"Decision Making Literacy" is a new phrase to enter into our industry's lexicon. It is intended to add depth and dimension
to the critical issue of patient-informed consent and empowerment at a critical moment of change that will help determine
our success in improving the quality and efficiency of medical care to the benefit of patients, providers, and payers.
The Privilege and Burden of Choice
The Patient Protection and Affordable Care Act (PPACA) includes significant attention to health literacy and medical decision
making. These competencies will become an increasing necessity as the privilege and burden of greater autonomy is placed on the consumer/patient—and they will increasingly become areas of patient support that
will be measured and evaluated by all advocates for improved healthcare quality and efficiency.
There are many definitions of health literacy to be found. One very good one is included in the "Healthy People 2010" report
issued by the US Department of Health and Human Services. In this report, health literacy is defined as: "The degree to which
individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate
Despite the appropriateness of this definition, however, the vast majority of programs and resources that our industry puts
into addressing this issue revolves around only one aspect of literacy—the effort to align the grade-level sophistication
of the language in which information and education is written and presented to most patients. The idea, of course, is that
if the patient cannot understand the language in which information about their health is communicated, then nothing is accomplished
at the fundamental level of information transfer.
Linguistic Competency—Necessary But Not Sufficient
An appropriate way to refer to this aspect of health literacy is "linguistic competency," concerning the basic understanding
of the dictionary definition of the language and some basic facts necessary for patient education. And this is, without doubt,
essential for patient understanding, engagement, and empowerment.
However, when we closely examine the attitudes and behaviors that patient education programs aim to alter, we learn that linguistic
competency is necessary—but not sufficient—for informed consent and medical decision making.
There are two additional competencies that must be added in order to create the necessary preconditions for informed consent
and patient empowerment—conceptual competency and statistical competency.
Conceptual competency refers to the ability to place information about diagnosis and recommended treatment in a "cause-and-effect"
context. This is an essential step that transforms a collection of facts about a particular diagnosis and the treatment options
offered to treat that condition into real and useable understanding.
For example, if a patient has been diagnosed as having hypercholesteremia, he needs to know that this means he has "high cholesterol."
He needs to know his goals for total cholesterol—LDL and HDL. And he needs to know that high cholesterol, if left untreated,
can lead to a heart attack or stroke.
However, if he is to truly participate in the decision to treat his high cholesterol, he needs to understand more. The patient
needs to understand that cholesterol comes from what he eats and that cholesterol is manufactured in the liver. The patient
needs to know that the medication recommended by his physician (a statin, for example) acts in the liver to reduce the amount
of cholesterol that is being manufactured by the body—thereby reducing his total cholesterol and LDL counts.
By understanding the connection between how the disease works in his body and how the prescribed medication counteracts the
disease in a cause-and-effect context (albeit a simple one), he is much better equipped to understand why taking his medication
every day is essential to his health—better able to understand the rationale for the "benefit" half of the classic and essential
risk/benefit ratio that is the cornerstone to all medical decision making.