Debra Roter - Reducing the Oral Literacy Burden of Medical Dialogue


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"Stripping it Down, Mixing it Up, and Bringing it Home: Reducing the e Oral Literacy Burden of Medical Dialogue" was presented at the Center for Health Literacy Conference 2011: Plain Talk in Complex Times by Debra Roter, DrPH, Professor, Johns Hopkins Bloomberg School of Public Health.

Description: The presenter will describe a framework for thinking about the oral literacy burden in medical dialogue, discuss the evidence that links oral literacy burden to patients’ satisfaction and comprehension of medical information, and propose practical ways to reduce the oral literacy burden of routine health communication with patients.

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Debra Roter - Reducing the Oral Literacy Burden of Medical Dialogue

  1. 1. Stripping it Down, Mixing it Up, and Bringing it Home: Reducing the Oral Literacy Burden of Medical Dialogue Debra Roter Professor Johns Hopkins Schools of Public Health, Medicine and Nursing
  2. 2. Objectives for today <ul><li>Discuss what we know about what makes it difficult for patients with restricted literacy to take an active role in their medical care – and in medical visit conversations. </li></ul>
  3. 3. A typical American patient will see a doctor approximately 320 times over a lifetime --– an average of 4 medical contacts per year. -- more if you suffer from a chronic illness, are a woman, have children, have a spouse or an elderly parent. Almost half of these patients have restricted literacy skills.
  4. 4. Literacy in Baltimore City <ul><ul><li>75% Baltimore City population can be characterized as suffering from significant literacy deficits. </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>38% of Baltimore City residents score as having below basic skills </li></ul></ul><ul><ul><li>35% score as marginally literate </li></ul></ul>
  5. 5. <ul><li>There is reason to worry about the effect of restricted literacy on oral communication </li></ul><ul><li>Low literacy is related to restricted expressive language -- overall passivity in the medical dialogue, less detailed medical histories, and less involvement in decision making. </li></ul><ul><li>Patients note that they do not feel listened to and have difficulty being understood . (Baker et al, 1996; Bennett, 2006) </li></ul>
  6. 6. <ul><li>Restricted literacy has been associated with poor listening skills --- poor comprehension and recall, and lower patient satisfaction with both physician informativeness, as well as interpersonal rapport. </li></ul><ul><li>Patients complain they are not given information about their problems in ways they can understand . .(Williams et al, 1998; Schillinger et al, 2004; Baker et al, 1996) </li></ul>
  7. 7. Medical Jargon Language Complexity Patient –Physician Nonverbal Interaction Patient –Physician Verbal Interaction Satisfaction with information and interpersonal rapport Dialogue Interactivity Adherence with medical recommendations Informational Context What makes it difficult for patients to understand and feel understood? Roter et al, 2007 Learning Recall/comprehension Patient centered communication Stripping it down Mixing it up Bringing it home Engagement in self care and preventive health practices
  8. 8. --- because part of medicine’s mystique is that it is written -- and often communicated in code. --- demystification begins with a translation from “Medicalese” to English Why is it important to strip it down?
  9. 9. ---Use of medical jargon is common Studies dating back 50 years have established that physicians use technical terms that patients do not understand But , patients rarely challenge their doctors to “speak English”
  10. 10. <ul><li>Aside from jargon, physicians often use grammatically complex language, long sentences, frequent repetitions, and the passive voice. </li></ul>Beyond jargon – general language complexity
  11. 11. <ul><li>Few speakers are self-aware of speaking style. </li></ul> Communication style is often “invisible” to the speaker
  12. 12. <ul><li>Too often medical dialogue is a largely one-sided series of mini-lectures interspersed by patient head nods and assents. </li></ul><ul><li>The engagement that comes from the up and back of true exchange is what transforms parallel monologues to a conversation . </li></ul>Interactivity – Mixing it up
  13. 13. Why is it important to mix it up? <ul><li>Interactivity – is engaging </li></ul><ul><li>Interactivity – is empowering </li></ul><ul><li>Interactivity – is instructive </li></ul>
