Are you getting through?

If you think patient literacy isn't a problem in your practice, think again. A 2004 Institute of Medicine report found that one out of two adults has problems understanding patient education literature, forms they're asked to complete, medication instructions, and information the doctor tells them about their health conditions and treatments.

Even patients with a high school education often leave the doctor's office scratching their heads, not knowing how to take medications or even when to return for a follow-up visit. For elderly, illiterate, semiliterate, non-English-speaking, unacculturated, hard of hearing, hard of seeing, emotionally upset, or mentally challenged patients, vital information you attempt to convey-and probably think you have conveyed-may be incomprehensible, confusing, or promptly forgotten.

Patients who don't understand may pretend to

The results can be tragic. One woman too embarrassed to reveal her limited reading skills was coaxed into signing a surgical consent form for a hysterectomy. She didn't learn what the operation was for until after she had it. Then there's the oft-told, perhaps apocryphal, but nonetheless possible story of the child with the ear infection. The mother didn't understand the label's instructions for administering the medication prescribed, so she did what seemed logical: She poured it into the kid's ear.

"We expect people to understand directions like 'Take one pill four times a day,' " says Rima Rudd, a senior lecturer at the Harvard School of Public Health and a leading expert on health literacy. "This assumes patients understand temporal relationships. A patient may take one pill at 7 a.m., another at 7:15, another at 7:30, and the last one at 7:45. He did exactly what he was instructed to do."

Poor comprehension isn't solely a patient problem. Physicians may exacerbate the situation by talking way over the patient's head. "How often have you been asked to play translator by a friend or relative who went to his doctor, was told a bunch of things, and didn't understand what was said?" asks Barry D. Weiss, professor of family and community medicine at the University of Arizona College of Medicine, Tucson. "Most physicians have had that experience."

Even patients with well-developed literacy skills may feign understanding. "When I anticipate or receive bad news, I shut down," admits Helen Osborne, president of Health Literacy Consulting in Natick, MA ( http://www.healthliteracy.com), whose clients include the CDC and Harvard Medical School. And in his useful treatise, Health Literacy: A Manual for Clinicians, Weiss tells of a prominent obstetrician who couldn't fully comprehend his orthopedist's explanation of his upcoming surgery.

What can you do to help clear up the confusion? Let's take a look.

Learn to spot patients who are at risk

Clues to who may have problems with reading, writing, numeracy, concepts of time, and understanding your explanations, instructions, and advice include:

Registration forms that are incomplete or inaccurate. Many patients find the long list of maladies to which they're supposed to check Yes or No inscrutable. "When people don't know the words on a medical history form," says Rima Rudd, "they'll often check the No box, because then no one will question them and find out that they didn't understand."