Pharmacist: Mr. Jones, please tell me what you know from the handout we gave you about what foods you should avoid while you are taking this medication that keeps your blood from clumping together.

Patient: I really don’t take care of all that stuff, don’t like to fool with it. My daughter lives with me and cooks my meals and organizes my pills. She does the grocery shopping, too. I’ll give her the handout and let her take care of it.

Pharmacist: Mr. Jones, it sounds like you’re very comfortable with your daughter helping you to manage your condition. That’s wonderful that she is willing to do that. The information on the handout about the foods is a very important part of doing that. I would like to talk with your daughter to make sure she has the information she needs to help you. What are your thoughts about that?

Patient: Yeah, that would be okay. She plans and cooks at our house, so she should get that handout and talk to you about it.

The pharmacist starts by probing for understanding of written material about foods that could hinder the patient’s anticoagulation therapy. This patient seems resistant to learning the information on his own and defers to his caregiver. Rather than getting drawn into the resistance, the pharmacist rolls with it and does not argue; instead, the pharmacist first reflects back the patient’s comfort with his caregiver. He then remains assertive about the importance of the information and uses an “I” statement, in a matter-of-fact and nonjudgmental tone, to make the point that he wants to give the important information to the daughter. The “I” statement exhibits confidence and sincerity; this reinforces the importance of the information. If the pharmacist had been indirect, the patient might have doubted the importance of getting the information. The pharmacist ends with an open-ended question, which is meant to tell the patient he is respected and in control of this decision to have his caregiver contacted by the pharmacist.

The communication skills of listening and empathy are the foundation of building a therapeutic alliance with any patient. They are especially important for helping to preserve self-esteem or “face” for a patient with literacy limitations during the provision of health care and related information. Some pharmacists may need to make a conscious decision to remain in a nonjudgmental mode of being and communicating with the patient. It is also important to remain assertive, confident, and matter-of-fact. Being assertive can feel confrontational and uncomfortable for some, but awareness and practice of assertiveness skills (see Chapter 7) can help the pharmacist overcome his or her discomfort and gain confidence.

When a health care provider begins, because of his or her own anxiety, to feel discomfort about an interaction, he or she may tend to react by beating around the bush, being indirect, and using avoidant verbal and nonverbal signals to “soften” the tone of the interaction. This makes the provider’s discomfort and anxiety readily evident to the other person. Furthermore, being indirect can be perceived as insincere. It creates dissonance and can erode trust. Persons who communicate directly and assertively convey—through their nonverbal cues and tone—honesty, caring, and a confidence that can be trusted. These points are illustrated by the pharmacist’s inappropriate and appropriate responses in the following dialogues. In this scenario, the pharmacist notices that the patient has been staring blankly at the disease management handout he just gave her.

Dialogue 1

Pharmacist: Ma’am is there anything I can help you with? I mean…I wanted to give you that so you can take it with you, but if you need something else, I can do that too…uh, just tell me what you need.

Patient: What do you mean? What else can you give me? They wouldn’t let me have an early refill of that oxy drug…Can you do that for me?

Pharmacist: No, I mean the information handout I gave you. It looks like maybe you’re having sort of a hard time reading it, so I thought you might kind of…uh…want somebody to read it to you? (with questioning inflection)

Patient (after a long pause): I’ll just take it with me; I don’t have time to think about it right now.

Pharmacist: But, I need to make sure you get the information and understand it.

Patient: I’m fine. (walks away)

Discussion

The pharmacist is trying to circumvent addressing the patient’s literacy limitations. This places the burden of disclosure on the patient, making the situation more uncomfortable than it needs to be. The patient misunderstands the pharmacist’s intentions and is then likely embarrassed not only about misunderstanding but also about the realization that the pharmacist is uncomfortable with her literacy limitations. The pharmacist argues with her that he “needs” to give her the information. The pharmacist’s first mistake is the indirect way in which he approaches the patient; he reveals his own discomfort by using filler words (“kind of,” “sort of,” “uh”) and a nonassertive, questioning inflection at the end of his statement. When the patient becomes resistant, he argues with her rather than rolling with it and focusing on her needs—his second inappropriate response. Third, he misses an opportunity for an empathic response that might have repaired the rift in trust and connection. After the patient says that she will “just take it” and does not have time, he could have responded, “Mrs. Smith, it seems like you are in a hurry, and perhaps I offended you by the way I approached this. I surely don’t want to do that. I’d like to start over. May I talk with you for a few minutes to be sure you understand what you need to know about this medication?”

