions would address access and culturalbarriers and could include using lay health advisors, parish nurses,or formal and informal community leaders. A price interventionmight also include role playing how to ask questions of a medialprovider to overcome possible social norms about questioningauthority figures.

Social marketing combines the knowledge of the publichealth practitioner with the experiences of the community tocreate a unique mix of services, outreach, messages, policy


change, and tangible products that make the behavior easier,more rewarding, and more acceptable. In populations with lowlevels of health literacy, the social marketing approach includesspecific interventions to increase effective communication.These

include lay health advisors or other trusted agents and outreachin important community institutions such as faith-basedsettings. NCMJ

REFERENCES

1 Williams MV, Parker RM, Baker DW. Inadequate functionalhealth literacy among patients at two public hospitals. JAMA.1995;274(21):1677-1682.

2 Eng E, Parker E. Natural helper models to enhance acommunity’s health and competence. In: DiClemente RJ,Crosby RA, Kegler MC, eds. Emerging Theories in HealthPromotion Practice and Research: Strategies for Improving PublicHealth. San Francisco, CA: Jossey-Bass; 2002:101-126.

3 Carlson BA, Neal D, Magwood G, et al. A community-basedparticipatory health information needs assessment to helpeliminate diabetes information disparities. Health PromotionPractice. 2006;7(3S):213-222.

4 Plescia M, Groblewski M, Chavis L. A lay health advisorprogram to promote community capacity and change. HealthPromotion Practice. Prepublished November 14, 2006.doi:10.1177/1524839906289670.

5 Vorhees C, Stillman FA, Swark RT, et al. Heart, body, and soul:impact of church-based smoking cessation interventions onreadiness to quit. Preventive Medicine. 1996;25:277-285.

6 Campbell M, Demark-Wahnefried W, Symons M, et al. Fruitand vegetable consumption and prevention of cancer: the BlackChurches United for Better Health Project. Am J Public Health.1999;89(9):1390-1396.

7 Hatch JW, Reid LV, Parrish T, Hoyo C. Promoting HealthyBehaviors in African-American Faith Communities: The ProjectDIRECT Experience. http://www.ncdiabetes.org/ProjectDirect/ManualsAndPublications/CHATCHAP.pdf. Accessed August27, 2007.

8 Fishbein M, Triandis HC, Kanfer FH, Becker M, MiddlestadtSE, Eichler A. Factors influencing behavior and behaviorchange. In: Baum A, Revenson TA, Singer JE, eds. Handbook ofHealth Psychology. Mahwah, NJ: Lawrence Erlbaum Associates;2001:1-7.

9 Smith W. Social marketing with no budget. Social MarketingQuarterly. 1999;2:6-11.

www.fiavolunteers.org


ave you ever thought just a wee little bit, of how itwould seem to be a misfit; and how you would feel

if you had to sit on the other side of the desk.”1 This is the firststanza of a poem entitled The Other Side of the Desk, a copy ofwhich I secured many years ago. While I don’t know the authoror the origin of this poem, its message is not unlike how mydad would describe his approach to medicine. As a generalpractitioner in Pennsylvania, Florida, and then North Carolinafor over 50 years, he spoke of 3 keys to treating patients—gathering a solid medical history, conducting a thorough physical,and putting yourself in the other person’s shoes. Although hedid not have as much specialized education and training as

some of his colleagues; at his funeral service this past June bothformer patients and fellow physicians shared their high regardfor his medical practice. The thing that made his practice sogood was that it was based on effective communication.

When I became administrator of the state’s second largestnursing facility in the late 1980s, I tried to heed my dad’sadvice. I actually taped The Other Side of the Desk to my desk’s

pull-out extension so I would have a constant reminder of howimportant effective communication is in any situation andespecially in long-term care where there can be many barriers.Still, I sadly recall too many situations where we provided lessthan ideal care to patients and less than adequate support tofamilies largely because we failed as communicators. Here is apartial list of issues that can interfere with the exchange andunderstanding of information in all long-term care settings:

� Functional illiteracy is a reality for many of our state’sresidents of all ages. It can be particularly troublesome whenpeople become vulnerable due to compromised health andsocial isolation. According to the Centers for Medicare andMedicaid Services Active Resident Information Report forthe first quarter of 2007, more than one-fourth of NorthCarolina’s nursing home residents have obtained no morethan an eighth grade education.2 While we should be carefulin linking schooling to functional literacy, it may still be anindicator of risk for effective communication. A recentlyreleased article in the Archives of Internal Medicine madenational news with the finding that medically illiterate olderpatients were 50% more likely to die within the 6 years ofthe study than patients who understood basic written medicalinformation and instructions about such conditions as asthma,diabetes, and heart disease.3

� Dementia itself denotes a cognitive impairment associatedwith a broad set of symptoms such as memory loss, confusion,compromised judgment, and, sometimes, personality changesor unusual behavior. Alzheimer’s disease is the most commoncause of dementia, affecting 1 in 10 people over age 65 yearsand nearly half of those over age 85 years.4 More than one-half(57%) of North Carolina’s nursing home residents have adementia diagnosis, including about 20% diagnosed withAlzheimer’s disease.5 Struggling with depression or anxietyand other mental health issues can compound the effect ofdementia and present significant communication challengesin their own right. Nearly one-half (46%) of nursing facilityresidents are diagnosed as depressed.6

Effective Practitioner-Patient Communication inLong-Term Care

DennisW. Streets,MPH,MAT, LNHA

COMMENTARY

Dennis W. Streets, MPH, MAT, LNHA, is director of the Division of Aging and Adult Services in the North Carolina Department ofHealth and Human Services.He can be reached at dennis.streets (at) ncmail.net or 2101 Mail Service Center, Raleigh,NC 27699-2101.

“H

“There is no well-keptsecret to effective

practitioner-patientcommunication in

long-term care; rather, itinvolves the routine

application of practicesthat are well known.”


� Even patients with well-functioning cognitive skills can findthemselves at high risk of exclusion from care decisions andpossible mistreatment due to sensory losses, especially sightand hearing. As reported in our 2007-2011 State Aging ServicesPlan, more than 1 in 4 North Carolinians age 75 years andolder have severe visual and/or hearing impairment.7 Aboutone-quarter of North Carolina’s nursing home residents arehearing impaired and nearly half are visually impaired.

� The high turnover rate among both professional andparaprofessional direct care workers creates higher risk formistakes and an atmosphere of instability and unfamiliarityfor workers and care recipients alike. In 2005 averageturnover rates for direct-care staff were 116% in nursingfacilities, 111% in adult care homes, and 46% among homecare agencies.7

� The increasing presence of workers and patients for whomEnglish is their second language can further aggravate otherexisting communication barriers. While a caring attitudecan help overcome this barrier, a linguistic disconnect cannonetheless jeopardize quality of care. Beyond language,there are many other cultural differences associated withincreasing racial and ethnic diversity. We cannot allowdiversity to contribute to disparity in health care.

� With long-term care patients, physicians can find themselvesespecially dependent on how well other professionals conveyand act upon information. Most often responding offsite torequests from multiple caregivers such as long-term carenurses, social workers, and pharmacists, the physician musttrust that information is shared accurately through multiplesources and acted upon appropriately. The complexity ofhealth care and health insurance only makes matters morerisky for providers and patients in long-term care.

The importance of health literacy vis-à-vis long-term carewill surely increase as North Carolina’s population ages. Already28 of our counties have more people age 60 years and olderthan 17 and younger—it is projected that seniors will outnumberyoung people in 75 counties by 2030.7 Those working in thehealth and long-term care sector will be especially challengedwith meeting the needs and demands of an aging population.The increasing interest in consumer-directed care is just oneexample of the changing landscape in the provision of servicesas more boomers join the ranks of those needing long-term carefor themselves or their parents.

In this commentary, I focused more on residents of nursingfacilities because descriptive data are generally more available onthis population than those receiving services and supports in othersettings. I want to emphasize, though, that the issues are certainlyno less important—and in some ways more important—for thosein assisted living or receiving home and community care wherethere is not likely to be around-the-clock professional assistance.

So the practitioner is left with many challenges—most, ifnot all, of which are well-known and experienced daily. Thequestion, then, is how to respond in providing the best possiblecare for consumers of long-term services and supports in all

settings. I propose 5 basic elements representing the fingers ofa hand extended to assist the most vulnerable:

(1)Don’t assume—take time to know the person. I recall anotherpoem among my collections that many senior groups haveappreciated. The key message is captured in the followingverses: “You tell me that I’m getting old; I tell you that’s notso. The ‘house’ I live in is worn out, and that, of course, Iknow…You only see the outside, which is all that most folkssee. You tell me that I am getting old? You’ve mixed my‘house’ with me.”8

(2)Show empathy for vulnerability and dependency. The idea ofputting yourself on the other side of the desk or bed shouldbe a guiding principle. People with compromised healthconditions and living environments should not have to alsoforego the patience and respect of others. Rather we shouldencourage and facilitate their participation in decisionswhenever possible.

(3)Recognize and appreciate the family caregiver.TheNorthCarolinaInstitute of Medicine’s 2001 Task Force on Long-Term Careacknowledged that most long-term care is provided informallyby family and friends.9 In 2006, nearly one-quarter (24%) ofadults in North Carolina reported providing regular care orassistance to a family member or friend.10 Family caregivers area vital conduit in the communications between patients andproviders.

(4)Encourage and support effective communication. We need topractice what we know: give information in as simpleand straightforward a manner as possible; give importantinformation verbally and in writing; don’t assumeunderstanding—use the “teach back” method and ask questionsto confirm it; be a good, reflective listener—“Now, Mrs.Jones, from what you have told me, you are mainly concernedabout ....”

(5)Follow up. For patients receiving long-term care in anysetting, there is no substitute for following up on interactionswith and for those patients to assure understanding andimplementation of care plans, address patient confusion andanxiety, and identify and respond to any other issues.Effective relationships with facility staff are essential as is anunderstanding of the so-called aging and adult servicesnetwork (eg, councils and departments on aging, seniorcenters, and county departments of social services) thatassists the majority of those still living in the communitywho need long-term services and supports.

There is no well-kept secret to effective practitioner-patientcommunication in long-term care; rather, it involves theroutine application of practices that are well known. Whilecommunication becomes more critical and yet more difficultwith patients receiving long-term services and supports becauseof the many barriers, the practitioner’s goal must remain toextend a caring hand to the most vulnerable who face chronicdiseases, disabilities, losses, and end-of life decisions. NCMJ


Acknowledgements: Heather D. Burkhardt, MSW, planningand evaluator team leader, and Sharon C. Wilder, state long-termcare ombudsman, both of the NC Department of Health and

Human Services Division of Aging and Adult Services, contributedto this article.


REFERENCES

1 “The Other Side of the Desk.” Illinois Department of HumanServices. http://www.dhs.state.il.us/ts/FamilySupportServices/Kaleidoscope07.asp. Accessed August 1, 2007.

2 Centers for Medicare & Medicaid Services, US Department ofHealth & Human Services. MDS active resident informationreport: first quarter 2007. http://www.cms.hhs.gov. Published2007. Accessed August 1, 2007.

3 Baker DW, Wolf MS, Feinglass J, Thompson JA, GazmararianJA, Huang J. Health literacy and mortality among elderlypersons. Arch Intern Med. 2007;167(14):1503-1509.

4 Division of Aging and Adult Services, North CarolinaDepartment of Health and Human Services. What isAlzheimer’s disease? http://www.ncdhhs.gov/aging/ad/AD_Related_Dementias_Brochure.pdf. Published 2007.

5 Centers for Medicare & Medicaid Services, US Department ofHealth & Human Services. MDS active resident informationreport: first quarter 2007. http://www.cms.hhs.gov. Published2007. Accessed August 1, 2007.

6 Centers for Medicare & Medicaid Services, US Department ofHealth & Human Services. MDS active resident informationreport. http://www.cms.hhs.gov. Published 2007. AccessedAugust 1, 2007.

7 Division of Aging and Adult Services, North CarolinaDepartment of Health and Human Services. North CarolinaAging Services Plan 2007-2011: Putting the Pieces Together.http://www.dhhs.state.nc.us/aging/stplan/NC_Aging_Services_Plan_2007.pdf. Published March 2007. Accessed August 1, 2007.

8 Johnson, Dora. Quoted by Ezra Marler, comp. Golden Nuggetsof Thought: Vol. III. Salt Lake City, UT: Bookcraft; 1958.

9 North Carolina Institute of Medicine. A Long-Term Care Planfor North Carolina: Final Report. Published 2001.http://www.nciom.org/pubs/long-term.html. Accessed August1, 2007.

10 North Carolina State Center for Health Statistics. 2007.http://www.schs.state.nc.us/SCHS/brfss/2006/nc/all/nc15q01.html. Accessed August 1, 2007.

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s part of its 2003 Clinical Performance ImprovementStrategic Plan, Iowa Health System incorporated health

literacy as a cross-cutting, system-wide quality initiative.1,2

With 10 senior hospital affiliates in 7 cities, a 14 rural hospitalnetwork, and 430 primary care physicians, Iowa Health Systemprovides health care for a third of Iowans. Health literacy teamshave been established at hospital affiliates, outpatient clinics,and home health agencies using the Model for Improvement,3

learning sessions, conference calls, training workshops, andelectronic communication to test and implement a variety ofhealth literacy interventions. Iowa Health System’s overarchinghealth literacy goals are targeted toward improving interpersonaland written communication and creating a patient-centered careenvironment that welcomes questions and encourages dialogue.

Teams chose to improve consent documents and processesas part of their goals to improve patient understanding throughplain language, teach back, and reader-friendly print materials.This was predicated on the increasing prominence of healthliteracy as a health care quality and safety priority; on case lawinvolving communication of risks wherein claims have involveda lack of informed consent; and on concern that consent formsare written in language that patients cannot understand. Belowwe describe our rationale, experience, and lessons learned.

Building the Case

Health Literacy as a Quality and Safety PriorityRecognizing and communicating that a diverse set of leading

health care organizations identify improving patient understandingduring the informed consent process as an important qualityand patient safety strategy helps garner support among physicians,staff, and organizational leaders.

The National Quality Forum (NQF) published Safe Practicesfor Better Healthcare4 in 2003. Updated in 2006,5 the reportpresents evidence-based practices that should be used universallyto reduce the risk of harm in the health care setting. SafePractice 2 (originally Safe Practice 10) states: “Ask each patient

or legal surrogate to ‘teach back’ in his or her own words keyinformation about the proposed treatments or procedures forwhich he or she is being asked to provide informed consent.”Additional guidance is provided about teach back; reading leveland language for consent documents; engaging in a dialogueabout the procedure for which consent is being sought; and use

of qualified medical interpreters or readers to assist those withlimited English proficiency or health literacy, or visual or hearingimpairments. Safe Practice 2 is relevant to practitioners in multipleclinical areas and to patient-centered care, especially for thosewho are particularly vulnerable to medical errors associatedwith communication barriers, including low health literacy.

