The Perfect Storm

By Martha Nolan McKenzie

Too often, patients become sicker because they can’t understand doctors’ instructions. Ruth Parker sees a dark cloud coming unless physicians address low health literacy.

Ruth Parker was working at Grady Memorial Hospital when a patient in his 60s was admitted with a severe leg infection. His chart showed that he had visited the ER twice in the past two weeks for the problem and was given antibiotics, but the infection continued to worsen.

For Parker, a professor of medicine at Emory, it was a red flag. After gently questioning the patient, she discovered he wasn’t sure what he was supposed to do with the antibiotics he was given during the previous ER visits and didn’t want to bother anyone by asking. He just filled the prescription and kept the pills in his pocket. He hadn’t taken a single one.

“Incidents like this happen all the time and not just at Grady,” says Parker.

Indeed, studies have shown that nearly half of all American adults—90 million people—have difficulty understanding and acting upon health information. Many lack the necessary vocabulary to comprehend their physician’s instructions and the literacy skills to read the instructions on their prescriptions. The impact of low health literacy is extremely costly on the national level and devastating on a personal one.

“Health literacy is like your currency for negotiating the health care system,” says Parker. “If you have low health literacy, you are more likely to use the ER, more likely to be hospitalized, and less likely to use preventive services.”

Yet most health care providers remain unaware of the problem. “It’s embarrassing for patients,” says Parker. “They don’t come out and say, ‘I don’t understand what in the heck you are telling me to do or what this pamphlet means.’ As a result, most of us in the health field still don’t realize that many of our patients struggle to understand what it is they need to do, and we certainly don’t practice medicine like that’s the reality.”

Parker is working to change this scenario. Since stumbling on the issue almost 20 years ago, she has emerged as one of the nation’s leading experts on health literacy. She co-authored the first published study of functional health literacy and helped develop the measuring tool now routinely used in studies. She currently consults with the FDA on an initiative to standardize and simplify instructions on pill bottles.

“As the investigator of one of the first studies showing the prevalence of low health literacy and the correlation between low health literacy and poor health outcomes, Ruth helped define the issue,” says Joanne Schwartzberg, director of aging and community health for the American Medical Association (AMA) and senior adviser on health literacy for the AMA Foundation. “Since then, she has pushed the issue everywhere.”

Thanks largely to Parker’s efforts, health literacy is emerging from the shadows. At Emory, the Health Literacy Working Group draws participants from the health sciences, Morehouse School of Medicine, Georgia State University, and state adult educational organizations to share information and seek funding. Emory’s medical school routinely introduces the topic in class and clinic settings, hoping to inform the next generation of physicians.

“Emory does a good job making sure we understand the issue,” says David Gutteridge, a 2011 MD candidate. “As a result, I’ve built some checks and balances into my actions to make sure the patient understands what I’m talking about. I ask them to tell me what they have understood about how they are supposed to take a medicine. I’m trying to open the door for them to ask me more questions.”

Across the nation, health literacy is beginning to get its due. Last year, the Association of American Medical Colleges began to set curriculum guidelines to make sure health literacy is addressed in all medical schools. Efforts are under way to include it on the national licensing test. And two senators introduced the National Health Literacy Act of 2007, though the bill did not make it to committee.

Parker is pleased with how far the issue has come but cautions that much remains to be done, particularly in light of future demographics. According to an article Parker recently co-wrote, U.S. literacy skills are expected to worsen by 2030, based on trends in immigration, birth rates among illiterate women, and employment.

“We have some pretty powerful people today who are paying attention to health literacy, so I’d have to say I’m optimistic,” says Parker. “But demographically, if we don’t address it, we are going to end up in a bad place. If we don’t change the direction in which we’re headed, we’re brewing the perfect storm.”

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Emory Medicine - Spring 2009