  14. 14. <ul><li>Speaker turn is defined as a continuous block of uninterrupted speech by a single speaker (excluding back channels and other ‘out of turn’ statements) </li></ul><ul><li>Dialogue interactivity is the rate of floor exchange per session minute. For example, a 13 minute PC visit may have 104 talking turns (52 speaker exchanges) with an interactivity rate of 3.9 speaker exchanges per minute. </li></ul>How is interactivity measured?
  15. 15. What does high interactivity look like?
  18. 18. <ul><li>Getting up close and personal </li></ul><ul><li>– what does this have to do with for me? </li></ul><ul><li>Decontextualized language conveys abstract ideas or novel use of language. People with restricted literacy tend to communicate in concrete terms about things they feel, see, know and experience. </li></ul><ul><li>For example, in the medical context a question regarding chest pain is typically “Is it a dull pain and heaviness like an elephant on your chest or a sharp, like a knife&quot; </li></ul><ul><li> In my study of chest pain – patients said things like “I don’t know what that feels like, this is new to me” … I just know my chest hurts here, I feel bad, I can't explain it” </li></ul>Why is it important to bring it home?
  19. 19. <ul><li> Personally Contextualized information in genetic counseling </li></ul><ul><li>We found that statements like: </li></ul><ul><li>“ Based on what you told me about your history , there is a 1 in 400 chance that your baby will have one of these genetic mutations” </li></ul><ul><li>were far better recalled than statements like: </li></ul><ul><li>“ Nobody has a risk of zero – a pregnant women over 35 has a 1 in 400 chance of having a baby with this genetic mutation” </li></ul>Contextualized Information is better remembered
  20. 20. Is reduced oral literacy burden consistent with positive patient outcomes? <ul><ul><ul><ul><li>YES! </li></ul></ul></ul></ul><ul><li>Interactivity is correlated with patient satisfaction ratings on a number of dimensions, including positive physician demeanor, interpersonal rapport and ratings of decision-making partnership. </li></ul><ul><li>For patients with low literacy skills, interactivity and personalized information was related to better recall of session information. </li></ul>
  21. 21. Communication is regarded as key to any significant improvements in health care quality -- patient-centered care is included alongside the core quality requisites of safety, timeliness, effectiveness, efficiency and equity. IOM reports: Crossing the Quality Chasm; To Err is Human; Health Professions Education. Patient-centered Communication has been linked to Health Care Quality and
  22. 22. What was lost in the practice of modern medicine?
  23. 23. Is reduced oral literacy burden consistent with patient-centeredness? <ul><ul><ul><ul><li>YES! </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Patient-centeredness is correlated with more speaker turns, higher interactivity, shorter duration turns (patient and physician), faster rate of physician and patient statements, and more total patient talk; it is not related to visit length, total physician talk, or turn density for either patient or physician. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Roter et al, Pt Ed Cnslng, 2007 </li></ul></ul></ul></ul>
  24. 24. What about patient activation? <ul><li>Communication interventions directed toward health care providers are effective and can be used to reinforce and compliment patient activation. And, interactive, patient activation interventions are well received and effective in a variety of patient populations – including those with restricted literacy. </li></ul><ul><li>Complimentary skill development can exponentially move the medical dialogue to the next level of therapeutic effectiveness . </li></ul>
  25. 25. The Time to Talk Cardio (TTTC) web-based communication tools <ul><li>The TTTC tool consists of 500 15 second video clips modeling key communication skills (separately) to patients and clinicians using the LEAPS heuristic. </li></ul><ul><li>Individual tailoring of skills through the use of a communication-challenge screener. </li></ul>
  28. 30. Does this approach work?
  29. 31. Yes! In a randomized trial patients using the TTTC website reported a significant increase in targeted communication skills and subsequent medical visit satisfaction.
  30. 34. Physicians using the website also reported a significant increase in the use of targeted communication skills.
  31. 35. <ul><li>“ A physician to slaves never gives his patient any account of his illness…The free physician, who usually cares for free men, treats their diseases first by thoroughly discussing with the patient and his friends his ailment.” </li></ul>In articulating the physician’s responsibility to be both teacher and healer, Plato laid the foundation for patient-centered medicine and collaborative models of therapeutic relationship and introduced the protection of patient autonomy