“Iowa Health System’soverarching health

literacy goals are targetedtoward improvinginterpersonal and

written communicationand creating a

patient-centered careenvironment that

welcomes questions andencourages dialogue.”


Mary Ann Abrams,MD,MPH, is a health management consultant in the Clinical Performance Improvement Department at the IowaHealth System. She can be reached at abramsma (at) ihs.org or 1200 Pleasant Street,Des Moines, IA 50309.

Barb Earles,RN,MHA,CPHRM, is director of risk management in the Iowa Health System Law Department.

COMMENTARY

Developing an Informed Consent Process With PatientUnderstanding in Mind

Mary Ann Abrams,MD,MPH; Barb Earles, RN,MHA, CPHRM

A

The Safe Practices are included in the Hospital Quality andSafety Survey of the Leap Frog Group, an organization workingto mobilize employer health care purchasing power to achievebreakthrough improvement in safety, quality, and affordability.6

The Joint Commission and Centers for Medicare andMedicaid Services promulgate standards and regulations relatedto informed consent. The Joint Commission standards addressinformed consent as stated in Standard RI.2.40—“Informedconsent is obtained,” and Standard PC.6.30—”The patientreceives education and training specific to the patient’s abilitiesas appropriate to the care, treatment, and services provided bythe hospital.” There are Centers for Medicare and MedicaidServices requirements related to informed consent for hospitals inseveral Conditions of Participation (CoP) (Patients’ Rights CoP at42 CFR 482.13(b)(2); Medical Records CoP at 482.24(c)(2)(v);Surgical Services CoP at 482.5 1(b)(2)). Revisions to interpretiveguidelines in 2007 demonstrate continued emphasis on theimportance of informed consent and patient involvement withinformed decisions:

The right to make informed decisions means that the patient orpatient’s representative is given the information needed in order to make‘informed’ decisions regarding his/her care…The patient or the patient’srepresentative should receive adequate information, provided in amanner that the patient or the patient’s representative can understand,to assure that the patient can effectively exercise the right to makeinformed decisions. (Interpretive Guidelines §482.13(b)(2))

The American Medical Association (AMA) states, “Informedconsent is more than simply getting a patient to sign a writtenconsent form. It is a process of communication between apatient and physician that results in the patient’s authorizationor agreement to undergo a specific medical intervention.”7 InHealth Literacy and Patient Safety: Help Patients Understand.Reducing the Risk by Designing a Safer, Shame-Free Health CareEnvironment,8 the AMA states:

Patient understanding is the first patient right and without suchunderstanding there are limitations on the ability to exercise all otherrights customarily credited or formally contracted to patients. Thisright is not one that physicians confer, but one they assist patients inexercising freely. It is neither just nor fair to expect a patient to makeappropriate health decisions and safely manage his or her care withoutfirst understanding the information needed to do so.

This is underscored in the 2005 White House Conferenceon Aging proceedings:

“Patients have the right to understand healthcare information thatis necessary for them to safely care for themselves, and to chooseamong available alternatives. Healthcare providers have a duty to provideinformation in simple, clear, and plain language and to check thatpatients have understood the information before ending theconversation.”9

Case LawNational case law addresses the way risk is communicated

and recognizes that claims have involved lack of informedconsent. Informed consent is a process, not merely the signingof a document. Consent documents, in conjunction withprovider documentation, are used as evidence that informedconsent was given. Studies have shown that 18% to 45% ofpatients are unable to recall the major risks of their surgery;44% do not know the exact nature of their operation; and 60%to 69% do not read or understand the information containedin a hospital consent form.10 Legally, a signed consent form is notproof of informed consent. If the patient does not understand,the form is meaningless.

ReadabilityIn Health Literacy: A Prescription to End Confusion, the

Institute of Medicine of the National Academies found that thereadability levels of informed consent documents for researchand clinical practice exceed the documented reading levels ofthe majority of adults in the United States, and that this hasimportant ethical and legal implications that have not been fullyexplored.1 Readability analyses from representative Iowa HealthSystem senior hospital affiliate consent forms demonstrated thatmany were written at or above 17th grade level.

The Iowa Health System Experience

In 2004, the trends described above led Iowa Health Systemto embark on its work to create a reader-friendly written consentdocument to prompt action on the informed consent processusing teach back. Beginning with the Consent for Surgery/Procedure document, an iterative process was used to developa plain language consent that improved readability andpatients’ understanding, ability to make informed choices, andsatisfaction. The revised document was also intended to helpproviders ensure that patients understand their procedures andhave the ability to ask questions as needed while not addingcomplexity to the perioperative care environment. The consentwas developed in collaboration with Iowa Health System healthliteracy teams, risk managers, health care providers, the IowaHealth System Law Department, and adult learners whoreviewed multiple drafts, clarifying terms, content, and design.A cardinal feature of the consent is a space for description of theprocedure not only in medical terms, but also in the patient’sown words—a form of teach back. Plain language characteristicsof the new consent include: simple words; short sentences; shortparagraphs; minimal medical terms; clear headings, bullets, andnumbering; generous white space; 12-14 point serif fonts; keyuses of bold text; and 1.5 line spacing. The final document hasa seventh to eighth grade reading level calculated manuallyusing the Fry formula and electronically using ReadabilityCalculations software.11

When team members had agreed on a near-final draft, anevaluation tool was developed for pilot testing at a singlehospital. Data were collected using the original consent formfollowed by the new consent form on patient demographics



and procedure type; time to complete the document; whetherthe consent was actually read; who read it (eg, patient, family,and/or nurse to patient/family); ease of patients in recountingthe name of the surgery in their own words (teach back);questions asked by patients or their families during the consentdiscussion; and patient/family and nurse satisfaction with theprocess and new consent form.

Results were positive for all types of patients and procedures.Patients and staff reported high satisfaction with the reader-friendlyform and process. Nurses did not find that asking for teach back(description of the procedure in the patients’ own words) duringthe consent process was awkward; all respondents moderately/highly valued this use of teach back. Nurses also reported it wasmuch easier to clearly evaluate patients’ knowledge about theirsurgery, and patients’ comfort level in asking questions wasenhanced by the “permission” wording on the form. Patients/families reported appreciation of the easier-to-read format andbeing asked to state in their own words the description of theirsurgery. Increases in time, interruptions, or extra calls to physiciansfor clarifications or answers to questions that arose when patientsactually read and understood the consent document have notbeen reported.

Following communication with key departments, senioradministration, physicians, and thought/opinion leaders, thefirst pilot hospital adopted the new consent document for allsurgical procedures. Three hospitals followed, and a fifth hospitalrecently initiated pilot testing.Testing is repeated at each hospital,somewhat more rapidly, to build will, acquire local data, andproblem solve at the local level. Each affiliate is asked to chronicletheir experience so others can learn from their work. As supportfor the new consent increases, widespread implementation atother affiliate hospitals occasionally has to be tempered as pilottesting, communication, and staff and provider education areconducted.

Additional health literacy-related consent work continues.The new Surgery/Procedure consent has been translated intoSpanish with additional pilot testing. English and Spanish versionsof a Blood/Transfusion consent have been developed and arebeing pilot tested by the hospitals. Work has begun on aConsent for Procedure by Non-Physician Providers.

Lessons Learned and Keys to Success

Building support among physicians, staff, and senior leadersrequires underscoring the increasing focus on health literacy byprofessional, payer, accrediting, and regulatory organizations;health literacy’s relationship to risk management; and evidencedemonstrating the impact of low health literacy and its integralrole in the informed consent process.

Documenting the processes of testing and adopting new

forms, conducting pilot tests, communicating proactively withaffected leaders, departments, and committees, and continuouslylearning from others’ experience build will, provide local datato support the effort, and help navigate potential roadblocks. Itis important to involve all those with roles in the consent process,organizational change, and quality of care. It is equally andvitally important to include patients and adult learners. Patientinput and feedback helped structure the ultimate content andlayout of the new consent and provided an effective counterpointto arguments against simplification.

All providers must be educated about the differencebetween the informed consent process and the consent form.Signing the consent form alone is not sufficient to meet legalrequirements for informed consent. It is the role of the providerto discuss, through a process of shared decision making, therecommended surgery, procedure, treatment plan, anesthesia, orother service. Physicians then need to be sure patients understandwhat is being recommended, its risks and benefits, otheroptions and their risks and benefits, and risks and benefits ofno treatment before patients make a decision.

Providers and staff also should be educated about the needto use simpler language and teach back. Building capacity onuse of teach back should be part of improving the informedconsent process because asking patients to describe or repeatback in their own words what they understood they have beentold is our way to make sure they really understand. If gaps ormisunderstandings are heard, further teaching can be done.Ultimately and ideally, teach back will be interwoven throughoutthe entire informed consent discussion, even if additionalassistance (eg, trained interpreters) must be provided to helppatients understand.

Other health care organizations are also working to improvethe consent process.12,13,14 Their efforts include standardizededucation using employee orientation and ongoing educationaland peer reinforcement and requiring documentation of teachback on the consent form or in the health care record prior tothe procedure.

As additional Iowa Health System affiliates adopt thereader-friendly consent, continuing emphasis will center onmoving beyond use of the new form toward incorporating teachback to check for and ensure understanding and documentingthese discussions during everyday interactions with patientsand families. In the context of patient-centered care, consent isa shared decision-making process between the patient and theirprovider, not an event or a signature on a form. True informedconsent is a core component of quality health care.

Acknowledgements: We would like to acknowledge thecontributions of the Iowa Health System Health Literacy Teammembers and the New Readers of Iowa.

REFERENCES

1 Institute of Medicine Committee on Health Literacy. HealthLiteracy: A Prescription to End Confusion. Washington, DC:National Academies Press; 2004.

2 Institute of Medicine Committee on Identifying Priority Areasfor Quality Improvement. Priority Areas for National Action:Transforming Health Care Quality. Washington, DC: NationalAcademies Press; 2003.

3 Institute for Healthcare Improvement. http://www.ihi.org.Accessed August 30, 2007.

4 National Quality Forum. Safe Practices for Better Health Care:A Consensus Report. Washington, DC: National Quality Forum;2003.

5 National Quality Forum. Safe Practices for Better Healthcare2006 Update. Washington, DC: National Quality Forum;2007.

6 The Leapfrog Group Hospital Quality and Safety Survey.http://www.leapfroggroup.org. Accessed August 30, 2007.

7 American Medical Association. http://www.ama-assn.org/ama/pub/category/4608.html. Accessed August 30, 2007.

8 American Medical Association Foundation and AmericanMedical Association. Health Literacy and Patient Safety: HelpPatients Understand. Reducing the Risk by Designing a Safer,Shame-free Health Care Environment. American MedicalAssociation Foundation and American Medical Association;2007.

9 Proceedings of 2005 White House Conference on Aging,Mini-Conference on Health Literacy and Health Disparities.American Medical Association, 2005. http://www.ama-assn.org/go/aging. Accessed August 30, 2007.

10 Baum N. Comprehension is key. Patient Safety and QualityHealthcare. May/June 2006;34-38.

11 Micro Power & Light Co, 8814 Sanshire Avenue, Dallas, TX75231. Phone 214-553-0105. http://www.micropowerandlight.com. Accessed September 10, 2007.

12 Wu H, Nishimi RY, Page-Lopez CH, Kizer KW. ImprovingPatient Safety through Informed Consent for Patients with LimitedLiteracy. Washington, DC: National Quality Forum; 2005.

13 National Quality Forum. Implementing a National VoluntaryConsensus Standard for Informed Consent: A User’s Guide forHealthcare Professionals. Washington, DC: National QualityForum; 2005.

14 Wynia M, Matiasek J. Promising Practices for Patient-CenteredCommunication with Vulnerable Populations: Examples fromEight Hospitals. Institute for Ethics, American MedicalAssociation; August 2006.


ffective patient-centered communication improves trust,patient satisfaction, health literacy, and health outcomes

and reduces health disparities and law suits that occur due topoor communication.1-3 For these reasons competency guidelinesoutlined by the Accreditation Council for Graduate MedicalEducation,4 the Liaison Committee on Medical Education,Accreditation Review Commission on Education for thePhysician Assistant,5 and theAssociation of AmericanMedical Colleges6 require thatcommunication skills trainingbe mandated in undergraduateand graduatemedical education.The Institute ofMedicine of theNational Academies report“Improving Medical Education”concluded that basic andcomplex communication skillsare a “high priority”2 in medicaleducation.

Despite growing evidencethat patient-centered careimproves health outcomes, medical students receive mixedmessages.7 In preclinical communications courses in USmedical schools, educators use available evidence to teach studentsto be open, reflective, and patient-centered, while in clinicalclerkships students often witness directive, doctor-centered

communication by those who have not had the training thatcurrent students receive.8,9 At Wake Forest University School ofMedicine Department of Family and Community Medicineour goal is to cultivate culturally competent, patient-centeredcommunication skills across the continuum of medical educationto more effectively address health literacy needs, reduce healthdisparities, and improve health outcomes. Since 2000, 5Title VII

Health Resources and ServicesAdministration grants havefacilitated the developmentof a culturally competent,patient-centered communicationcurriculum for faculty, familymedicine residents, andmedical and physician assistant(PA) students. Each grant wasenvisioned as a step towards thelong-range process necessaryto create patient-centeredteachers, clinicians, and students.This article presents an overviewof curricular innovations, the

evaluation process, early outcomes, and next steps.The curriculum across learner groups (faculty, residents,

medical and PA students) was developed using CommonGround,10 a criteria-based training model derived from theKalamazoo Consensus Statement.11 This model was adopted for

“Despite growingevidence that patient-centered care improves

health outcomes,medical students receive

mixed messages.”


Gail S.Marion,PA-C,PhD, is an associate professor in the Department of Family and Community Medicine atWake Forest UniversitySchool of Medicine. She can be reached at gmarion (at) wfubmc.edu or Medical Center Boulevard,Winston-Salem,NC 27157-1084.

Sonia J.Crandall, PhD,MS, is a professor in the Department of Family and Community Medicine atWake Forest University School ofMedicine.

Frank Celestino, MD, is a professor in the Department of Family and Community Medicine at Wake Forest University School ofMedicine.

William McCann, PsyD, is an assistant professor in the Department of Family and Community Medicine at Wake Forest UniversitySchool of Medicine.

