Stripping it Down, Mixing it Up, and Stripping it Down, Mixing it Up, and Bringing it Home: Reducing the Oral Bringing it Home: Reducing the Oral Literacy Burden of Medical Dialogue Literacy Burden of Medical Dialogue

Debra RoterDebra RoterProfessorProfessor

Johns Hopkins Schools of Public Health, Johns Hopkins Schools of Public Health, Medicine and NursingMedicine and Nursing

Objectives for todayObjectives for today

Discuss what we know about Discuss what we know about what makes it difficult for patients what makes it difficult for patients with restricted literacy to take an with restricted literacy to take an active role in their medical care – active role in their medical care – and in medical visit conversations.and in medical visit conversations.

A typical American patient will A typical American patient will see a doctor approximately 320 times see a doctor approximately 320 times over a lifetime --– an average of 4 over a lifetime --– an average of 4 medical contacts per year. -- more if medical contacts per year. -- more if you suffer from a chronic illness, are a you suffer from a chronic illness, are a woman, have children, have a spouse woman, have children, have a spouse or an elderly parent. or an elderly parent.

Almost half of these patients have Almost half of these patients have restricted literacy skills.restricted literacy skills.

Literacy in Baltimore CityLiteracy in Baltimore City 75% Baltimore City population can be

characterized as suffering from significant literacy deficits.

http://www.casas.org/lit/litcode/Search.cfm

– 38% of Baltimore City residents score as having below basic skills

– 35% score as marginally literate

There is reason to worry about the effect There is reason to worry about the effect of restricted literacy on oral communication of restricted literacy on oral communication

Low literacy is related to restricted Low literacy is related to restricted expressive language -- expressive language -- overall passivity in overall passivity in the medical dialogue, less detailed medical the medical dialogue, less detailed medical histories, and less involvement in decision histories, and less involvement in decision making.making.

Patients note that they Patients note that they do not feel listened do not feel listened to and have difficulty being understoodto and have difficulty being understood. . (Baker et al, 1996; (Baker et al, 1996;

Bennett, 2006)Bennett, 2006)

Restricted literacy has been Restricted literacy has been associated with poor listening skills associated with poor listening skills --- --- poor comprehension and recall, and lower poor comprehension and recall, and lower patient satisfaction with both physician patient satisfaction with both physician informativeness, as well as interpersonal informativeness, as well as interpersonal rapport.rapport.

Patients complain they are not given Patients complain they are not given information about their problems information about their problems in ways they in ways they can understandcan understand...(Williams et al, 1998; Schillinger et al, 2004; Baker et al, 1996).(Williams et al, 1998; Schillinger et al, 2004; Baker et al, 1996)

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 What makes it difficult for patients to understand and feel understood? understand and feel understood?

Roter et al, 2007

Learning Recall/comprehension

Patient centered communication

Stripping it down Stripping it down Mixing it up Mixing it up Bringing Bringing it homeit home

Engagement in self care and preventive health practices

--- because part of medicine’s --- because part of medicine’s mystique is that it is written -- and mystique is that it is written -- and often communicated in code. often communicated in code.

--- demystification begins with a --- demystification begins with a translation from “Medicalese” to translation from “Medicalese” to EnglishEnglish

Why is it important to strip it Why is it important to strip it down?down?

---Use of medical jargon is ---Use of medical jargon is commoncommon

Studies dating back 50 years have established that Studies dating back 50 years have established that physicians use technical terms that patients do not physicians use technical terms that patients do not understand understand

ButBut, patients rarely challenge their doctors to , patients rarely challenge their doctors to “speak English” “speak English”

Aside from jargon, physicians often Aside from jargon, physicians often use grammatically complex language, use grammatically complex language, long sentences, frequent repetitions, and long sentences, frequent repetitions, and the passive voice.the passive voice.

Beyond jargon – general Beyond jargon – general language language complexitycomplexity

Few speakers are self-aware of Few speakers are self-aware of speaking style.speaking style.

Communication style is often Communication style is often “invisible” to the speaker“invisible” to the speaker

Too often medical dialogue is a largely one-sided series of mini-lectures interspersed by patient head nods and assents.

The engagement that comes from the up and back of true exchange is what transforms parallel monologues to a conversation .

Interactivity – Mixing it up

Why is it important to mix it Why is it important to mix it up?up?

Interactivity – is engaging Interactivity – is engaging

Interactivity – is empoweringInteractivity – is empowering

Interactivity – is instructive Interactivity – is instructive

Speaker turnSpeaker turn is defined as a continuous is defined as a continuous block of uninterrupted speech by a single block of uninterrupted speech by a single speaker (excluding back channels and other speaker (excluding back channels and other ‘out of turn’ statements) ‘out of turn’ statements)

Dialogue interactivityDialogue interactivity is the rate of is the rate of floor exchange per session minute.floor exchange per session minute. For For example, a 13 minute PC visit may have 104 example, a 13 minute PC visit may have 104 talking turns (52 speaker exchanges) with talking turns (52 speaker exchanges) with an interactivity rate of 3.9 speaker an interactivity rate of 3.9 speaker exchanges per minute.exchanges per minute.

