Teaching Doctors to Talk

The first step in improving patients' health literacy is getting doctors to realize that it's their problem, too.
Sep 01, 2003

A recent study shows that patients forget most of what their doctor tells them less than six minutes after walking out the door. That's a serious problem if they were just given a new prescription or instructions to prepare for surgery. But even patients, whose physicians give them advice about something less urgent like preventive care, may not be getting enough out of their office visits because they simply don't understand what they were told and they're too embarrassed to admit it. That's why the American Medical Association Foundation seeks to improve the exchange between patients and doctors, by encouraging doctors to converse with their patients in clear, simple language.

In an interview with Pharmaceutical Executive, AMA Foundation president Duane Cady, MD, says the organization has already distributed its health literacy tool kit to more than 10,000 doctors worldwide and has begun to track its effectiveness. Although several studies have been published on the topic, Cady hopes that other stakeholders-including managed care and pharma companies-will support research to demonstrate the link between health literacy and patient outcomes. For now, the goal is simple: to raise awareness among physicians that low health literacy is a problem, because, according to the foundation's recent survey, only a third of its members even recognize the phrase.

PE: How is it possible that doctors are unfamiliar with the health literacy problem?


Duane Cady, MD, is president of the AMA Foundation.
Cady: They all understand that there is a poor compliance problem, but nobody knows exactly why. If you don't even realize that your patients may not be able to read or understand what you told them, clearly they won't be compliant. So improving health literacy is an important way of improving compliance. Also, doctors need to create a shame-free environment for their patients and help them feel safe and comfortable asking questions. Because when patients fully understand why a regimen has been prescribed, they are much more likely to adhere to it, although they need follow-up. You can't do it in just one visit and say, "Do you understand this?" When they come back, you have to keep reinforcing it. Doctors ought to use simple language, talk slowly, and talk about only one or two concepts at a time.

PE: How is the foundation helping?

Cady: We created a variety of resources for physicians including a website, a quarterly newsletter, and a tool kit that includes an accredited CME course, a video documentary, a manual, and reprintable information they can use for their patients and for training their staff about health literacy. With Pfizer and other private and public organizations, we founded the Partnership for Clear Health Communication.

Through our Fund for Better Health, we awarded about $25,000 last year in grants supporting health literacy education and research programs for medical students helping patients-some in an Albany pediatric clinic, some in county medical societies-and to the County Medical Society Alliance, a spouses' foundation. We are also doing a "train the trainer" program at state and county medical societies to train physicians who are interested in conducting educational programs on health literacy.

We advocate use of the "teach back" method in which doctors ask patients, "Do you understand what I told you?" and "What medications are you going to stop using?" and "How are you going to change your dosages?" A study published in the Archives of Internal Medicine found that only a small percentage of doctors actually did that, but the patients of those who did had better outcomes.

We suggest that patients bring a friend or a relative into the counseling and planning part of their appointment so that the other person can also hear what's being said. Having been a patient myself, I didn't always listen to what doctors said. I was more concerned about what was going to happen to me than I was about what he was saying.

PE: Among medical societies, patient advocacy groups, pharma companies, and other healthcare organizations involved in patient education, what is the most logical allocation of duties?

Cady: I don't think that I would make one more responsible than another. Physician groups, the specialties, the state societies, the pharmaceutical companies, the managed care companies-all have a responsibility to make sure patients understand the information that they're given. They can all play a role. For example, the managed care companies may want to give our kits to their doctors or use them to train their doctors.

PE: Can pharma-sponsored DTC advertising play a role?

Cady: I don't think DTC advertising is a methodology for educating patients. It may alert them to the availability of a new drug. But it's not what we're talking about when you have a one-on-one situation in a patient–physician relationship-that's really where the best education takes place. We hope that any DTC ad would say to the consumer, "Discuss with your physician whether this particular drug is right or wrong for you."

In DTC, issues come up about accuracy, side effects, complications, risks, alternatives-the kinds of things that we discuss with patients in our office and give them "informed consent," so to speak, about treatment options. The same principles ought to apply to advertising, and that's difficult in a one-minute ad. I don't know how you do that-probably not very well.

PE: How do doctors feel about patients asking DTC-inspired questions about medications?

Cady: I think it's changing. Physicians now and in the future will appreciate patients knowing more about their illnesses and asking the right questions. We want the patient to be involved and say, "What's my problem? What do I need to do? Why is it important for me to do this?" We want them to interact more in the treatment process. And with the right information they ask the right questions. If you go to the NIH website, you'll get the right stuff. Unfortunately, there is a lot of misinformation out there. So it's a mixed bag. No physician wants a misinformed patient.

PE: Do you think if pharma sales reps offer your tool kits that might help them get in to see doctors who are inaccessible?

Cady: That's a loaded question. I don't know. Doctors appreciate educational materials that pharma reps bring. Whenever I talked with reps, I always appreciated the research articles they brought about their products, recognizing that their company may have sponsored some of it, but I could at least read and decide on my own whether their product was better than another. We would certainly appreciate the ability to get these health literacy kits into the doctors' offices. I think they would be better received than a pen or a pad or a golf putter, because they can really be used to improve patients' health.

I would certainly not object to a pharmaceutical company that came in and said, "We want to buy 100,000 of your health literacy kits and distribute them to doctors." I don't think the doctors would look at that as a gimmick to come in and sell products, per se. At the same time, doctors aren't stupid. They know what the detail person is there for. But if they can get something that's useful in their practice, we'd have to think about how we would consider an offer like that.