Julienne Kirk, PharmD, is an associate professor in the Department of Family and Community Medicine at Wake Forest UniversitySchool of Medicine.

COMMENTARY

Cultivating Patient-Centered Communication SkillsTraining Across the Medical Education Continuum:A Model for Practice

Gail S.Marion, PA-C, PhD; Sonia J. Crandall, PhD; Frank Celestino,MD;WilliamMcCann, PsyD;Julienne Kirk, PharmD

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its ease of use in the clinical setting and for the associatedCommon Ground Assessment Instrument (CGAI) which hasconstruct validity, internal consistency, test-retest reliability,and generalizability across clinical cases.10 The model includes6 core skills: rapport building, agenda setting, informationmanagement, active listening, addressing feelings, and reachingcommon ground. The curriculum was incorporated into facultydevelopment, residency training, and medical student trainingin the Department of Family and Community Medicine andalso into the curriculum of the Department of PhysicianAssistant Studies. The following sections describe the activitiesinto which the curriculum was included.

Department of Family and CommunityMedicine Activities

Faculty DevelopmentAn Administrative Units award provided infrastructure

support for patient-centered communications research andfunded 6 faculty pilot projects. Outcomes of this grant led toseveral other communications research projects including 2National Cancer Institute grants, and to numerous presentations,publications, and curricular innovations.

Residency TrainingA residency training award facilitated development of a

cultural competency curriculum for residents and medicalSpanish and immersion training in Guatemala for faculty, staff,and residents. It also fostered ties with 2 Latino clinics.Outcomes of this grant included the addition of 20 hours ofcommunication skills training provided during the HumanBehavior Rotation for first-year residents. Evidence indicatesmindfulness training may improve a physician’s self-awarenessand other-awareness, help decrease anxiety, and help develop arelaxed alertness that might contribute to the incorporation ofcommunication skills in clinical practice.12-14 The new trainingincludes (1) relaxation/ mindfulness training and practiceincluding an examination of their roles in development ofhigher order communication skills; (2) introduction to andpractice with the CGAI; and (3) videotape reviews of residents’patient encounters using the CGAI. Common Ground skillsare reinforced during the required geriatric outpatient rotationin the second year. During the second and third years, residentsattend a Balint support group which provides an opportunityto consider how patient-centered communication can facilitatepatient care.

Medical Student CurriculumA predoctoral training grant allowed us to develop a

collaborative project with the Departments of General InternalMedicine and Pediatrics to implement a communication skillscurriculum in 3 third-year clerkships. This grant facilitated acontinuity experience for clinical students to further developand refine patient-centered communication skills taught inthe preclinical years to better serve diverse and vulnerablepatient populations.

We worked with the course and clerkship directors to revisethe first-year communications course and with the familymedicine clerkship patient simulation to reflect the CommonGround skills. All evaluation instruments and the interviewskills template used by the students are explicitly linked to theCommon Ground skills domains. Three new standardizedpatient assessments focusing on vulnerable and high-riskpatients were designed for and implemented in the third yearambulatory care clerkships. In the last 2 years we trainednonfaculty raters to reliably assess students’ communicationskills using the Common Ground criteria.

Outcomes of this grant led to the training of over 90 faculty,nonfaculty, and community preceptors as raters to reliablyassess communication skills throughout 4 years of the curriculum.Use of the CGAI has helped to ensure that we are evaluatingcommunication skills objectively across multiple assessments inpreclinical and clinical years. To evaluate effectiveness of thecommunications curriculum, the trained nonfaculty raters wererandomly assigned student interviews from the standardizedpatient assessments to rate. To date, they have reviewed over3000 videotaped interviews to find that skills have significantlyimproved across 3 classes of first-year medical students. The nextstep is to evaluate longitudinal data which include a total of 14digitally recorded video encounters per student from baselineto graduation.

Department of Physician Assistant StudiesActivities

A recently completed grant established a culturally competent,patient-centered curriculum. For first-year students, corecommunications elements were incorporated. Students areoriented to Common Ground while reviewing DVDs of clinician-patient dyads using the CGAI. In small groups, studentspractice using patient-centered skills with standardizedpatients. To further improve communication skills studentsparticipate in a required medical Spanish course and are trainedand evaluated on effective use of medical interpreters. Eightstandardized patient assessments over both years and site visits inthe clinical year are used to evaluate these skills. Outcomes include(1) significantly improved patient-centered communication skillsacross the last 2 classes (nonfaculty raters have reviewed over1000 randomly assigned recorded interviews); (2) effective studentinteraction with interpreters and an increased student ability touse medical Spanish in the clinical setting; and (3) completionof an international Spanish language immersion program by 17students.

Because we know there is no one factor more predictive of poorhealth status than low health literacy,3 the current grant is devotedto integrating health literacy throughout both years (preclinicaland clinical) of training; this new component will be embedded inthe well-established patient-centered communications curriculumwithin the clinical applications and professionalism courses.Skill 6 of the Common Ground model trains learners how to(1) summarize the patient’s problems and concerns; (2) check forunderstanding; (3) check for feasibility; (4) check for agreement;


and (5) establish mutual responsibility for the plan. Using thisguide, students will consider health literacy as well as cultural,financial, and other factors as they develop a plan with thepatient that effectively ties the visit to what happens when thepatient leaves the office. Among other teaching strategies,standardized patient instructors (portraying patients who needto stop using tobacco or alcohol, lose weight, exercise more, ormanage diabetes) will provide the students with multipleopportunities to practice and receive feedback (using validatedinstruments) to further develop these skills to care for patients inthe clinical year. All students are required to review and self-assesstheir video recorded encounters after they receive feedbackfrom the standardized patient assessments to improve futureperformance. These skills will be assessed and reinforced duringsite visits and standardized patient assessments in year 2 on atleast 4 occasions.

Conclusion

Common Ground is highly transportable. Currently,among others, it is used in the California medical schools. Wehave trained faculty at other medical schools and physicianassistant programs in North Carolina and Virginia. The modeland its associated criteria-based instrument make it feasible toprovide basic training for faculty in about 4 hours. Withschools looking for ways to provide communication skillstraining in undergraduate and graduate medical education, thismodel offers an ideal method to incorporate patient-centered

communication into clinical training programs. Health Resourcesand Services Administration or other medical education fundingto incorporate this curriculum is helpful, but not essentialbecause the model and curriculum materials lend themselves torelatively short training.

Future goals of the Wake Forest University School ofMedicine include translating these curricula and outcomes toother health disciplines, providing an advanced communicationskills elective for fourth-year medical students, and developingpatient-centered communication curriculums for practicingclinicians to address health literacy assessment and use. Goethewrote, “Knowing is not enough: we must apply. Willing is notenough; we must do.” Growing evidence suggests that we arenot applying what we know and are failing to provide adequatecare for millions of patients in a country with the most expensivehealth care system in the world using doctor-centered modelsof care.15 We must be willing to do what is necessary to produceeffective patient-centered clinicians to improve health outcomesfor our patients. NCMJ

Acknowledgements: We wish to acknowledge the support of theHealth Resources and Services Administration for the following TitleVII Grants for Primary Care: Academic Administrative Units,Residency Training, Predoctoral Training, and Physician AssistantTraining; and Dr Forrest Lang of East Tennessee State University for hisextraordinary vision and tireless work on behalf of patient-centeredcommunications and “reaching common ground.”We also want to expressour gratitude to Carol Hildebrandt for her diligent editorial efforts.


REFERENCES

1 Stewart MA. Effective physician-patient communication andhealth outcomes: a review. CMAJ. 1995;152(9):1423-1433.

2 Vanselow N. Improving Medical Education: Enhancing theBehavioral and Social Science Content of Medical SchoolCurricula. Washington, DC: Institute of Medicine of theNational Academies; 2004.

3 Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP.Literacy and health outcomes: a systematic review of theliterature. J Gen Intern Med. 2004;19(12):1228-1239.

4 Accreditation Council for Graduate Medical Education.http://www.acgme.org/acWebsite/navPages/nav_commonpr.asp.Accessed August 05, 2007.

5 Accreditation Review Commission on Education for thePhysician Assistant, Inc. Accreditation Standards for PhysicianAssistant Education. 2nd Edition. 2001. http://www.arc-pa.org/.Accessed August 05, 2007.

6 AAMC Ad Hoc Committee of Deans. Educating Doctors toProvide High-Quality Medical Care: A Vision for MedicalEducation in the United States. Washington, DC: Association ofAmerican Medical Colleges; July 2004.

7 AAMC Group on Educational Affairs. Implementing the Vision.Washington, DC: Association of American Medical Colleges;September 2006.

8 AAMC Task Force on the Clinical Skills Education of MedicalStudents. The AAMC Project on the Clinical Education ofMedical Students. Washington, DC: Association of AmericanMedical Colleges; 2005.

9 Committee on Health Literacy of the Institute of Medicine.Health Literacy A Prescription to End Confusion. 1st edition.Washington, DC: The National Academies Press; 2004.

10 Lang F, McCord R, Harvill L, Anderson DS. Communicationassessment using the common ground instrument: psychometricproperties. Fam Med. 2004;36(3):189-198.

11 Makoul G. Essential elements of communication in medicalencounters: the Kalamazoo consensus statement. Acad Med.2001;76(4):390-393.

12 Wenk-Sormaz H. Meditation can reduce habitual responding.Altern Ther Health Med. 2005;11(2):42-58.

13 Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. JPsychosom Res. 2004;57(1):35-43.

14 Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.15 Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for

receiving poor-quality health care? N Engl J Med.2006;354(11):1147-1156


arge numbers of immigrants have settled in NorthCarolina in recent years. The immigrant population

grew 58.1% (373 000 to 590 000) between 2000 and 2005.Most immigrants are unfamiliar with the basics of the UShealth care system and lack adequate knowledge to makeinformed decisions about their own health. These difficultiesblock many immigrants from attaining self-sufficiency andbecoming full participants in our society. Basic health literacyand assistance gaining access to community resources couldprevent these families from becoming mired in poor health forgenerations.

The University of North Carolina at Greensboro Center forNew North Carolinians Immigrant Health ACCESS Projectrecognizes language and cultural barriers as principal healthcare problems for over 50% of newimmigrants in North Carolina, asdefined by both the providers andthe limited English speakingcommunity. Most newcomershave limited English proficiency,utilize traditional health practicesfrom their cultures, live close tothe poverty level with inadequatehealth insurance, work in hazardousjobs, and have limited familiaritywith our health systems or preventivehealth practices.

With more than a dozendifferent major ethnicities in thestate and an immigrant populationthat represents several differentdemographic profiles, languages, cultures, and needs, NorthCarolina health providers face extraordinary challenges. Howwell and how rapidly we replenish the bilingual and biculturalhealth care practitioner workforce in our state determines ourability to eliminate language barriers, improve health behaviorof new immigrants, and save on scarce financial resources inorder to reach more residents, newcomers, and the uninsured.

The state of North Carolina does not yet have enough bilingualhealth care personnel and culturally appropriate policies inplace to fully tackle disparities among immigrants in the state.Title VI of the Civil Rights Act of 1964 requires that limitedEnglish proficiency populations have access to “culturally andlinguistically appropriate services” at no cost to the client. Healthproviders, including both public and private entities thatreceive federal funds, are required to take reasonable steps toensure meaningful access to the information, programs, andservices they provide. Very few North Carolina providers offerservices in multiple languages through qualified interpreters. Somerely on family members, including children, or use untrained orunqualified interpreters, thus creating ethical and confidentialityissues.

Cultural competency gaps magnify the health communicationproblems. Health care practitioners are often unfamiliar withthe traditional practices of their patients and may not ascertainwhat interventions the patient is already using or willing to use,thus creating an additional health hazard. Newcomer immigrantpatients who are unfamiliar with US health practices do not knowhow to best access health systems, put into practice preventive

Communicating Health Information to English as aSecond Language Patients

H.Nolo Martinez,MS, PhD

COMMENTARY

H. Nolo Martinez, MS, PhD, is interim director of the Center for New North Carolinians at the University of North Carolina atGreensboro.He can be reached at nmartinez (at) uncg.edu or 413 S Edgeworth Street,Greensboro,NC 27401.

L

“Health care practitioners are oftenunfamiliar with the traditional

practices of their patients and maynot ascertain what interventions thepatient is already using or willing touse, thus creating an additional

health hazard.”


health behavior, or use medications as directed.A large number of new North Carolina immigrant residents

do not have the English-speaking capabilities to fully accesshealth care, and practitioners cannot communicate in thepatients’ languages. As a consequence, patients are not able tospeak freely with their practitioners and do not receive informationon how they can better take care of themselves or their families. Ifthe practitioners cannot explain to their patients their conditions,they cannot tell the patients why or how to follow lifestylechanges or explain why medication is necessary. Limited Englishproficiency immigrant patients cannot ask questions or makeagreed upon changes to their treatments with their practitioners.

Communication barriers are not only connected to theinability to speak English. Immigrant residents in NorthCarolina show some cultural behaviors that interfere withhealth communication:

� Some immigrants have identified the stigma of being arefugee as a detriment. It destroys their sense of beingpart of the general community and may create barriers ofmistrust with the health care provider, which makescommunication difficult.

� Immigrant patients may be troubled when health carepractitioners ask many personal questions, take notes ofconversations, and fill out forms

� Men may particularly feel that talking about suffering isa sign of weakness and may be reluctant to talk aboutpsychological dimensions of pain.

� Due to misunderstanding the role of some health careprofessionals (eg, nurses), some patients may feeldiscriminated against and refuse communication.

� People who are not confident with their Englishproficiency may refuse to disclose information to medicalprofessionals.

� Many find it difficult to follow the legal procedures inNorth Carolina but may not ask for advice.

The key to ensuring meaningful health access for limitedEnglish patients is the ability to reach effective communicationbetween the patient and the health provider. One strategy toachieve more effective communication, in addition to complyingwith the terms of Title VI to provide culturally and linguisticallyappropriate services, includes using trained and culturallycompetent interpreters. Improving the quality of interpreterservices can reduce health costs, increase prevention efforts, anddecrease primary care use by non-English speaking residents.Another strategy is to assist case management efforts of safetynet providers by using lay health advisors to support immigrantclients’ better understanding and navigation of the health caresystem. Lay health advisors are trusted members of thecommunities in which they serve. Their assistance can helpimmigrant clients develop stronger relationships with theirpractitioners.

Cultural competence means the capability and will of aprovider or service delivery system to respond to the uniqueneeds of an individual considering the culture of the person.