How is interactivity measured?

HIGH INTERACTIVITY VISITSHIGH INTERACTIVITY VISITS

LOW INTERACTIVITY VISITSLOW INTERACTIVITY VISITS

Getting up close and personal Getting up close and personal – – what does this have to do with for me?what does this have to do with for me?

Decontextualized language conveys abstract ideas or novel Decontextualized language conveys abstract ideas or novel use of language. People with restricted literacy tend to use of language. People with restricted literacy tend to communicate in concrete terms about things they feel, see, know communicate in concrete terms about things they feel, see, know and experience.and experience.

For example, in the medical context a question regarding For example, in the medical context a question regarding chest pain is typically “Is it a dull pain and heaviness like an chest pain is typically “Is it a dull pain and heaviness like an elephant on your chest or a sharp, like a knife" elephant on your chest or a sharp, like a knife"

In my study of chest pain – patients said things like “I 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 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” my chest hurts here, I feel bad, I can't explain it”

Why is it important to bring it home?

Personally Contextualized information in genetic counseling Personally Contextualized information in genetic counseling We found that statements like:We found that statements like:

“ “Based on Based on what you told me about your historywhat you told me about your history, there is a 1 in , there is a 1 in 400 chance 400 chance that your baby will have one of these genetic that your baby will have one of these genetic mutations”mutations”

were far better recalled than statements like:were far better recalled than statements like:

““Nobody has a risk of zero – a pregnant women over 35 has Nobody has a risk of zero – a pregnant women over 35 has a 1 in 400 chance of having a baby with this genetic a 1 in 400 chance of having a baby with this genetic mutation” mutation”

Contextualized Information is better remembered

Is reduced oral literacy burden Is reduced oral literacy burden consistent with positive patient consistent with positive patient

outcomes?outcomes?YES!YES!

Interactivity is correlated with patient satisfaction ratings on a number of dimensions, including positive physician demeanor, interpersonal rapport and ratings of decision-making partnership.

For patients with low literacy skills, interactivity and personalized information was related to better recall of session information.

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

What was lost in the practice of modern medicine?

YES!YES!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.

Roter et al, Pt Ed Cnslng, 2007

Is reduced oral literacy burden Is reduced oral literacy burden consistent with patient-consistent with patient-centeredness?centeredness?

What about patient activation?What about patient activation?

Communication interventions directed Communication interventions directed toward health care providers are effective and toward health care providers are effective and can be used to reinforce and compliment can be used to reinforce and compliment patient activation. And, interactive, patient patient activation. And, interactive, patient activation interventions are well received and activation interventions are well received and effective in a variety of patient populations – effective in a variety of patient populations – including those with restricted literacy.including those with restricted literacy.

Complimentary skill development can Complimentary skill development can exponentially move the medical dialogue to the exponentially move the medical dialogue to the next level of therapeutic effectiveness .next level of therapeutic effectiveness .

The Time to Talk Cardio The Time to Talk Cardio (TTTC) web-based (TTTC) web-based communication toolscommunication tools

The TTTC tool consists of 500 15 second The TTTC tool consists of 500 15 second video clips modeling key communication video clips modeling key communication skills (separately) to patients and skills (separately) to patients and clinicians using the LEAPS heuristic. clinicians using the LEAPS heuristic.

Individual tailoring of skills through the use Individual tailoring of skills through the use of a communication-challenge screener. of a communication-challenge screener.

TIME TO TALK CARDIOTIME TO TALK CARDIOwww.timetotalkcardio.cowww.timetotalkcardio.comm

TIME TO TALK CARDIOTIME TO TALK CARDIOwww.timetotalkcardio.cowww.timetotalkcardio.comm

Does this approach work?Does this approach work?

Yes! Yes!

In a randomized trial patients In a randomized trial patients using the TTTC website using the TTTC website reported a significant increase reported a significant increase in targeted communication in targeted communication skills and subsequent medical skills and subsequent medical visit satisfaction.visit satisfaction.

Physicians using the website Physicians using the website also reported a significant also reported a significant increase in the use of targeted increase in the use of targeted communication skills. communication skills.

““A physician to slaves never gives his patient any account of his illness…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 The free physician, who usually cares for free men, treats their diseases first by thoroughly discussing with the patient and his friends his ailment.”first by thoroughly discussing with the patient and his friends his ailment.”

In articulating the physician’s responsibility to be In articulating the physician’s responsibility to be both teacher and healer, Plato laid the foundation for both teacher and healer, Plato laid the foundation for patient-centered medicine and collaborative models of patient-centered medicine and collaborative models of therapeutic relationship and introduced the protection therapeutic relationship and introduced the protection of patient autonomyof patient autonomy