Dialogue 2

Pharmacist: Mrs. Smith, I’d like to be sure we’ve given you all the information you need to manage your medication when you get home. What is your understanding about the information I’ve just given you?

Patient: Well, I’m not sure. Which parts are you talking about? The front or the back?

Pharmacist: It sounds like maybe I’ve confused you. Can we take a few minutes and sit over here? I’d like to go over it with you section by section so I can point out the important parts and explain anything we might have confused you about.

Patient: Yeah, that would be good. That way I’ll know what’s most important.

Discussion

The pharmacist is direct and caring. His initial question probing for understanding is assertive. It accomplishes an assessment of literacy, and it also places the burden for understanding on the pharmacist rather than the patient—which avoids embarrassing the patient. The patient’s response is a cover for the literacy limitation. A patient’s focus on a broad issue (such as whether the pharmacist means the front or the back of the page) rather than on the medical information is a red flag that the patient has limited ability either to read or to understand the printed material.

This pharmacist gives an appropriate empathic response; he not only tries to help the patient feel understood but also places the burden of understanding on himself and shields the patient from having to reveal her vulnerability. The pharmacist also shows respect for the patient by offering to have the conversation in a more private area. This demonstrates empathy; it considers that the patient may feel embarrassed about her literacy limitation. In addition, the pharmacist’s use of an open-ended question about her understanding makes the conversation feel less like an inquisition. His request for permission to give information then shows respect for the patient’s right to choose to receive the information; this supports her autonomy. Patients who are feeling powerless, as patients with literacy limitations may, need to have their autonomy supported; this helps build trust in the relationship. The intent is to make the patient feel safe. At some future point in the relationship, it may be safe to broach the subject of literacy directly and to offer helpful tools or resources, or even discuss educational opportunities. The initial encounter may or may not be the ideal time to approach such subjects with a new patient.

IMPLICATIONS OF LIMITED HEALTH LITERACY

In the past 10 to 15 years, it has become recognized that low health literacy—separate from written- or spoken-word literacy limitations—has a substantial negative impact on a person’s health. New emphasis has been placed on addressing health literacy limitations. In 2004, the Agency for Healthcare Research and Quality, the Institute of Medicine, and the American Medical Association all released reports of studies on health literacy. These reports concurred that large segments of the U.S. population do not have the health literacy skills needed to function for optimal outcomes in the current health care system.^8,13 Processing and using health information requires cognitive and social skills that many patients may not have. According to these three reports, up to one-half of all U.S. adults may lack the skills necessary to function optimally in a health care environment, such as being able to give the correct dose of cold medicine to a child or being able to interpret informed consent documents. Furthermore, the 2003 National Assessment of Adult Literacy suggested that only 12% of U.S. adults have a health literacy level of proficient and that 15% (30 million adults) have below basic health literacy.^14,15

Health literacy is defined in the U.S. Department of Health and Human Services Healthy People 2010 initiative as “the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services needed to make appropriate health decisions.” A patient may be able to read, write, and speak the English language yet lack the cognitive or social skills necessary to process the meaning in an interaction with a health care provider. Lower health literacy has been shown to result in more hospitalizations, higher health care costs, poorer health status, less understanding about how to manage illness and medications, less use of preventive health services, and significantly poorer self-management in diabetes, HIV, and asthma.^6,14,16–18 Limitations in health literacy affect a patient’s ability to

         Navigate the health care system, locate providers and services, fill out forms, and negotiate with insurance companies for covered services or claims,

         Share health history and other personal information with providers,

         Engage in the requisite behaviors for self-management of disease, and

         Understand concepts such as probability and risk, mathematical calculations (e.g., of cholesterol and blood glucose levels), measuring medications, and evaluating nutrition labels on food packages.

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