Using interpreters and lay health advisors as cultural brokers canhelp health providers attain knowledge regarding beliefs,cultural values, and preferences. This knowledge becomescritical when a practitioner creates interventions to meet aperson’s needs. Immigrant lay health advisers have the ability touse the individual’s culture as a resource or tool to aid in theintervention and explain the health needs or problems. Thecapacity to provide equal access to individuals fromdifferent cultural and linguistic populations results from thenew understanding of immigrants’ distinct needs which isgained through collaboration with lay health advisors. Culturegives meaning to health communication and provides thecontext for understanding health information. Health literacyeducation programs must be developed to reflect the uniquelanguage and cultural backgrounds of North Carolina’s immigrantpopulations.

Communicating with patients who have limited Englishproficiency requires more than just finding someone whospeaks their language to assist with interpretation. According tothe Civil Rights Act of 1964 and Executive Order 13166,patients with limited English proficiency have the right to atrained interpreter. Trained language interpreters have formaleducation in interpreting and abide by a professional code ofethics that includes confidentiality, impartiality, accuracy, andrespect. Good medical interpreters are not only fluent; they arealso familiar with medical terminology and have experience inhealth care. Although there are several accredited trainingprograms for medical interpreters, there is no nationalcertification. Only the state of Washington offers state testingand certification. The University of North Carolina atGreensboro Center for New North Carolinians has developedcurricula and testing to certify that North Carolina healthinterpreters have received training and certification.

A great obstacle to the practitioner-patient relationship ortherapeutic bond happens when a language barrier exists betweenthe practitioner and patient. More attention needs to be given tothe process of language translation during this interaction. Somehave suggested increasing the number of Spanish and otherlanguage courses for practitioners as an option for reducing thelanguage barrier. I encourage the learning of other languages,but a quick or survival language course can also lead to significantmistakes on the part of the practitioner. Unless the practitioneris fluent in the language, it is prudent to always use an interpreter,especially following the exam, to ensure and document patientunderstanding. The interpreter should ask the patient if he orshe has any additional questions and then request that thepatient repeat back any instructions from the practitioner.

Most providers use translation of messages, documents, andmaterials into other languages to reach nonnative speakers ofEnglish. This process is flawed because the English language,especially technical language concerning complex medicaltopics, does not always translate well into other languages andmay result in misrepresentations and misunderstandings.Furthermore, translating documents is also complicated by thesheer number of different languages used by residents in NorthCarolina. It is a tremendous and expensive challenge to translate


health communication materials into a range of differentlanguages, and meaning can be lost in translation.

Nevertheless, language is important for both access to andquality of care. Using trained and qualified interpreters can andshould be implemented to improve access to health informationfor consumers who are not native English speakers. Healthliteracy is a complex issue, and improvements in the healthliteracy of limited English proficient clients require a variety ofapproaches. Health literacy not only involves the communicationskills and abilities of immigrants to understand spoken, written,and mass-media communication about health and health care,but it also involves the communication skills and disposition ofhealth care providers and the support of those that understandthe client’s culture and language. Effective health communicationwith thousands of new North Carolinians must be interactive

and adaptive, utilizingmany different channels of communication.North Carolinians are well aware of the increasing diversity

across the state. In grocery stores in any county one can hearmultiple languages and dialects spoken. Visiting reception areasof any of our health service agencies, one will encounter peoplefrom many cultural backgrounds. The public schools reportthat more than 90 different languages are spoken in the homeof children enrolled throughout our state’s educational system.Human service providers and educators are challenged to findthe best way to meet the needs of an increasingly diversepopulation. Partnerships between lay health advisors, qualifiedinterpreters, health care providers, and consumers whodesperately need relevant health information can help overcomemany problems related to health literacy. NCMJ

ubstantial research provides clear evidence of the relationshipbetween communication failures and malpractice claims.

Communication failures among health care practitioners areassociated with most avoidable adverse outcomes.1,2,3 Poorcommunication skills also adversely impact patient-providerrelationships, increasing the likelihood that families sue whenfaced with adverse outcomes whether or not errors haveoccurred.4,5,6

In spite of the research, many within medicine cling tomyths concerning why they get involved in claims, asserting,“Everyone in my specialty gets sued,” or “It’s just a cost ofdoing business.” Others contend they attract litigation-pronepatients or attend to the most challenging cases. Unfortunately,such myths pose a stumbling block to one approach to reducingmalpractice claims that everyone should support: identifyingand addressing ways to promote improved patient-practitionercommunication.

Our goal is to focus on just one factor promoting lawsuitgeneration—poor practitioner communication skills. We willreview research concerning why families file suit, why somepractitioners have a “dark cloud,” and the role that poor providercommunication skills play in observed claims’ disproportionality.Finally, we will offer suggestions concerning what health carepractitioners can do to identify and address risk.

Studies reviewed widely in the media by researchers atHarvard focused national attention on errors in medicine.Their studies involving chart review suggested that 1% to 2%of hospitalized patients in the US experience adverse outcomesdue to medical errors.7,8 Study results should convince us thatwe share a duty to make medicine safer. How to make medicinesafer is beyond the scope of this commentary, but we do wantto focus on an often overlooked finding that suggests anotherproblem needing attention. In completing thousands ofreviews, the Harvard team identified cases where errors causedadverse outcomes and where families filed suit. However, for

every family who filed a “valid” claim, the Harvard team identified5 families who sued with no evidence of negligence.9 Such find-ings are consistent with information from state-based claimsreporting. Data from the state of Tennessee reveals that in 2006over 80% of closed malpractice claims were dropped withoutan award or settlement.10

When such data are reviewed, many practitioners fall back ontheir old myths or seek to blame the plaintiff bar without askingtwo questions: Why are so many nonvalid claims filed, and isthere anything we can do? Nonvalid claims create burdens for thefamilies filing them because many relive painful experiences, forthe practitioners who are named because they may experienceemotions from anger to depression, and for members of societywho ultimately pay the bill.

To understand why people sue, you begin by asking familieswho have filed claims. Although such studies are subject torecall bias, they provide evidence of how communication failuresprompt some families to sue. When asked what promptedthem to seek legal advice 25% of families interviewed mentionthe need for money.4 Most, however, cited noneconomic reasons

“...risk is predicted by thepractitioner’s inability tocommunicate effectively

and establish andmaintain rapport withpatients, especially in theface of an adverse event.”

Identifying and Addressing Communication Failures as aMeans of Reducing Unnecessary Malpractice Claims

Gerald B.Hickson,MD; A.Dale Jenkins

COMMENTARY

Gerald B.Hickson,MD, is associate dean for clinical affairs, director of the Center for Patient and Professional Advocacy, and directorof Clinical Risk and Loss Prevention at Vanderbilt University Medical Center. He is also professor of pediatrics and associate professorof Family andHealth SystemsNursing atVanderbilt.He can be reached at gerald.hickson (at) vanderbilt.edu or at the Center for Patientand Professional Advocacy at Vanderbilt, 405 Oxford House,Nashville,TN 37232-4220.

A.Dale Jenkins is chief executive officer of Medical Mutual Insurance Company.


S


including belief in cover-ups and the need for information.4,5

Results also highlight how often families believe that no oneever expressed concern about the family’s loss or offered anapology in the face of what the family believed was an error.

Studies examining why some physicians attract more thantheir fair share of lawsuits offer additional insight into howpoor communication skills promote claims. Sloan and colleaguesreported that physicians can be sorted into 3 risk groups: thosewith no suits, those with an occasional claim, and a third groupwith high claims. Between 2% and 8% of physicians by specialtyaccount for more than one-half of all malpractice-relatedcosts.11 In a follow-up study, Bovbjerg identified that claimsexperience is constant over time such that physicians at highmalpractice risk today will be at high risk tomorrow.12 Studyresults raise an obvious question: Why do certain physiciansgenerate so many suits? Multiple hypotheses have been proposed,but studies reveal that individual claims experience is notpredicted by patient characteristics, illness complexity, or eventhe physician’s technical skills.13,14 Instead, risk is predicted bythe practitioner’s inability to communicate effectively andestablish and maintain rapport with patients, especially in theface of an adverse event.4,6,13,14 In a study examining perceptionsof care, patients seeing high-risk obstetricians were 3 times morelikely to assert that their physicians would not answer questionsor listen when compared with families seeing obstetricians withno malpractice claims.14 Over 30% of study subjects seeinghigh-risk physicians voiced dissatisfactions with care even afterdelivering healthy newborns.

In spite of evidence linking poor communication skills withclaims experience, the question remains: Is there really anythingthat can be done to reduce risk? In response to this question,researchers with the Vanderbilt Center for Patient andProfessional Advocacy developed 2 hypotheses. First, high-riskproviders are unaware of their status. Second, if made aware,many will seek to change their practices or communicationbehaviors in ways to reduce risk.

To help make high-risk physicians aware of their status, theteam sought a proxy for malpractice claims that is linked to riskevents but occurs frequently enough to be counted and fedback to the at-risk clinicians. Many groups, clinics, and hospitalshave patient advocates, called ombudsmen, who listen to familieswho are dissatisfied with care. Advocates record the stories andattempt to address what is perceived as wrong. Analysis ofthousands of stories reveals that unsolicited complaints are notrandomly distributed. Just like malpractice claims, 30% to50% of practitioners never attract a complaint. An equalnumber get an occasional complaint. However, when coded forcomplaint type (34 separate categories) by practitioner, thecomplaint reports can be used to reliably identify a smallsubset of physicians (4% to 8% of any group) who account forover 40% of claims and 50% of all malpractice-relatedcosts.15,16

The Vanderbilt team then turned its attention to howcomplaint data could be used to promote awareness. At eachstudy site, peer messengers are trained to deliver interventionmaterials to their at-risk colleagues, including (1) a report card

illustrating the individual’s relative ranking, (2) a table illustratingthe complaint type distribution, and (3) the actual complainttext so physicians can review and gain insight.17,18 Visits averagejust over 30 minutes and are mostly received professionally.Currently, the identification and intervention model is operationalin 25 geographically-distributed sites (from free-standing grouppractices to major medical centers) with over 16 000 medicalpractitioners assessed yearly.

Intervention results are encouraging and reveal that manyhigh-risk practitioners, when made aware, address recurringsources of patient dissatisfaction within their practices.18 Justunder 60% of those receiving awareness interventions respond.Unfortunately, approximately 20% depart their practices, someseeking what is referred to as a “geographic solution,” while anequal number require an authority-based intervention thatmandates anything from a practice review to a comprehensivemental health evaluation.

The intervention study affirms that practitioners can act toreduce sources of patient dissatisfaction that promote risk withintheir practices. The study also provides important insight intocommon communication failures that promote risk. Review ofover 200 000 unsolicited patient complaint reports leads us toa few suggestions that should benefit any provider who wantsto improve patient-practitioner communication even if only forthe purpose of reducing personal malpractice risk.These includemaking patients feel respected, using the informed consentprocess to build practitioner-patient relationships, and lettingpatients know the practitioner cares about feedback.

The first important strategy is for practitioners to send clearmessages to their patients that they are respected as fellowhumans. For a host of reasons, including anxiety, illnesscomplexity, and the pressures of modern medical practice,patients sometimes can perceive a loss of connectedness withtheir health care providers. Such a loss impacts quality of medicalhistory-taking, adherence with medical care plans, and risk oflitigation. Practical means of sending a message of respect wereidentified in a study by Levinson.19They include attention to bodylanguage (Do you look rushed?), efforts to solicit patients’ opinions(“Which option seems most workable for you?”), and encouragingpatients to talk (“What can we talk about today?” followed by amandatory pause). Such strategies take time. However, in theLevinson study, providers modeling respect-generating strategiesaveraged just over 3 minutes more per encounter than theircolleagues who did not but who were subjects to suits.

Another strategy for improving communication suggests thepractitioner view the informed consent process as an opportunityfor relationship building. Review of unsolicited complaintreports reveal that families often express uncertainty about theintended procedures including what they should expect, risksversus benefits, and specifically, when they will get follow-upinformation. One predictor of malpractice risk is a patient’sassertion that the practitioner involved failed to show up afterthe procedure. We commend national efforts to promoteteach back in association with informed consent.20 Patientsshould have an opportunity to describe back to the practitionerthe proposed procedure, the most common complications, and

when they should expect a follow-up discussion.The final recommended step for improving communication

is for practitioners to send the message that they want to hearfrom their patients, especially if the patients are dissatisfied.Both marketing and medical studies reveal that most familieswho experience significant dissatisfaction with care are hesitantto speak up to the provider involved or a representative of the

group.21,22 Consequently, hospitals and medical groups may failto recognize recurrent sources of dissatisfaction that put them atrisk. Most of us tend to be defensive in the face of a complaint,but complaints, if seen as an opportunity to learn, offer animportant key to identifying and addressing unnecessarymalpractice risk as well as a way of allowing patients to have arole in improving care for everyone. NCMJ


REFERENCES

1 Pichert JW, Hickson GB, Bledsoe S, Trotter T, Quinn D.Understanding the etiology of serious medical events involvingchildren: implications for pediatricians and their risk managers.Pediatr Ann. 1997;26(3):160-4,167-8,170-2.

2 Morris JA, Carrillo Y, Jenkins JM, Smith PW, Bledsoe S,Pichert JW, White A. Surgical adverse events, risk management,and malpractice outcome: Morbidity and mortality review isnot enough. Ann Surg. 2003;237(6):844-852.

3 Graber ML, Franklin N, Gordon R. Diagnostic error in internalmedicine. Archives Intern Med. 2005;165(13):1493-1499.

4 Hickson GB, Clayton E, Githens P, et al. Factors that promptedfamilies to file malpractice claims following perinatal injuries.JAMA. 1992;267(10):1359-1363.

5 Vincent C, Young M, Phillips A. Why do people sue doctors?A study of patients and relatives taking legal action. Lancet.1994;343:1609-1613.

6 Hickson GB, Clayton EW, Entman SS, et al. Obstetricians’prior malpractice experience and patients’ satisfaction with care.JAMA. 1994;272(20):1583-1587.

7 Brennan TA, Leape LL, Laird NM, et al. Incidence of adverseevents and negligence and hospitalized patients. N Engl J Med.1991;324(6):370-376.

8 Thomas EJ, Studdert DM, Burstin HR, et al. Incidence andtypes of adverse events and negligent care in Utah andColorado. Med Care. 2000;38(3):261-271.

9 Localio AR, Lawthers AG, Brennan TA, Laird NM, Hebert LE,Peterson LM, Newhouse JP, Weiler PC, Hiatt HH. Relationbetween malpractice claims and adverse events due to negligence.Results of the Harvard Medical Practice Study III. N Engl JMed. 1991 Jul 25;325(4):245-251.

