A 49-year-old man comes to the office due to dysuria and hematuria. Vital signs are within normal limits and physical examination is unremarkable; urinalysis shows gross hematuria but is otherwise normal. The physician discusses potential causes and the need for a cystoscopy. The patient is told what to expect during the procedure and is given written information and a referral list with instructions on how to schedule an appointment with a urologist. He anxiously glances over the papers, saying he will make an appointment soon. Office staff had informed the physician that the patient was unable to follow the directions on the sign-in sheet and declined to fill out paperwork. Which of the following physician responses is the most appropriate at this time?
This patient's difficulty following written directions and reluctance to fill out paperwork are clues that suggest low health literacy, a common and underrecognized barrier to health care. Low health literacy (ie, difficulty with accessing, understanding, or using medical information to make decisions) contributes to poor health care access and outcomes, including medication errors, missed appointments, and failure to follow up with tests and referrals.
Although formal literacy tests have been used in research, they are not recommended in clinical settings because they can be stigmatizing. Effective communication requires a patient-centered approach that avoids causing shame and embarrassment. Using an open-ended question that encourages discussion of any concerns about making the appointment is the best way to address the issue without shaming the patient. If this patient expressed difficulty, he could be assisted in scheduling the appointment while in the office.
(Choice A) How far someone went in school does not necessarily indicate literacy level. In addition, this may be perceived as judgmental and condescending.
(Choice B) Many patients with low literacy levels are embarrassed and attempt to conceal their difficulty. This confrontational approach assumes the patient has difficulty reading and writing, which may make him increasingly anxious and uncomfortable.
(Choice C) This response inappropriately puts the patient on the spot to assess his literacy level.
(Choice D) This response ignores the clues that suggest possible low health literacy. Failing to address this increases the risk that the patient will not schedule the cystoscopy and be lost to follow-up.
Educational objective:
Low health literacy is a common and underrecognized barrier to health care. It is important to assess patients' understanding of provided information without shaming or causing embarrassment.