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Lessons and Tips from the Field

LESSON:  Be alert to clues of low literacy.

TIP: "The best clue in my office is whether new patients can fill out our form to indicate their concerns. If they cannot write answers to even the most basic questions, it is usually due to low literacy. That is true, too, if patients don't know what long-term medications they are taking or how often they take them."   —Primary Care Physician, the Northeast 

TIP: "In the Pre-Admission Clinic, we ask patients to complete a nursing assessment form. Clues to low literacy are comments like "I forgot my glasses", "My hand hurts too much to write," or "My sister will do this for me."  —Donna Slicis, MS, RN, Staff nurse, Massachusetts General Hospital, Boston



LESSON: If you suspect low literacy skills, avoid making the patient feel ashamed of that.   

TIP: "I try never to embarrass a patient I think may be having difficulty. I try to involve a family member to help the patient read and/or remember her medications. Also, the office staff makes follow-up phone calls to confirm appointments as well as the patient's knowledge of the treatment plan."  —Primary Care Physician, Brighton, Massachusetts



LESSON: Reduce the need to recognize low-literate patients by communicating with all patients on a simple level in plain language.

TIP: “In patient education, you to have to be careful not to misjudge a person’s literacy level based on appearances. One young man who seemed well educated came to the learning center looking for information on the diagnosis he had just received. We assumed he wanted a lot of high-level information, but he finally told us that because he had been ill, he could cope only with the basics about the disease. No one has ever told us that the information we have given them is too simple; if they want more, they will ask for it.”  —Ruth Dempsey, RN, Patient and Family Learning Center, Massachusetts General Hospital, Boston 

TIP: "In the context of the doctor-patient encounter I assume that all patients have a lower level of functional health literacy and I communicate accordingly."  —Dean Schillinger, MD, Assoc. Prof. of Clinical Medicine, UCSF, San Francisco General Hospital; Fellow, Open Society Institute


LESSON: Give the patient a chance to tell his/her story uninterrupted. 

TIP: "I ask the patient to express his concerns and perceptions, and I become an active listener. I use the patient's responses to tailor my message linguistically and emotionally."  —Dean Schillinger, MD, Assoc. Prof. of Clinical Medicine, UCSF, San Francisco General Hospital; Fellow, Open Society Institute.

LESSON: Use the “Teach-Back” technique, using “how” and “what” questions to confirm understanding. Corollary: Limit major concepts to no more than 3 per visit. 

TIP: “On the first visit, I help the patient a maximum of 3 goals. If appropriate, either I or the patient write them down in plain language, or at the end of the visit I ask him/her to repeat in their own words what we discussed and what we decided to do.  —Registered dietitian, Greater Boston area

TIP: “At the end of the pre-admission interview, I ask patients to tell me two things: exactly where they are going to come on the day of their surgery, and what they are going to eat or drink before same-day surgery. If the patient doesn’t rephrase the important concepts himself, you can’t be sure they are clear to him. For example, one patient was told not to eat anything at home before coming in for surgery. He thought that meant it was okay to have breakfast before his operation just as long as it was in the hospital cafeteria.” —Donna Slicis, MS, RN, Staff Nurse, Massachusetts General Hospital, Boston

TIP: "You need to listen carefully to make sure the patient’s own words reflect what you want him to know. Even an instruction you think is clear may not be to the patient. For example, although I wasn't directly involved in this aspect of his care, a patient I was following was told to drink ‘plenty of’ fluid. In a few days he was readmitted to the hospital with water intoxication, resulting from too much fluid consumption."-Ellen Forman, LICSW, Coordinator, Community Resource Center, Social Service Dept., Massachusetts General Hospital, Boston


LESSON: Use pictures, graphics, and real devices to demonstrate procedures and ideas.

TIP: “As a dietitian, I use food models, food plates, and pictures to convey information. I am also involved in home care, so I am able to demonstrate dietary recommendations using foods and kitchen utensils in the patient’s home."
—Registered dietitian, Greater Boston area

TIP: “As an acute care nurse, I would, for example, talk patients through the steps for emptying a surgical drain. Then, I would give them one and ask them to show me how they were going to do it themselves.” —Deborah Jameson, RN, MS, Librarian, Treadwell Library, Massachusetts General Hospital, Boston

TIP: “I use a lot of pictures because they cut across all levels of literacy, work particularly well in dental practice, and are more effective than models.”  —Charles M. Seitz, DDS, Boston, MA 

TIP: “My best tool is “The Chair-Side Instructor”, a book that uses pictures and graphics to explain oral health care. And, dentists have an advantage over doctors because patients can see and feel their teeth. We can demonstrate oral health care easily by using mirrors and even video cameras.  —David Russell, DDS, MPH, Tufts University School of Dental Medicine, Boston, MA



LESSON: Convey information orally while using written material mostly as a back-up and a reminder. Corollary: Be sensitive to the reading level of the material.

TIP: “In creating written materials for health promotion, we need to use short, action-oriented words in succinct sentences to make the point. Assessment of reading level is critical.”  —Erica Streit, MSW, MPH, Community Health Promotion Coordinator, Greater Boston area

TIP: “When I write instructions, I use graphics whenever possible and combine them with brief messages and short words. For example, I wrote a letter to remind patients who had no alternative transportation about how and when to arrange for taxi pick-up. I found that patients were more likely to read it after I added a small picture of a taxi. They could quickly see what it was about and then prioritize among all the papers they received. Even excellent readers, when under stress, may not have the patience or concentration to read and absorb everything they’re given.”  —Ellen Forman, LICSW, Coordinator, Community Resource Center, Social Service Dept., Massachusetts General Hospital, Boston 

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