10 State of Tennessee Department of Commerce and Insurance.Tennessee Medical Malpractice Claims Report. 2006.

11 Sloan F, Mergenhagen EM, Burfield B, et al. Medical malpracticeexperience of physicians; predictable or haphazard? JAMA.1989;262(23):3291-3297.

12 Bovbjerg RR, Petronis KR. The relationship between physicians’malpractice claims history and later claims: does the past predictthe future? JAMA. 1994;272(18):1421-1426.

13 Entman SS, Glass CA, Hickson GB, et al. The relationshipbetween malpractice claims history and subsequent obstetricscare. JAMA. 1994;272(20):1588-1591.

14 Sloan F. The injuries, antecedents, and consequences. In: SloanF, Githens P, Clayton E, Hickson G, Gentile D, Partlett D, eds.Suing for Medical Malpractice. Chicago, IL: University ofChicago Press; 1993:1-49.

15 Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaintsand malpractice risk. JAMA. 2002;387(22):2951-2957.

16 Hickson GB, Federspiel CF, Blackford JU, et al. Patientcomplaints and malpractice risk in a regional healthcare center.So Med J. 2007;100(8):791-796.

17 Pichert JW, Hickson GB, Blackford JU, Federspiel CF, MillerCS. Using patient complaints to communicate concerns tocolleagues. In: 2004 Academic Compensation & ProductionSurvey for Faculty & Management. Medical Group ManagementAssociation: Englewood, CO; 2004;16:16-19.

18 Moore IN, Pichert JW, Hickson GB, et al. Rethinking peerreview: detecting and addressing medical malpractice claimsrisk. Vanderbilt Law Review. 2006;59:1175-1206.

19 Levinson W, Roter DL, Mullody JP, Dull VT, Frankel RM.Physician-patient communication: the relationship withmalpractice claims among primary care physicians andsurgeons. JAMA. 1997;277(7):553-559.

20 Implementing a national voluntary consensus standard forinformed consent: A user’s guide for healthcare professionals.Washington DC: National Quality Forum; 2005.http://www.qualityforum.org/pdf/reports/informed_consent_guide.pdf. Accessed September 20, 2007.

21 Carroll KN, Cooper WO, Blackford JU, Hickson GB.Characteristics of families that complain following pediatricemergency visits. Amb Peds. 2005;5(6):326-331.

22 Annandale E, Hunt K. Accounts of disagreements with doctors.Soc Sci Med. 1998;46(1):119-129.


“Think like awiseman, but communicate in the language of the people.”W. B. Yeats

he awareness of the importance of health literacy hassynergistically combined with concerns regarding disparities

in access to care, questions relative to patients rights, and thegrowth of consumerism to initiate a reevaluation of how thevarious health professions communicate with their patients on adaily basis. Practitioners are beginning to examine not only howthey communicate but how well the information is beingreceived, understood, and applied to create a more positiveoutcome for those they counsel and serve.These types of questionshave been debated for several yearswithin the dental community, and dueto that ongoing discussion I believethe dental profession may be moreadvanced in this arena than other healthprofessions.

Dentistry has been exploring thisissue for quite some time since mostpeople view dental treatment decisionsas being more elective than those madein medical offices. Up until recently,this has seemed to be a reasonableassumption given that most dentalproblems were not perceived as beingdirectly related to systemic disease or aspotentially life-threatening. However,new research strongly suggests thatthere are indeed associations between chronic oral infectionsand heart and lung diseases, diabetes, stroke, and preterm lowbirth weight. Therefore, the ability to clearly communicatewith patients has taken on a new level of importance from theperspective of the practitioner as well as the patient and otherhealth professionals.

Communication Styles

Currently, dentists use a variety of approaches to helppatients understand their oral health status and ways to help makeit better. Since most dental school curriculums do not includecourses to improve communication skills, most practitionersgraduate without any guidance as to how to effectively deliverthe information they have acquired. Many dentists don’t go anyfurther than merely telling the patient the results of the examand the recommended treatment. There is no attempt toinvolve the patient in the discovery or decision-making process.While the paternalistic style of doctor-patient communicationmay have produced the desired outcome for patients of previous

generations, members of the current generations want to bemore involved in their health care. The rise of consumerismcoupled with a more informed public has sown the seeds for amore interactive communication dynamic. In fact, many dentistshave begun to define the people they serve as “clients” ratherthan “patients.” This change in perspective serves to reminddental teams that the people they serve want to be moreinvolved in decisions regarding the care they receive. Many

A Perspective on Doctor-Patient Communication in theDental Office

M.Alec Parker, DMD

COMMENTARY

M.Alec Parker,DMD, is executive director of the North Carolina Dental Society.He can be reached at aparker (at) ncdental.org or POBox 4099, Cary,NC 27519.

T

“Since most dental schoolcurriculums do not include coursesto improve communication skills,

most practitioners graduatewithout any guidance as to how toeffectively deliver the information

they have acquired.”

patients arrive in the practitioner’s office having already doneresearch on the Internet.They are better prepared to ask questionsand no longer want to abdicate treatment decisions to the dentistor other members of the dental team. Today, clients seekingdental care expect to have proposed treatment plans presentedin an understandable format and to have the opportunity todiscuss the merits of possible alternative procedures. They wantto be informed consumers and expect practitioners to provide thefacts they need to make a decision that best fits their personalgoals and values.

In order to assist patients in the decision-making process,some dentists have realized that they need to make a moreconcerted effort to deliver their findings in a comprehensibleform. In fact, one of the more frequently cited barriers to oralhealth literacy identified by consumers is the practitioners’ useof technical dental terminology during their conversations withpatients. Although the use of dental jargon seeks to provideclarity when used among dental professionals, its use withconsumers tends to widen the communication gap.Unfortunately, most dental teams have not been trained toconvey technical thoughts using less intimidating terminology.In many instances, while the dental team may have spent anadequate amount of time informing a patient about their oralconditions and making sound treatment recommendations, theoverusage of technical jargon results in patients leaving theoffice more bewildered than when they arrived.

To further complicate the issue, most patients are reluctantto admit they do not fully understand the explanation deliveredby the practitioner. Exacerbating this is the fact that manydentists tend to be introverts and are not comfortable withconfrontation. This lack of confrontational tolerance mayimply to some patients that their questions are not welcome,thus setting up additional barriers to further understanding byboth parties. To counterbalance this situation, many dentistswho possess an introverted personality elect to utilize dentalauxiliary personnel with more open communication styles tohelp patients feel more comfortable asking for additionalinformation.

Dental Technology

The ever-expanding use of dental technology has greatlycontributed to the ability of the dental team to bridge some ofthe communication gaps that previously existed in dentistry.Most of these new technologies seek to provide patients withthe ability to better comprehend their oral health status. Othersprovide an opportunity for patients to view possible treatmentoptions that may provide solutions. The first technologicalbreakthrough in this arena was the intraoral camera. This deviceconsists of a small camera lens and a light source positioned ina wand-like device that enables the operator to capture magnified,high resolution intraoral images that are instantly visible toboth the patient and the practitioner on a video monitor. Usinga close focusing lens, the camera captures views of the oral cavitythat have previously gone unnoticed by the average patient.From a patient education and communication perspective, one

of the more useful features is the use of split screen views toillustrate and compare normal, healthy oral structures withthose that may exhibit pathology. These images seem to stimulateboth curiosity and concern from most observers. It provides thepractitioner the opportunity to answer questions that, perhapsfor the first time, are truly meaningful to patients since they canrelate the images uniquely to their own personal situations orsymptoms. When patients are presented with personalizedhealth information and given the opportunity to ask morequestions, an environment is created that is much more conduciveto learning than situations where patients are presented with ageneric brochure that may be poorly written and difficult tounderstand.

Another technological innovation is the use of digitalradiography. In addition to allowing dental personnel to takeradiographs at a much lower exposure level than that oftraditional radiographs, the instantaneous viewing of capturedradiographic images is a major step in assisting clinicians intheir diagnostic procedures. These images are magnified andprojected on a computer monitor providing greater detail andlegibility than the small intraoral films used in the past. Dentalteam members utilize computer monitors located in the treatmentrooms to assist patients in learning what structures are visibleon the image and why they are relevant. Like the images takenby the intraoral camera, digital radiographic images may beused as a baseline measurement as well as an adjunct to dentistswhen helping patients to understand their current dentalconditions. Conditions such as decay, abscessed teeth, impactedteeth, and periodontal disease are readily visible on digitalradiographs.

Specially configured digital cameras have also become availableand are a wonderful communication tool. Using a macro lensand specialized flash designs, these cameras can capture oralconditions in great detail. Those images are useful in manyways to the practitioner for the benefit of the patient. A growingnumber of dentists use the digital camera as frequently asradiographs to render a diagnostic opinion, especially when thearea of concern includes a soft tissue component. Examples of softtissue parameters that are better illustrated using a photographinclude gingival inflammation, swelling, recession, or the presenceof exudate. Prior to rendering a diagnostic opinion, thoseimages may be sent to other practitioners, including dentalspecialists, to provide the most comprehensive information tothe patient.

The field of dentistry that has experienced the most growthin recent years is cosmetic dentistry. Practitioners who providecosmetic services have become highly dependent upon digitalphotography to communicate with patients. Sophisticatedsoftware programs utilize imported digital photographs thatpermit dental personnel to provide clinically accurate renderingsof various cosmetic procedures for patient consideration.Dentists also use these images to illustrate desired cosmeticchanges to laboratory personnel who may not have the benefitof direct communication with the patient.

Any discussion of technology relating to patientcommunication would be incomplete without mentioning the



growing use of software programs that allow patients to betterunderstand treatment options. These programs usually providevisual presentations of treatment choices delivered in easilyunderstandable terms by a professional vocalist. Some vendorseven offer interactive software that allows the viewer to controlnot only the subject of the information but also how themessage is delivered. Although these new technologicaladvances can come with a steep price tag, most dentists feel thatthe expense is justified since it invariably helps patients makebetter choices. It also provides the patient with a consistentmessage, thereby eliminating the possibility that importantpoints might be inadvertently omitted from the discussion bythe dentist or auxiliary personnel.

While technology has definitely had a positive impact ondentistry’s ability to communicate with patients, there is nosubstitute for the personal touch. In fact, any attempt on thepart of the practitioner to humanize the health care experiencewill be appreciated. Most people prefer health care professionalswho are truly interested in them as persons rather than justbeing remembered as a number or a name on a chart. Thechallenge for the practitioner is to develop a delivery modelthat allows this interaction to take place without sacrificingtimeliness and efficiency. Many practitioners have come toappreciate the value of incorporating a brief interview into theirnew patient experience. The dentist or a trained auxiliary canspend this time reviewing the patient’s health history, clarifyingprescription drug information, and asking open-ended questionsthat will help discern the patient’s expectations for the day’svisit as well as their oral health literacy level. A highly trainedand intuitive person can gather a great deal of information inthis short time frame that will support the rest of the dentalteam in their efforts to personally connect with this particularpatient. Following the interview, some patients will appreciatea brief office tour. This affords an opportunity for the staff tofamiliarize the new patient with the physical layout of the officewhile also providing the chance to meet other team members.It is also a great time to introduce some of the technology thatis available. The astute auxiliary will not only explain what thetechnology does but also how it helps patients better understandand participate in their treatment.

Some Ideas Enhancing Communication

There are several ways dentists can help patients make betterdecisions relating to their oral health. First, we need to realizethat most patients are not well-informed about their oralhealth. Since the oral cavity is not readily visible, and many

dental disease processes remain asymptomatic for long periodsof time, dentists and auxiliary personnel need to make sure thatthey schedule enough time to allow patients to ask questionsand learn more about their conditions. Second, dentists shouldconsider purchasing various technologies that enable thepatient to learn via the modality that is most effective for theirindividual learning style. Third, dentists and their teams needto evaluate their own ability to communicate with theirpatients. How well are they able to assess a patient’s literacylevel? Do they have a “one size fits all” approach or are they ableto adjust their communication style to one that best serves thepatient’s level of understanding? During my years in privatepractice, the ability to individualize and tailor my communicationwas clearly the most challenging for me. Remember that dentistsusually have contact with every patient who walks in the door,even those who are there for their routine continuing care visit.This means that the dentist must be able to change his or herstyle of personal interaction several times within a relativelybrief time frame. With experience, practitioners will be able toidentify those patients who want to “get in and get out” as well asthose who look at their dental appointment as a social occasion.

Conclusion

The May 2000 document, Oral Health in America: A Reportof the Surgeon General, drew national attention to the importanceof oral health and provided scientific evidence of the integralrelationship between oral health and general health. It alertedthe entire medical and dental community that the gap betweenthe oral cavity and the rest of the body needed to be addressedin a way that informed patients and changed behavior in aneffort to improve the quality of life for all Americans. Sevenyears later, oral health literacy remains a challenge. Americacontinues to become a more diverse country. Each ethnicbackground exhibits its own unique culture, customs, andcommunication preferences. Recognizing those challenges,dental education has begun to incorporate communicationtraining into its curriculum. Dental technology continues to bedeveloped that will help enhance the ability of patients tounderstand more about their oral health. It is incumbent onthose who did not receive formal communication skills trainingto assess their own abilities. Then, they can take the appropriatesteps to ensure they have done everything possible to providetheir patients with the information they need to become partnersin both their dental treatment and the prevention of future oralhealth problems. NCMJ

he issue brief makes a case for the increasingly importantrole the patient plays as part of the health care team in

managing chronic illness, improving health outcomes, andnavigating the complex health system.This commentary discussesthe history of patient engagement in care decisions to show thatempowering the patient to play a stronger role cannot be donein isolation. Health care practitioners must be taught new waysof relating to patients and incorporate those practices into theirday-to-day routines.

One of the challenges and opportunities the North CarolinaArea Health Education Centers Program (AHEC) has is towork with health professions schools and other educators toincorporate these new approaches to care intothe curricula for undergraduate and graduatestudents, residents, and practicing healthprofessionals.This is no simple task since studentsand practitioners are already stretched to thelimit. They are asked to assimilate new materialabout medications and treatments, understandthe changing economic realities of health care,and develop new ways to deliver services. As aresult, AHEC looks for practical ways that wecan introduce evidence-based practices forpatient education and practitioner-patientcommunication throughout the spectrum ofhealth professions education and practice.

