Overcoming Patient Literacy Challenges with Dr. Danielle Wales

A doctor provides a printed sheet of results to a patient.
Photo courtesy NCI/Unsplash

September 6, 2023

By Heather Duncan

Patient literacy is an often overlooked barrier to healthcare access in the United States, where the average adult reads at an eighth grade level. Patients whose native language is not English may face even greater difficulties navigating the healthcare system, and there is also significant overlap between racial minority status, low socio-economic status, and low literacy skills. This can result in compromised care and patient misunderstanding, leading to problems such as medication not being taken properly, confusion over a diagnosis or prognosis, uncertainty about one’s level of risk, and so on.

Recently, Dr. Danielle Wales of the Department of Health Policy, Management, and Behavior co-authored a study evaluating the reading level of result letters sent to patients in a primary care setting. The study compared the reading level of letters composed by resident versus attending physicians. Patients were screened using a single-item literacy screener and were then categorized according to their level of risk for low reading skills. They were also rated according to the severity of their health problems.

One important insight gained through this study is that patients with more complex medical needs also had a higher risk of low reading ability.

“This means that some of the sickest patients in our practice are also the most likely to have difficulty understanding correspondence from their providers. Previous studies of literacy and healthcare had never compared these two measures, so this is an important finding,” Dr. Wales explains.

The study also found that attending physicians did a better job of writing for the appropriate reading level than residents did.

“Residents often think they are being clearer than they actually are,” says Dr. Wales. “Residents have also not had as much time to get to know the types of patients that we see in our practice. It takes experience to understand those needs.”

The Joint Commission currently recommends that physicians write their correspondence with patients at a fifth grade reading level, which is the average reading level of a patient on Medicare. Dr. Wales and her co-authors suggest strategies like writing in short, clear sentences, avoiding words with three or more syllables, and eliminating any extraneous information that could be confusing to the patient in order to improve readability.

“These strategies take relatively little time to deploy, and they can improve the readability of medical correspondence by up to 3.6 grade levels,” explains Dr. Wales. “Providers should also pay closer attention to language and word choice when reaching out to seriously ill patients, where a misunderstanding could lead to serious consequences.”

The study also highlights the role that electronic health records could potentially play in alleviating this problem, by incorporating software that automatically generates a readability score and suggests ways to improve it. As access to telehealth increases, tools like these will be critical to ensuring that vulnerable patients are not negatively impacted.

Dr. Wales and her colleagues acknowledge that more studies need to be done on the impact of medical correspondence readability on patient outcomes. For example, their study only enrolled native English speakers, and the sample had limited racial and ethnic diversity. More research must be done to determine how to improve communication with these patients.