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Introduction
Initiating a Health Literacy Curriculum in your institution will be a creative process. The guidelines given here are meant to serve as a rough guide for you as you look about for opportunities to teach the important skills of recognizing which patients are unable to understand their medical needs and how to help those patients reach that understanding. General illiteracy, deafness and inability to comprehend English will be the most frequent types of Health Literacy issues you will see.
Tasks to consider before starting the course:
- It is important that you perform an institutional survey to see exactly what the proportions of the various types of literacy are in your patient populations. You can do a quick and dirty chart review. Each institution is required by JCAHO to fill out adult and pediatric discharge planning tools. Usually, the nursing staff complete these. This form may go by various names, such as Multidisciplinary Teaching Form or Educational Record. Assessing the ability of the patient to understand or some record of their educational level is required by accrediting bodies such as JCAHO and NCAQ. Or you may want to do a formal survey such as the one that UVA did in one of our busiest clinics to get a snapshot of the populations and needs. Remember that with the increasing immigrant populations, these numbers will be a moving target.
- Look at the references provided on this web site and contact those organizations that have resources for you to use. Especially take time to obtain a copy of the AMA Foundation’s CD and Video that have good examples of patient scenarios for you to use in teaching when real patients are not available for you to use as illustrations. After you know what cultural and linguistic groups you serve, look for web sites that delineate the cultural traits and preferences of that group. Some are listed in the bibliography on this site.
- Look for institutional, local and state resources in your area. Find the number of the local Adult Literacy group in your community and consider referring your illiterate patients to this group for teaching. It is just as important as the antibiotic you prescribe. The sample UVA lecture shows the listing of resources in the Charlottesville area and at UVA. Contact information for interpreters is particularly important.
- Go into various clinics and pick up samples of literature meant for patients. See if you can assess the reading level of those materials. Especially look at Informed Consent documents. It is a federal requirement that Informed Consents be written in the simplest possible terms.
Now you are ready to tackle the curriculum issues at your institution
- Get buy-in from the top. There must be a mandate from the highest level possible in your institution. At UVA, our Dean has been very supportive as have our Associate Deans for Medical Education and Curriculum. You will know best who in your school is the person who can best bless your activities. This leadership is essential because it gives credibility to your activities and smoothes your path. And, if funding becomes a necessity, it also becomes the first step toward achieving a budget. I hope that the method I describe here will prove to be very low cost, but having the option is important.
- Find a champion who is widely connected. Sometimes, this will be you, yourself! However, sometimes, you need a second person below the Dean but who is highly regarded by a multiplicity of course directors and clinical support personnel. This “connector” or “persuader” can be very helpful in identifying the key people to talk to and getting you resources and credibility.
- Prove the need. As described above, you should have some clear understanding of the patient literacy issues most commonly seen in your institution—especially if those at the top are skeptical of the need to add this issue to an already crowded curriculum. The scope of this problem will probably stun them and they will agree that this is an issue of importance. If you have not already done this “homework” prior to approaching your leadership, do it now.
- Inserting the curricular thread. You are now ready to use what I call the “Stealth Technique” of curriculum reform. You look at the existing courses in your institution and see where this information can go. You should look for opportunities that allow you to weave repetition of the information and occasional “live” clinical examples. Starting a stand-alone course is much more difficult to do in terms of both time and resources. For example, most schools have general courses in the first two years that deal with interviewing skills, the Doctor-Patient relationship, how to perform physical exams and clinical problem solving. Any and all of these are good places to insert this information. But first, think through how you would like the information to be woven into these courses. Our course directors were much more receptive about including this new material when we presented a well-thought out plan of action and took the responsibility to make it work. You should leave some room for the course director to leave his or her own imprimatur on the module, but having it well-fleshed out saves them time, aggravation and extra work on their own parts.
- For example, at UVA, we have a first year course, Practice of Medicine-1. This course deals with communication and interpersonal skills as well as how to perform the physical exam and how to deal with death and dying, chronic disease, substance abuse, domestic violence, spirituality, sexual history, and cultural differences among other topics. The course has a weekly 1 hour lecture and a weekly, 3 hour long, small group meeting of six students and two faculty mentors (one MD and one non-MD). We give a lecture on Health Literacy in the fall as part of the Communication skills part of the course to the entire class at once. We invite a patient with a literacy issue to the course and demonstrate to the class how to communicate with that patient. That lecture is on this website and you are welcome to use it and modify it to suit your needs.
- The small groups in this first year course utilize case discussions, interviews of real patients, visits to community based preceptors and nursing homes, standardized patients and a variety of other techniques to practice their skills. We have introduced some literacy issues into the case discussions and are piloting some standardized patient scenarios that we will put on this web site as they are finished—hopefully by the fall of 2003. We are grateful to the AMA Foundation for the grant that is allowing us to pilot these cases. We have a faculty development handbook that aids the faculty in guiding the students in these exercises.