Several key regulatory and policy changesover the past 35 years have had a major influencein advancing evidence-based practices in patient education andimproved practitioner-patient communication. These includethe American Hospital Association’s Patient’s Bill of Rights(1972), Medicare’s prospective payment with Diagnosis RelatedGroups (1983), and the Joint Commission on the Accreditationof Health Care Organizations making patient and familyeducation a focus area (1993). Each has raised awareness of the

professional responsibility for teaching and the skills neededto communicate effectively with patients and families.Throughout these developments in accreditation and federalregulation, health care providers and institutions have called onthe AHEC Program for continuing education and clinicaltraining to prepare health professionals and students with theknowledge and skills they need to meet agency and publicexpectations for patient and family education. Many of the firstpatient education programs were hospital-based. The healthcare delivery system has changed dramatically, and clinicianspractice in many different roles and settings. Patient educationis integrated into care delivery in each of these.

Professional Responsibility for Patient andFamily Education

In 1972, in response to the American Hospital Association’sPatient’s Bill of Rights, hospitals emphasized informed consentas the way to ensure the patient’s “right to know.” Specifically,the patient had the right to know about his illness, the diagnostic


Karen D. Stallings, RN,MEd, is associate director of the North Carolina Area Health Education Centers Program at the University ofNorth Carolina at Chapel Hill. She can be reached at karen_stallings (at) med.unc.edu or University of North Carolina at Chapel Hill,Campus Box 7165, Chapel Hill, NC 27599-7165.

Thomas J.Bacon,DrPH, is executive associate dean and director of the North Carolina Area Health Education Centers Program at theUniversity of North Carolina at Chapel Hill.

COMMENTARY

Health Professions Education to Promote Health Literacy:Leverage Points and New Opportunities

Karen D. Stallings, RN,MEd; Thomas J. Bacon,DrPH

“Many health professionalscontinue to struggle with what

to teach, how to identifysurvival skills, and how to

pare down instruction to maketeaching practical.”

T

and therapeutic processes to be used, and the prognosis forphysical recovery. The patient had a right to refuse treatmentand to be informed about the consequences of those actions.This led to formal statements by professional groups includingphysicians, nurses, and pharmacists that addressed patient teachingresponsibilities in their practice standards. The Area HealthEducation Centers Program responded by offering continuingeducation programs to teach health care practitioners the legaland ethical responsibilities for patient education.

The curricula for students in the health disciplines, whethermedicine, nursing, allied health, pharmacy, dentistry, socialwork, or others, underscore the professional, legal, and ethicalresponsibilities they will have to share their medical knowledge ina way that is understandable and usable in the daily managementof health. Student and resident learning about patient-practitionercommunication begins in the classroom. The Area HealthEducation Centers Program facilitates community-based clinicalexperiences in a variety of settings including home care, freeclinics, health departments, schools, senior centers, and long-termcare facilities where students are able to learn that health careencounters extend beyond basic evaluation and diagnosis; theyalso require communicating health care information to patientsand teaching them the skills and knowledge for self-management.This process involves a relationship between patient andpractitioner that is long-term and takes advantage of everyencounter with the health care system to promote healthybehaviors.

Developing Patient EducationMaterials

In developing consent forms and patient educationbrochures, patient reading ability, understanding, language, andculture must be addressed by replacing medical terminologywith plain language, basic concepts, and illustrations. AHEChas advised and continues to advise students and practitionersto develop materials that are at the fifth grade reading level, in thepatient’s native language, and sensitive to cultural and religiousbeliefs. While great strides have been made, researchers continueto find that patient education materials are written far abovethe reading levels of most patients and contribute to problematiclow health literacy. Patients cannot understand directions, lackself-care skills, misuse medications, and are unable to accessneeded services. Health care professionals are frequently notaware of the gap in reading level and patient understanding andof how to rectify it. In light of the report of the North CarolinaInstitute of Medicine task force on low health literacy, theAHEC Program understands that we must continue to raiseawareness among health care practitioners about the prevalenceand impact of low health literacy in North Carolina. The newCenter for Health Literacy Excellence proposed by the taskforce offers North Carolina an excellent opportunity to create acentral source for the best evidence-based tools and curricula forpractitioners so that these resources don’t have to be developedlocally.

Discharge Planning and Patient Safety

In 1983, Medicare’s prospective payment with DiagnosisRelated Groups tied financial incentives to shorter hospitalstays. Patient education efforts focused on discharging patientssafely with the ability to manage some aspects of care at home,especially medications, modified diets, and use of medicalequipment. The pressure to teach more in less time and impartskills (such as insulin injection) needed for self-care initiallymeant that more staff were teaching patients, and teaching wasstarted earlier, often when patients were too ill to absorb theinformation. The Area Health Education Centers Programcontinuing education workshops teach practical strategies tocoordinate teaching provided by various health disciplines,document patient learning, and provide consistent informationto patients and families. Practitioners are urged to reduce thenumber of handouts and facts to be taught and actively engagepatients in learning using teach back, role play scenarios, andreturn demonstration of skills. Many health professionalscontinue to struggle with what to teach, how to identify survivalskills, and how to pare down instruction to make teachingpractical.

In 1993, the Joint Commission on the Accreditation ofHealth Care Organizations (JCAHO) made patient and familyeducation a focus area, insisting that all patients and familiesreceive the education necessary to acquire survival skills, utilizecommunity resources, and understand the role patients mustplay in their treatment plans. The Joint Commission’s patientsafety initiatives place patients and families at the center of thehealth care team and open lines of communication amongpatients and practitioners which are viewed as essential. Manyhospitals have called on AHEC to assist with staff developmentefforts for managers and front-line staff related to JCAHOmandates for accreditation.

Chronic Illness and DiseaseManagement

Today there is a growing awareness of the improvementsin health outcomes that can be realized by incorporatingevidence-based prevention and disease management strategiesinto the patient care practices of physicians and other primarycare practitioners. Patient involvement and empowerment areessential for the success of these approaches, however, andpatients with chronic diseases who also have low health literacyhave less knowledge about their disease, more complications,and worse health outcomes. Patients and families may seekhealth information from other sources including the Internet,relatives and neighbors, and cultural or religious communities.The ability to exchange ideas, identify inaccurate information,and acknowledge patient choice requires openness and flexibility.The Area Health Education Centers Program continuingeducation efforts bring health librarians to teach practitionersabout information patients find in lay literature and on theInternet and how to help patients access reliable sources.

The cornerstones of chronic illness management include



smoking cessation, weight loss, regular exercise, stress reduction,and adherence to medication regimens. Patient educationefforts drive home in a forceful way the changes that patientsneed to make.

Health professionals tend to view cooperation or complianceas a single choice. Following a therapeutic diet, however, involvesmultiple choices throughout every day. Being compliant with atreatment plan for chronic illness may be costly, painful, orsocially isolating. It is important to acknowledge the frustrationthat many practitioners feel when patients are unable or unwillingto comply with all the behavioral changes that are prescribedand to stress that patient teaching for effective management ofchronic illness should have broader goals than compliance. Aswe prepare present and future health care practitioners to teachpatients, AHEC student and continuing education programsshould stress that helping patients understand their disease is agood beginning, but self-efficacy also relies on very specificaction plans and daily strategies that patients choose to engagein which will ultimately lead to achieving long-term goals.Practitioners can incorporate practical strategies such as limitingthe number of changes, making easier changes first, and workingwith families to anticipate barriers such as the cost of medications.Patient education is a partnership in which professionals mustalso strive to be role models and coaches for these health practices.

Future Opportunities

New initiatives currently underway in North Carolina toimprove quality and patient safety in physician offices, hospitals,health departments, and other settings offer exciting opportunitiesto incorporate better patient-practitioner communicationtechniques, improve patient education materials, and create abetter system of care that includes the patient as a critical partof the health care team. Incentives to improve outcomes willinclude moves by Medicare, Medicaid, and private insurers tobegin rewarding physicians and other practitioners through payfor performance programs. The new climate will enhancemotivation for health professionals to utilize the most advancedtechniques in educating patients, simplifying processes of care,and incorporating the patient into the process.

North Carolina is on the cutting edge in developingprograms to enhance quality and patient safety. The nationalprogram Improving Performance in Practice, funded by theRobert Wood Johnson Foundation and others, selected NorthCarolina as one of 2 pilot states. The project, a collaborativeeffort of the Community Care Networks, AHEC, the medicalprofessional societies, and state health agencies has beensuccessfully implemented in 2 regions this year and will bedeveloped in 3 more regions this fall. The program seeks tosupport physician practices in collecting data on how chronicillness is managed in the practice and then offer assistancethrough a regional quality improvement coach to makeimprovements that lead to better health outcomes for patients.

The North Carolina Center on Hospital Quality andPatient Safety of the North Carolina Hospital Associationengaged more hospitals than any other state in the national

100 000 Lives Campaign and now leads North Carolinahospitals in participating in the 5 Million Lives Campaign. Bothinitiatives seek to improve outcomes in hospital quality throughquality collaboratives, educational programs, and greatertransparency of data on quality measures of care.

Particularly in the outpatient setting, these quality initiativesrequire new approaches to managing chronic illness and fosteringprevention at both the individual patient level and the practicelevel. Practitioners will be required to learn new skill sets, butpatients will also have to be more engaged in the process ifsuccessful outcomes are to be achieved.

AHEC Statewide Initiatives to PromotePatient-Practitioner Communication

The Area Health Education Centers Program is committedto playing its traditional role of incorporating educationalmaterials and curricula into all phases of the educationalprocess in collaboration with the educational institutions of thestate. The following recommendations address new efforts tomeet the needs and challenges mentioned in the precedingparagraphs:

(1)AHEC can assist the health science schools in identifyingand utilizing community-based clinical experiences thatadvance students’ skills in patient education. Our mutualgoal is to help students take concepts introduced in theclassroom and apply them with the guidance of skilledcommunity preceptors. The Area Health Education CentersProgram can offer grant funding to support the developmentor expansion of new clinical experiences for health sciencestudents and would place priority for funding decisions onprojects that include interdisciplinary collaboration, use ofeffective written patient instructions, patient and familyteaching, and assessment of learning outcomes. Patients andtheir family members can be incorporated into trainingprograms by sharing their stories about living with andmanaging chronic illness. This will add another dimensionto what is taught in the classroom.

(2)AHEC will continue to offer continuing education programsthat address how to evaluate and rewrite materials and thatidentify practical ways to screen patients for low healthliteracy. Interdisciplinary AHEC continuing educationworkshops with case studies and role play can helppractitioners become more skillful using the teach-backmethod. It is important for each discipline to consider theunique contributions it can make to teaching. For example,when practitioners confirm the diagnosis and the dailymanagement needs with patients, this sets the stage forongoing teaching by other disciplines. Sharing experiencesamong different disciplines illustrates the gap between whatpatients need and what is provided. For example, whennurses make home visits, they become aware that a writtenaction plan is critical to activating patients for self-care.

(3)AHEC librarians can provide health care practitioners withinformation about resources available on the Internet, howto evaluate Web sites for reading level and illustrations, andhow to steer patients to reliable and accurate sources. At thesame time, we must look for new ways to make thisinformation available when practitioners and patients needit. Online resources, materials developed through theproposed Center for Health Literacy Excellence, and othernationally developed tools need to be available in real time,and practitioners need to be educated to use them mosteffectively. The Area Health Education Centers Program canhighlight these resources in continuing education programsand include links to them via the AHEC Digital Library.TheNorth Carolina Institute of Medicine Task Force on HealthLiteracy has identified many experts and agencies withvaluable resources that can assist us in transforming patienteducation practices to address low health literacy, and AHECcan raise awareness among health care professionals.

(4)AHEC can develop learning collaboratives and invitepractitioners to participate in the sharing of best practices and

practical strategies for patient-practitioner communication inthe management of chronic illnesses. In caring for childrenwith asthma, the consistent use of daily management plans,family teaching, and consistent follow-up with asthmaregistries are effective. These effective techniques can beshared to improve care for other chronic illnesses.

For over 3 decades, the AHEC Program has been activelyengaged in efforts to promote patient partnership and patienteducation. Incorporating communication and patient educationtechniques in continuing education and patient training hasgained momentum as the result of new regulatory measures.The current climate places a much greater emphasis on betterpatient outcomes, including establishing uniform standards ofcare for managing chronic illnesses and assisting practitionersin measuring and improving the outcomes of their practices.This serves as a catalyst for greater strides in patient education. Ifwe are to realize fully the kinds of improved health outcomes thateveryone wants, it will be essential for patients to be fully engagedin the process of managing chronic illness and to play a greaterrole in making better decisions about lifestyle issues. NCMJ


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How to Reach Us

ost people who have seen the classic movie Cool HandLuke will never forget the famous admonition by the

chain gang’s boss, played by Strother Martin, to Paul Newman,just after he submits him to a vicious beating for insubordination.The boss justifies his psychopathic actions by informing Newmanand his fellow inmates, “What we have here is a failure tocommunicate.” Our profession has heard from multiple quartersover the past decade that we have failed to communicate inmany ways with our patients and with one another. When wehear such accusations, we recall this iconic scene and the dreadedpunishment for so failing. We certainly do not want be beatenup nor do we advocate beating up on ourselves. In the best spiritof professionalism, we need to examine communication problemsand actively seek and apply solutions.

Some observations are obvious. We glibly use the vocabularyof medicine that took several years of intense study and repetitionto master to communicate with our colleagues and, too frequentlywe admit, with our patients. We have allbeen guilty of using seemingly simplewordsor phrases such as “lesion,” “bronchoscopy,”or “intravascular catheter” and then wincedat our insensitivity when our patients’ eyesglazed over or faces grimaced in confusion.Sensitivity on our part would go a longway in helping our message in suchcircumstances. Many of our medicalschools are now addressing sensitiveand patient-centered methods ofdoctor-patient communication.

Research in the growing field ofhealth literacy demonstrates betterpatient understanding when words arecarefully chosen in speech or writtencommunication and are targeted at 4thto 6th grade reading levels even when formal education may beat a much higher level.1 Current estimates indicate that nearlyone-third of our population, or over 90 million Americans,

read at this basic level. Another 15 million have extremelylimited to no ability to read.1 This is not a small or isolatedproblem.

One immediately visible area where reading literacy affectshealth literacy is in administration of prescription medicines.Recent investigations show significant patient confusion overmedication use and prescription directions, and this work hasled to recommendations and policy actions to improve writtenmaterials for patients and parents or guardians of children.2

Confounding this are the confusing ways pharmacies labelmedicine containers; there is no systematic pattern to the labelsand the print is not large enough for much of our elderlypopulation to read without magnification. Since most pharmacylaws are specific to each state, we need to advocate for changethat will improve patient understanding and readability ofmedication labeling and of all things that we share in writingwith our patients.

