Time constraints frequently limit the amount of face time doctors and patients share together. To optimize their office visit, patients often answer written questions while awaiting their turn to see their doctors. In two separate studies presented at the 2008 Clinical Congress of the American College of Surgeons, Viraj A. Master, MD, PhD, assistant professor of urology at Emory University School of Medicine, Atlanta, GA, pointed out a profound gap in the understanding of physicians about the literacy levels of their patients as it relates to the efficacy of screening tools.
In reporting on the first of the Emory studies on literacy, Dr Master said, "In our particular 300-patient cohort of men with an average age of 61, the average reading level in our inner-city hospital was fourth grade. In the seven questions that we asked from the International Prostate Symptom Score (IPSS), for example, only 16 percent of patients understood all seven questions. Possibly the most worrisome thing was the number of patients who thought they understood this test – the most commonly used instrument in urology worldwide – but did not."
Evaluation of responses to the IPSS test, which asks such questions as: "During the last month or so, how often have you had to push or strain to urinate?" further showed that only 38 percent of patients understood more than half the questions, 18 percent understood fewer than half, and 28 percent understood none. After controlling for education, age, income, employment status, race, homelessness, and English as a second language, however, the only thing that emerged as an independent predictor of understanding of this instrument was the number of years of schooling.
The most frightening thing about these poor results, according to Dr Master, is that communication and understanding is not as simple as being able to read a sentence. "We also expect people to be reasonably numerate and capable of discussing numbers and quantities. Doctors, in particular, want patients to be able to answer, on a scale of one to 10, ‘How are you?’ and be able to communicate whether symptoms occur ‘half the time’, or ‘a third of the time’."
Dr Master had previously thought that if a patient were literate, he would be numerate as well. And, if he were illiterate, he would be innumerate. His curiosity was aroused, however, after meeting a patient who was a distinguished PhD. Despite years of schooling, this patient had no clear idea that 33 percent was a different quantity than one-in-four, when they were reviewing the patient’s Symptom Score together. As a result of that interaction, Dr Master decided to design a study based on numeracy, and in the second study, which he presented during the Clinical Congress, Dr Master reported on what he calls the "shocking results" of this research.
In the second study, 266 patients with an average age of 58 completed a validated, three-question Woloshin-Schwartz numeracy quiz. The quiz asked questions such as "Imagine that we flip a coin 1,000 times. What is your best guess about how many times the coin will come up heads in 1,000 flips?" (Answer: 500 times).
Results showed that only 16 percent of respondents answered all three questions correctly and 15 percent answered two correctly, so only 31 percent fell into the ‘numerate’ category. Most respondents were innumerate, with 33 percent having one correct answer and 35 percent having no correct answers.
"Even after controlling for age, race, homelessness, English as a second language, income, and a host of other variables including educational level, numeracy was shown to be an independent predictor of misunderstanding," Dr Master said. "Being innumerate, in addition to being illiterate, results in high levels of misunderstanding that severely limit access to appropriate health care for millions of patients."
Having established that both words and numbers are drivers of illiteracy in America, Dr Master and his colleagues suspected that adding carefully designed pictures to their screening tests to help depict the concept being discussed would improve patient understanding. To test this hypothesis, they designed a robust randomized prospective trial, which has been completed, and is to be published as a letter to the editor in the October 2008 issue of the Journal of Urology. However, the results show that pictures did not improve understanding. During a shopping trip with his family, Dr Master was struck by the number of people pleasantly immersed in video games, rapidly absorbing an incredible amount of information. Suddenly an idea was born. "I thought, how do we translate that into the health care arena?" he said. So, he and his colleagues designed another randomized clinical trial – this one a computer program. The program allowed patients to look at a figure who was speaking to them and asking the very same questions that were on the Symptoms Score questionnaire.
This third study, presented at the American Urology Association meeting in May 2008, was highly significant and quite successful, Dr Master said. "The computer program improved understanding for all patients at all educational levels. Importantly, it even improved understanding for individuals who had no familiarity with computers."
The lesson in all of this research is that "there is a true epidemic of health illiteracy in this country. Do not assume that your patients are literate with either prose or numeracy," Dr Master said.
Assisting Dr Master with these studies were Timothy Van Johnson; Ammara Abbasi; Samantha Ehrlich; Renee Kleris; Evan Schoenberg; Ashli Owen-Smith; and Michael Goodman, all from Emory. He received no funding for this research.
(Source: American College of Surgeons: October 2008)