- In the second year, Practice of Medicine-2 is our clinical problem-solving course. There are very few lectures in this case-based, self-problem-solving course—only an introductory lecture for each disease category—e.g. Cardiology, Endocrinology, Pediatrics, etc. The main teaching elements of the course are problem sets—a list of questions and scenarios that the students research each week or so—and paper case scenarios that are worked through in weekly, two hour long, small groups of six students and one MD mentor. The cases are meant to stimulate both history taking skills and formation of a differential diagnosis that will in turn guide decisions on testing, procedures and treatment. Several of these cases have been slightly modified to include a literacy element in them. Either the patient does not understand some question from the interviewer or does not comply with treatment due to misunderstanding. These cases are not primarily directed at the issue of health literacy but rather reinforce concepts hopefully learned the year before. ( I will be glad to send you examples upon request.)
- Also in the second year, the students participate in a weeklong preceptorship in a community-based practice. They are asked to bring back focused notes on five of the many patients that they have seen. One of these notes is supposed to be about a health literacy issue they have seen during the week. Most are legitimate health literacy issues, but occasionally, the review of the cases shows that the student really does not understand the meaning of health literacy or that they have not done enough to help the patient. This gives us a chance to reinforce these concepts with the student as well as with the community-based doctor who hosted the student. In this way, we feel we have added to the practicing physician’s understanding of the issue as well.
- In the third year, the only opportunity for reinforcement of these concepts by the faculty is by their level of awareness and interest in the problem. We are working on ways to encourage the faculty to point out literacy issues more frequently during this very busy but important time of clinical learning. Our faculty development handbook will hopefully be made available to all faculty in the near future.
- We hope to include a literacy case in our Clinical Performance Exam given at the end of the third year. This OSCE/CSAE-type exam has the students examining 7-8 standardized patients and charting their differential diagnoses and plans. This exam is required for graduation at UVA.
- In the fourth year, we plan an elective in Health Literacy that will offer the student a chance to look at whatever aspect of health literacy interests them. Some examples of student projects include: testing patients’ literacy levels in various clinics, reviewing patient ed literature for reading levels and revising the materials, looking into the legal and regulatory consequences of failure to recognize illiteracy, use of interpreters, setting up a course in medical Spanish, designing laminated cards with common Spanish medical phrases on them, planning and executing a Health Literacy Awareness day, working with Adult Literacy agencies to teach a patient to read and many more.
- Plans to offer both lectures and standardized patient scenarios in the residency years are in progress.
- Faculty development and support. Busy faculty have little time or patience for discrete faculty development sessions. So rather than ask for their time in a room for a lecture, we developed a faculty development handbook of resources. This handbook is backed up by several resource faculty who are interested in this issue and includes both medical personnel, pharmacists, interpreters, our standardized patient staff, and educators from our Curry School of Education. It is important to have these resource faculty available for consultation. Because of copyrights, we cannot reproduce this handbook here but would suggest the following contents:
- A copy of the JAMA article that addresses Health Literacy: “Health Literacy: Report of the Council on Scientific Affairs”. JAMA. 1999; 281(6): 552-557. This summarizes the scope of the Health Literacy issue.
- The federal guidelines for provision of interpreters for patients with limited English proficiency: available at http://www.hhs.gov/ocr/lep/press.html
- Various cultural references—especially any that address the most prevalent populations served by your institution. Examples are available in the bibliography. Also, consider “Lost in Translation”. Pharos. Spring 2002; 65(2): 20-25. Make available for use a copy of The Spirit Catches You and You Fall Down by Anne Fadiman, New York: Farrar, Straus and Giroux, 1999.
- A copy of your introductory lecture with annotations. So they know what you told the students.
- Bibliography, sample cases and hints about how to teach.
- List of institutional, local and national resources.
- If you are using paper cases, put in an annotated copy of the cases with discussion points.
- Make available the AMA Foundation video showing patients with functional illiteracy problems.
- Include examples of patient literature from your institution with annotations on why this is a good or poor example of literature.
- A summary of the REALM test for assessing health literacy. (Contact me for an example and how to get the full test.)
- Consider a copy of the 1992 NALS Survey. Available at: http://nces.ed.gov/naal92/overview.html
- The AMA Foundation’s Health Literacy Kit also includes a manual that is full of examples that can be used as teaching tools. Call the AMA Foundation to have a free kit sent to you: http://www.amafoundation.org
- Copies of your institutions Multidisciplinary Care form or equivalent with areas referring to literacy and patient comprehension clearly marked.
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