We also have to increase our current glacial slouching towardthe broad adoption of electronic medical records. With electronicmedical records, we will see a comprehensive assessment of the

A Failure to Communicate

TimothyW. Lane,MD; J. Carson Rounds,MD

COMMENTARY

TimothyW.Lane,MD,FACP, is a professor ofmedicine at The University of North Carolina at Chapel Hill andMoses Cone Hospital andgovernor of the North Carolina Chapter of the American College of Physicians. He can be reached at tim.lane (at) mosescone.com or1200 N Elm Street, Greensboro,NC 27401-1020.

J. Carson Rounds,MD, is president of the North Carolina Academy of Family Physicians, Inc.

M


“We have all been guilty of usingseemingly simple words or phrasessuch as ‘lesion,’ ‘bronchoscopy,’ or‘intravascular catheter’ and thenwinced at our insensitivity whenour patients’ eyes glazed over orfaces grimaced in confusion.”


quality of care we provide in terms of process and outcomes.The hope is that electronic medical records will promotelegibility, monitoring of chronic disease management programs,sharing of important information with other practitioners, and,not least, delivery to our patients of literacy-sensitive documentssummarizing and educating them about their health.

As professionals we have always philosophically held to theprinciples of accountability, quality, and fairness and now, asnever before, our work is cut out for us. However, despite the

burdens and tasks of practicing medicine in the 21st century,we must never lose sight of our common goal and mostimportant outcome: the well-being of our patients. As Harvardphysician Francis Weld Peabody so succinctly said in 1912,“...the secret of the care of the patient is in caring for thepatient.”3 New approaches to health literacy, evidence-basedapplication of our skills, and our own sensitivity are just someof the tools of caring that we must have in our metaphoricalblack bags. NCMJ

REFERENCES

1 Institute of Medicine of the National Academies. HealthLiteracy: A Prescription to End Confusion. Washington, DC:National Academies Press; 2004.

2 DeWalt D, Berkman N, Sheridan S, Lohr K, Pignone M.Literacy and health outcomes: a systematic review of theliterature. J Gen Intern Med. 2004;19(12):1288-1239.

3 Peabody, FW. The care of the patient. JAMA.1927;88(12):877-882.

Nationally recognized integrated healthcare system in Virginia Beach has immediate openings for full time

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The University of North Carolina Hospitals (UNC-H)is calling for applications to a:

Residency in General PreventiveMedicine/Public Health

at UNC Chapel Hill(Commencing July, 2008)

The resident will:1. In the academic year, undertake a Master’s Degree in

Public Health at UNC, and2. In the practicum year, pursue research and practicum

rotations in a variety of clinical and public health settings.

Graduates will be board eligible in Preventive Medicine.

Applications will be made to both the Preventive MedicineResidency (deadline November 1) and to the UNC School ofPublic Health (deadlines vary by department, but beginaround January 1).

Applicants must have completed an internship year in aprimary care specialty in an ACGME-accredited program; be aU.S. citizen or permanent resident; have completed medicaltraining in an LCME-accredited medical school; possess acurrent certificate from the Education Commission for ForeignMedical Graduates (if applicable); and have a valid medicallicense in the United States.

For information on the preventive medicine residency andhow to apply, please see: http://www.med.unc.edu/wrkunits/2depts/soclmed/PREVENTIVEMED/PrevMedHomePage.htm

For further information, please contact

Deborah Porterfield,MD,MPH, Residency Director atporterfi (at) email.unc.edu or (919) 843-6596.


Spotlight on the Safety NetA Community Collaboration

Mike Darrow,CFRE

PractitionerVolunteerism at Free Clinics: A Critical Need

What Is a Free Clinic?A free clinic is a private, nonprofit, community-based organization that provides medical care at little orno charge to low-income, uninsured, and underinsured persons through the use of volunteer health careprofessionals and partnerships with other health care providers. The North Carolina Association of FreeClinics (NCAFC) has 69 member clinics—more free medical clinics than any state in the country. The firstfree clinic in North Carolina was the Open Door Clinic in Raleigh, which was established in 1985.

No 2 free clinics are alike. They are custom designed by communities to meet identified health care needsusing the community's unique health care assets and resources. Free clinics are governed by volunteerboards of directors that represent a broad cross section of the community.They may provide acute and/orchronic health care, laboratory, dental, pharmacy, substance abuse, and/or mental health services. Licensedprofessional practitioners render all services to the clinics’uninsured patients.

Because they are private, nonprofit organizations supported primarily by cash and in-kind contributionsfrom the private sector, volunteerism is a central feature of free clinics. Clinic services are provided primarilyor exclusively by volunteer health care professionals serving in the clinic's own facility or in their own privatepractice settings. Lay volunteers also perform a variety of administrative and clerical tasks, which keepsoverhead costs low.

In North Carolina, low-income, uninsured, and underinsured adults have the greatest difficulty accessingaffordable health care services.While eligibility criteria vary from one clinic to the next, free clinics conductrigorous eligibility screenings to ensure that the patients they serve are truly in need. Free clinics believethat inability to pay should not prevent people from receiving quality health care. To this end, the clinicsprovide services at little or no charge. Free clinics place a strong emphasis on providing nonjudgmental,compassionate care that respects the dignity and self-worth of every patient.

Volunteer Practitioner TrendsIn 2005 free clinics in North Carolina reported utilizing 6443 volunteers,of which 1167were physicians.a Thetotal number of physician volunteers in free clinics actually declined from 2004 to 2005 by 10.3% while thetotal number of hours volunteered increased by 3.8%. It appears that clinics are losing volunteer physicians,but the ones who continue to support the work of free clinics are volunteeringmore hours.The decrease inNorth Carolina’s practitioner volunteers reflects a nationwide trend.1

continued on page 375

According to recent estimates 1.4 million people in North Carolina, or over 17% of the adult population,have no health insurance. North Carolina’s uninsured population is growing at a rate faster than thenational average. Free clinics act as a safety net by attempting to bridge the gap in health care access forthe state’s uninsured. Because free clinics are local, volunteer-based organizations, the supply of practitionervolunteers is critical to their survival and success in serving the needs of the uninsured.Free clinics strugglewith obtaining sufficient practitioner volunteers to meet the demands for services.

a It is important to note that these numbers are most likely underreported.They do not include 12 new clinics addedto NCAFC since 2005, and 7 clinics reported no data.The latter reflects the difficulty clinics have in tracking volunteerhours.


There are a number of reasonswhy fewer practitionersmay choose to volunteer in free clinics.First, the numberof theuninsuredand theproportionneeding chronic care is increasing.Managing thegrowingdemand for thecomplex services needed to treat those with chronic diseases adds additional strain and stress on volunteerphysicians.There is also increasing economic pressure on active physicianswho are facing reduced third-partypayments and increased operating costs in their private practices. This requires physicians to spend moretime seeing patients in their practice, thus reducing the amount of time available to volunteer.

There are also a number of actual and perceived barriers to volunteering.Physicians often cite malpracticeor insurance issues as compelling factors in deciding not to volunteer. Additionally, retired physicians citemaintaining continuingmedical education hours as another barrier.Physicians alsomention confusion aboutmaintaining their licenses, unaware of the volunteer license specifically designed for volunteering at a freeclinic.

Strategies to Increase Volunteerism by PractitionersThere are several strategies that NCAFC is undertaking to increase the number of physician volunteers infree clinics. The first is to increase recruitment of retired physicians. The NC Association of Free Clinics isworking with the American Health Initiative on a project entitled TAP-IN, which is a Web-based projectfocusing on increased awareness of volunteer opportunities for retired medical providers in free clinics.This program was piloted in 3 clinics and resulted in additional volunteer practitioners in those clinics.Theprogram went statewide as of April 2007.

The NC Association of Free Clinics is also focusing onmarketing free clinics to raise awareness of their workand the people they serve. On April 24, 2007 NCAFC sponsored a Statewide Open House in which all 69NCAFC member clinics were open to the public on the same day. The Open House received statewidemedia attention as well as local exposure.Raising overall awareness of free clinics and publicizing the needfor volunteers should have a positive effect on practitioner recruiting.

TheNCAssociation of Free Clinics views its partnershipswith theNorth CarolinaMedical Board and theNorthCarolinaMedical Society as critical to the success of free clinics.Both organizations are very supportive of thework of free clinics and have been instrumental in streamlining the volunteer licensing application, informingretiringphysicians about changing their licenses fromactive to volunteer,andworkingwith clinics and retiredphysicians from out of state to obtain volunteer licenses. The NC Association of Free Clinics also works inpartnership with these organizations to enhance the volunteer experience for the practitioner.

Finally, NCAFC is collaborating with insurance providers to offer special professional liability policies forvolunteer practitioners at very affordable rates.This is a very important factor in recruiting more practitionervolunteers.

ConclusionWith 1.4 million uninsured in North Carolina, free clinics cannot be the solution to providing health care toour friends and neighbors.However,with the assistance of practitioner volunteers, our clinics can continueto help bridge the gap for the uninsured in our state while long-term solutions are developed.Rather thanwait for those solutions, the North Carolina Association of Free Clinics is acting now to engage NorthCarolina’s communities and enlist thousands of volunteer practitioners.

continued from page 374

MikeDarrow,CFRE, is executive director of theNorth Carolina Association of Free Clinics.For information on volunteering at a free clinic,go towww.ncfreeclinics.org orwww.TAP-IN.org.

REFERENCES

1 Isaacs SL, Jellinek P.Grantwatch Report: Is there a (volunteer) doctor in the house? Free clinics and volunteerphysician referral networks in the United States.Health Affairs. 2007:26(3): 871-876.


he General Baptist State Convention of North Carolina(GBSC) has actively sponsored disease prevention and

health promotion services since 1978. The Faith and HealthInitiative, sponsored by Kate B. Reynolds CharitableTrust, is themost recent of several area-based health promotion efforts.Whilethe focus of GBSC health initiatives vary, including maternal andchild health, smoking cessation, nutrition education, enhancementof parenting skills, and reduction in incidence and control ofdiabetes, faith-driven values and strategies motivate and direct thedevelopment, implementation, and ongoing work of each project.

Project efforts utilize the historic role of the African-Americanchurch as initiator, enabler, and sponsor of activities to improvelife at the community level. Programs are initiated by discussingspecific health concerns with pastors and selected lay leadersand asking them if programs focused on these concerns seemright for their congregations. Potential benefits to participantsare considered as well as the role the church will be asked to playin implementation. A long tradition of lay leader participationin setting congregation priorities benefits program implementation.Each church has a structural authority to select prioritiesindependently of central governance structures. A key componentof these programs is the selection and training of volunteerswho will be responsible for recruiting participants, coordinatingchurch and community resources, facilitating participation,and providing specialized training when appropriate.

The Faith and Health Initiative, a primary and secondaryprevention program, was designed to significantly change riskbehaviors through encouraging nutritionally sound dietarypractices, increasing physical activity and exercise, and utilizingthe intersection between faith and health to strengthen andincrease project viability and sustainability. Four GBSCAssociations (regional subunits of the statewide Convention)serving rural underserved counties in the northeastern part ofthe state served as the targeted intervention points. Althoughthe geographic area may be characterized as socioeconomicallychallenged, it is rich in human, cultural, and spiritual resources.

To build on this strong infrastructure, center leadership firstenhanced the relationship between the Associations’ pastoralfaith leaders (called moderators) while seeking a shared vision asthe springboard for the project. These leaders were instrumentalin assisting the project in identifying 4 project facilitators (1 foreach association) to coordinate the project at the regional level.

Facilitators were diverse in demographic background (eg,education, age, sex, and occupation). However, the commondenominator was their active involvement with their associationsand the way in which they were respected by other parishionersand the community in general.

From the beginning of the project, the faith leaders of theparticipating associations were engaged. Recognizing the criticalrole pastors play in supporting project efforts and in translatinghealth teachings in relation to theological understandings, theproject continued to actively include pastors in project planningand updates through quarterly meetings of participatingchurches’ pastors. These meetings provided an opportunity toexpose pastors to the project curriculum and selected activities,allowing them to better assist in the diffusion of information toparishioners. Also key to parishioner involvement and support,were the lay volunteers and natural helpers recruited for therespect they receive, the guidance they are sought for, and thehelping role they play in the lives of fellow parishioners andothers in their network.

An essential component of the Faith and Health Initiativeand other GBSC projects is the development of partnershipswith local human service agencies. These partnerships are criticalin the continued support and sustainability of these locally ownedprojects. The Faith and Health Initiative enjoyed partnershipswith both public and private entities.These working relationshipsnot only maximized the resources available to the project andcommunity, but also resulted in some of the relationshipsbetween resource staff and project leaders surviving past the formalproject funding period.

Positive project outcomes were evident at both the individualand organizational level. Individuals experienced increasedknowledge and behavioral modification (eg, increased fruit andvegetable consumption and increased physical activity) and becameadvocates within their social networks for health promotion policyand environmental changes. At an organizational level, churchesand associations made system-level policy and environmentalchanges including establishment of health committees as ongoingorganizational components, changing to healthier menu selectionsat congregational meal functions, and establishing walkingtrails on church grounds. The groundwork laid by the Faithand Health Initiative continues to provide fertile soil foraddressing health disparities in these communities.

Health Promotion and African-AmericanBaptist Churches in North Carolina

T

PHILANTHROPYPROFILES

M.Anita P.Holmes, JD,MPH; John Hatch,DrPH,MSW

M.Anita P.Holmes, JD,MPH, is the past executive director of the Center for Health and Healing, a nonprofit affiliate of the General BaptistState Convention of North Carolina.She currently services as branch head in theHeart Disease and Stroke Prevention Branch,NCDivision ofPublic Health,and as executive director of the Justus-Warren Heart Disease and Stroke PreventionTask Force.

JohnHatch,DrPH,MSW, is a senior programdevelopment officer for the Center for Health andHealing.

Running the NumbersA Periodic Feature to InformNorth Carolina Health Care Professionals

About Current Topics in Health Statistics

From the State Center for Health Statistics,NCDepartment of Health andHuman Serviceshttp://www.schs.state.nc.us/SCHS

Selected Data Related to Health Literacy in North Carolina

Health literacy is the ability of people to understand basic health information, communicate with healthpractitioners, and properly use health services. Low health literacy might be associated with, for example, theinability to read and comprehend basic health-relatedmaterials such as prescription bottles and appointmentslips.Studies suggest that people with low health literacy are less likely to take their medications as prescribedor follow treatment protocols, less able to manage their chronic conditions, andmore frequently hospitalized.1

There is new evidence that people with low health literacy have higher death rates.2 Health literacy problems aremore common among racial and ethnic minorities, the elderly, and people with lower education achievement orlower income, but people from all walks of life struggle with health information.

Some of the surveys fielded by the State Center for Health Statistics in North Carolina provide information aboutthe level of health knowledge on certain topics.Health knowledge deficits may reflect underlying health literacyproblems. Low rates of health knowledge could reflect that the population had difficulty understanding themessage, but it could also reflect a failure of message dissemination.

The data summarized in this article are drawn from 2 surveys. The Behavioral Risk Factor Surveillance System(BRFSS) is a random telephone survey of persons ages 18 years and older in the state. The Pregnancy RiskAssessment Monitoring System (PRAMS) is a random mail and telephone survey of new mothers in NorthCarolina. Below are selected data from these surveys that give insight into health knowledge in our state.

continued on page 378


Measure Source Year PercentagePercentage of newmothers who have ever heard or read thattaking the vitamin folic acid can prevent some birth defects PRAMS 2004 83.1

Percentage of diabetics who check their blood for glucose orsugar every day BRFSS 2005 62.2

Percentage of diabetics who check their feet for sores orirritations every day BRFSS 2005 71.9

Percentage of diabetics who have ever taken a course orclass in how to manage your diabetes yourself BRFSS 2005 54.7

Percentage of adults who identified all 5 heart attacksymptoms correctly BRFSS 2005 10.0

Percentage of adults who identified all 5 stroke symptomscorrectly BRFSS 2005 16.6

Percentage of adults age 50+ years who think that peopletheir age or older who do not have symptoms should betested for colon or rectal cancer BRFSS 2005 94.9

Percentage of men age 40+ years who rated theirunderstanding of the advantages and disadvantages of PSAtests as excellent or very good BRFSS 2005 49.0

Table 1.North Carolina Health Knowledge


The low percentages shown in the table for individuals who practice proper diabetes management, correctlyidentify heart attack and stroke symptoms, and report they understand PSA tests suggests substantial problemswith health knowledge in the overall population of adults in North Carolina.More detailed data (for example,broken out by demographic categories) can be found at www.schs.state.nc.us/SCHS (click on BRFSS or PRAMSon the left side of the page under Health Data). For example, the 2005 percentage of adults who identified all5 stroke symptoms correctly was 6% for those with less than a high school education compared to 26% forthose with a college degree.

A study on a North Carolina heart failure self-management program showed that an intervention designed forpatients with low literacy reduced the rate of hospitalization and death in the intervention group as comparedto a control group.3 In another study, patients with diabetes and low literacy benefited more from a diseasemanagement intervention compared to those with diabetes and higher literacy skills.4 These studies suggestthat well-designed programs to engage and educate patients about their own chronic illness and diseaseself-management will help reduce morbidity and other problems associated with low health literacy.

Health literacy depends not only on individual capacity to communicate and understand health informationbut also on the demands posed by society and the health care system.5 For example, health care professionalshave a responsibility to reduce the complexity of their speech and written materials and simplify access tohealth care services. Finally, improving the levels of literacy, education, and income in the general populationwill have the effect of increasing health literacy in North Carolina.

continued from page 377

Contributed by Paul A.Buescher,PhD,State Center for Health Statistics; Alexander E.White, JD,MPH,Heart Disease and Stroke Prevention Branch,NCDivision of Public Health;Darren A.DeWalt,MD,MPH,

Division of General InternalMedicine,University of North Carolina at Chapel Hill

REFERENCES

1 DeWalt DA, Berkman ND, Sheridan S, et al. Literacy and health outcomes: a systematic review of the literature.J Gen InternMed. 2004;19(12):1228-1239.

2 Baker DW,Wolf MS, Feinglass J, et al.Health literacy and mortality among elderly persons.Arch InternMed.2007;167(14):1503-1509.

3 DeWalt DA,Malone RM,Bryant ME, et al. A heart failure self-management program for patients of all literacylevels: a randomized, controlled trial.BMCHealth Serv Res. 2006;6:30.

4 Rothman R,DeWalt DA,Malone RM,Bryant B, et al. Influence of patient literacy on effectiveness of a primary-carebased diabetes disease management program. JAMA. 2004; 292(14):1711-1716.

5 Baker DW.The meaning and the measure of health literacy. J Gen InternMed. 2006;21(8):878-883.


To the Editor:

The North Carolina Institute ofMedicine should be commended for itstimely recognition of the issues relating tomedical manpower as addressed in theMay/June 2007 issue of the North CarolinaMedical Journal. The North CarolinaAcademy of Family Physicians publishedsimilar concerns over a decade ago in itspublications Who Will Take Care of OurPeople? and Who Will Care for OurCommunities? These were red flags to theNC General Assembly and the academiccommunity from family physicians in thisstate who realized that the population wasincreasing while growing more aged andsickly, and that fewer medical students were choosing primarycare and family medicine as a career. Sadly, there was noresponse, but this was the age of managed care, and we did seea small increase in family medicine match rates. Since thattime the state’s population has more than doubled and becomeon average older, and we find significant maldistributions ofhealth care. Many of our state’s citizens are underserved andface health care disparities. Unfortunately, both of our callswent unheeded. Perhaps your efforts will meet with moresuccess in arousing public awareness of this urgent issue.

It is not surprising the NC Institute of Medicine foundthat even if we begin training more primary care and familyphysicians today, there will still be a deficit in the providers offirst line care in the foreseeable future. Our answer: THEREALREADY ARE too few primary care physicians to provide amedical home for all of the citizens of our state. Unless there isa change in the number of students choosing careers in primarycare, the crisis threatens to be catastrophic.

There has been significant discussion about increasingclass size at each of the four academic institutions as well asproposals for a fifth training site in Charlotte. None of thesuggestions include an increase in the number of primary careproviders in North Carolina. For many years the legislaturehas required that our universities report the specialty selection ofthe senior class of each school. However, this is an accountingof merely the intern year and does not consider matches ingeneral internal medicine/pediatrics for a preliminary yearwhere many go on to subspecialize. Strong considerationshould be given to a change in legislation that requiresaccountability upon completion of residency. The AmericanAssociation of Medical Colleges and the American MedicalAssociation have recommended a graduation rate of 50%primary care and 50% specialty care physicians. This is nothappening in our state and has contributed to the currentshortage of primary care providers.

If past history is a predictor of the future, the plight ofhealth care in this state will only worsen, and North Carolina

citizens will have to pay more for a system inwhich they receive care that is fragmentedand reactive rather than preventative orcomprehensive.

Why do countries such as Cuba andGreat Britain rank higher in quality ofcare despite spending significantly lesson health care than the United States?The answer is quite simple. It is theuncomplicated access to well-trainedprimary care physicians. The data inBarbara Starfield’s research supportsthis premise. We have in this statedemonstrated—through the work ofCommunity Care of North Carolina—asystem which achieves better access and

improved quality of care while also achievinga cost savings. The basis of this system is that each patient isassigned a primary care medical home. The model utilizes caremanagers, pharmacists, nutritionists, and project specialists toassist in education of patients and improve standards of care.This is the model that has the potential to achieve the desiredimprovements in health outcomes sought by the NC Instituteof Medicine. We do not need academic centers to createanother model of inefficient, costly care.

I challenge our academic leaders to study the CommunityCare of North Carolina model, embrace the concepts ofquality-based and accessible care, and provide physicians whocan serve those needs in this state.

The North Carolina Academy of Family Physicians standsready to aid in achieving this lofty goal.

Respectfully,Michelle F. Jones, MD, FAAFP

PresidentNorth Carolina Academy of Family Physicians

To the Editor:

I would like to comment on some issues that were touchedupon in the article by Dr Harvey Estes in the May/June issueof the North Carolina Medical Journal. I feel compelled to saythat it was through Dr Estes’ diligent efforts and pioneeringwork at Duke that the Physician Assistant Program came intobeing in North Carolina and subsequently became a vital linkin health care delivery in our state and a model to the nation—with the Nurse Practitioner Program to follow.

I think the real core of dissatisfaction in the general publicabout the health care delivery system centers around concernsof expense, the limited availability (not the quality) of health

Readers’ Forum


care, and the general perception of diminished interest in theindividual patient by physicians. It is my perception that thepublic would readily accept the expense and logic for thecreation of another state-owned medical school. I have alwaysfelt that there has been an abundance of qualified NorthCarolinians for medical training.

Since the advent of the Brody School of Medicine at EastCarolina University, North Carolina has grown 2 million inpopulation. It is interesting to recall that this school was violentlyopposed during its inception by the state’s then 3 medicalschools.

I also feel that economic and social changes are apparent inthe culture of the medical profession. There is a willingness toaccept more professional regimentation in order to escape theadded hours and business aspects of practice and a seemingdesire to escape close personal relationships with clientele.

This capitalistic approach is, to me, the excessive zeal for theaccumulation of wealth which leads to unfettered capitalism,control through ownership, and favoritism to hospitalemployed or affiliated physicians. This situation serves as adeterrent to physicians with the same credentials and staffmemberships to enter private or small group practices; ergo,establishing a private or small group practice starts out morerisky, and its growth and survival is problematic.

Here in my hometown there is a strong feeling or recognitionin private practices that if the hospital's ownership doesn’t extendto your practice, you probably won’t get equal opportunity toshare in the patient pool. New physicians do not come to acommunity expecting to be discriminated against by themanagement of local hospitals. Equal opportunity should beapplied to physicians regardless of affiliation.

Respectfully,John R. Gamble Jr, MD

Lincolnton, NC

To the Editor:

The May/June 2007 issue of the NC Medical Journal definedthe challenges faced by North Carolina in providing primarycare, obstetric care, and psychiatric services to individualsacross the state. As a clinical specialist in child and adolescentpsychiatric and mental health nursing since 1990, and a recentlylicensed family psychiatric and mental health nurse practitioner(PMH-NP), I would like to respond from an individualpractitioner perspective.

In my work with children and families, I became acutelyaware of the impact of limitations in the availability ofpsychiatric practitioners. Primary care practitioners (PCPs)have been instrumental in filling the gap when medicationwas part of the treatment plan. However, with publicizedwarnings about possible side effects of some psychiatricmedications and a growing demand for PCP services, somePCPs became less willing to manage psychiatric medications.In my experience, it was not unusual to see a child wait monthsto see a child psychiatrist, which often resulted in majorimplications for the child’s academic and social functioning.These experiences motivated me to obtain post-masters

education as a family PMH-NP at the University of NorthCarolina at Chapel Hill School of Nursing.

I am fortunate to work for an organization that supportedmy ability to pursue the education and clinical placementsnecessary for training. FirstHealth of the Carolinas has alsofacilitated my ability to arrange collaborative practice agreementsand supervision time with three highly skilled and experiencedpsychiatrists. This has been vital in my transition to thisexpanded role.

As resources for psychiatric and mental health servicescontinue to be stressed, it is important that psychiatrists andcommunity organizations be willing to provide the kind offacilitation that I have experienced. I also support Erin Fraher’srecommendation to develop innovative models of interdisciplinarycare that incorporate advanced practice psychiatric nurses intothe psychiatric team. It is my hope that educational institutions,psychiatrists, and nursing leaders will continue to work towarddeveloping models that serve to expand clinical resources to ourcitizens.

Sincerely,Elizabeth Watson, MSN, PMH-NP

FirstHealth of the CarolinasOutpatient Behavioral Services

Pinehurst, NC

To the Editor:

Your recent issue on physician supply indicated that theremay be an emerging shortage of general surgeons. I havedecided to pursue general surgery in my residency next year,and it may be useful for others to know why.

There are many reasons that I have decided to apply togeneral surgery residency programs this fall. During medicalschool, I discovered that I like the intensity of the interactionbetween patient and surgeon, the variety of health care issuesfaced while working in a clinic and an operating room, andthe opportunity to master technical skills in addition to thediagnostic skills required of all physicians. Becoming any kindof surgeon could satisfy these interests, but I have chosen topractice general surgery. Although the old paradigm of generalsurgeons being similar to family doctors on the front lines ofprimary care is probably no longer true, except for in the mostrural settings, the concept still appeals to me. I respect thecommunication and shared decision making skills that manyprimary care physicians possess, and I hope to emulate themin my own practice. I value practicing in a field of medicinethat is accessible and comprehensible to patients. And, it isfulfilling to know that my career as a general surgeon mighthelp fill an unmet need in the country’s health care system.

Katharine L. McGinigleMedical student

The University of North Carolinaat Chapel Hill

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Important Safety Information: In clinical trials the most common side effect assessed as possibly or probably related to ACIPHEX with a frequency greater than placebo was headache (2.4% vs 1.6% for placebo).

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IsYourPractice Lookingfor aPhysician?

TheNorth Carolina Medical Journal classified section isone of the the few channels that reaches large numbersof North Carolina physicians with information about

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Our classified ads can help your practice find the rightphysician as well as helping physicians find compatible

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Coming in theNovember/December 2007 issue of the

NorthCarolinaMedicalJournal

a look at:

Arthritis

CLASSIFIED ADS: RATESAND SPECIFICATIONS

The Journal welcomes classified advertisements butreserves the right to refuse inappropriate subjectmatter. Cost per placement is $60 for the first 25 wordsand $1/word thereafter.

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5501 Fortunes Ridge,Suite EDurham,NC 27713

Include phone number and billing address, and indicatenumber of placements, if known.


Index of Advertisers

Carolinas HealthCare System ..................................................IFC

MAGMutual Insurance Company........................................298

Medical Protective ......................................................................303

Moses Cone Health System ......................................................BC

North Carolina Immunization Branch ................................384

PriCara,Unit of Ortho-McNeil Inc. ...............................381-383

Southeastern Regional Medical Center ..............................IBC

SunTrust ..........................................................................................297

TimeLine Recruiting ...................................................................373

UNC Preventive Medicine Residency Program...............373

Eastern Carolina University Physicians ..............................300

Walker Allen Trial Attorneys....................................................304

Compassion†ransformed

in†o art.Compassion and caring come in

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Even more enchanting is knowing

behind each tree is a sponsor

whose contribution helps fund the

efforts of Southeastern Hospice

and our new center for end-of-life

care, Southeastern Hospice House.

‘Tis the season for giving, and

few expressions of kindness mean

more than helping someone be at

ease during life’s most difficult time.

www.srmc.org | 910-671-5000 | Lumberton, NC

22ND ANNUAL

SOUTHEASTERN HOSPICE FESTIVAL OF TREES

DECEMBER 2- 4, 2007

State-of-the-Art Technology with a Hometown Touch

Sandra InmanBrain Surgery Patient

Date post:	10-Nov-2023
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Addressing health literacy through improved patient-practitioner communication

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