Feb 8, 2016

Interview Transcript

Dr. Jones: Doctor's instructions can be hard to understand, especially when leaving the hospital. But why is that and what can be done about it? I'm Dr. Kyle Bradford Jones, family physician at the University of Utah School of Medicine and we're talking about this on The Scope.

Announcer: These are the conversations happening inside health care that are going to transform health care. The Health Care Insider is on The Scope.

Dr. Jones: So I'm joined today by Dr. Martin Zielinski, who is an Associate Professor of Surgery at the Mayo Clinic in Rochester, Minnesota and who practices as a trauma surgeon. Now, Dr. Zielinski, you recently published some research that talks about how well trauma patients understand their instructions for care when being discharged from the hospital. What kinds of things did you find?

Dr. Zielinski: The reality is that our dismissal summaries were written at extremely high readability levels. What readability is, is a concept that most of us are familiar with. Essentially, it's the grade level that a piece of text is written at. So if you're in the sixth grade, you should theoretically be able to read at about a sixth-grade reading level. And what most major medical institutions, including the AMA recommend, is to have a reading level at approximately the six to eighth-grade. Unfortunately, ours was substantially higher than that and up to the tenth and eleventh reading levels.

Dr. Jones: So considering that the majority of our population has graduated high school, theoretically, they would have a higher reading level. Do we have any sense in terms of why we need to go down to sixth to eighth-grade level like you mentioned?

Dr. Zielinski: Turns out that even though you graduated from high school or perhaps even have higher college degree education, most American adults will read at five grades lower than their highest attained grade. So if you did graduate high school, in theory, you will probably read around the seventh-grade reading level, it turns out. And so in order to be able to account for people that graduated high school or have not yet graduated high school, the reading levels really should be lower.

Dr. Jones: Okay. Now, going back to your study, how did the increased difficulty in understanding these discharge instructions, how did that impact the patients after they were released out of the hospital?

Dr. Zielinski: So it turns out a large proportion of patients are functionally illiterate when it comes to healthcare tests. What we hypothesized is that this would result in more calls back to our trauma service as well as more readmissions. And the reason is because if someone doesn't necessarily understand what they've been given, hasn't had the opportunity to really digest and figure out the meaning of what we are trying to say, they'll have more questions and that will either result in more questions back to us or perhaps them following advice that they thought was correct but, in reality, is not perhaps maybe what we meant to have.

Dr. Jones: Now, with these being trauma patients, is there any difference if they had severe head trauma verses those that hadn't and their ability to understand?

Dr. Zielinski: That is certainly a big part of this. Traumatic brain injury isn't just the major epidermal hematomas that we read about in popular media. Concussions are extremely common within our patient population. And whether it's a permanent or temporary defect, the ability to understand even spoken language can be difficult for some of these patients. So for us to expect them to also understand something that they're reading with diminished understanding levels and ability to concentrate, you really need to have those patients' texts written at even lower levels and recommendation to that are fifth to sixth-grade reading levels.

Dr. Jones: Now, did you notice a difference between any other groups such as age groups? Could this be a generational thing?

Dr. Zielinski: We didn't look specifically at age. What we did as result of this study, we were, quite frankly, embarrassed of the high level of our dismissal summaries. So we actually went back and changed them all. So now, all of our templates will ensure that they're at a sixth-grade reading level currently. Now that we've done that, we can go back and study the difference that effect is made.

Dr. Jones: Patients, when they get discharged from the hospital, they get multiple contacts. So the nurse might give them instructions or the discharge planner and the physician. And if they're in a teaching hospital, like at Mayo, they'll probably have a resident and an intern. Does all these different people giving instructions, does that tend to be a good thing or a bad thing in order for understanding?

Dr. Zielinski: I think the potential exists for both. My primary impression, though, is that the more times you go over instructions, the more a patient will retain that knowledge and ensure that they understand that and have the opportunity to think about it over time. When the next person comes and talks about the same issue, they may have a question that they didn't quite understand and so they can clarify. But, certainly, you can have too many cooks in the kitchen and perhaps two different interpretations may be provided to the patient. And we try to avoid any kind of situation like that, of course.

Dr. Jones: Now, obviously, this speaks to a broader issue in health care, of health literacy and making sure that patients are understanding instructions from physicians and what is ideal for them to take care of their own health. So you mentioned something that you guys have changed since this study. What are some other things we can do, in general, in health care to make sure that the patients are understanding instructions?

Dr. Zielinski: Coming from a hospital discharge instruction standpoint, I think there are a lot of things. And one of them that you just mentioned is to make sure that you have a system in place where when the patients are dismissed, they have providers going over the details of what they're supposed to be doing to ensure the highest level of care they can attain. So that's certainly an important thing.

Then, not to be intimidated, perhaps, by calling back if you do have further questions. We certainly encourage our patients to call us back if that occurs. We have 24-hour, 7-days-a-week support to be able to do those kinds of things.

Dr. Jones: So with your study of the instructions being given to trauma patients, how do you feel like this expands to kind of a more general population?

Dr. Zielinski: I think this is extremely generalizable. We did it within our own institution and a specific service at our institution. But we've subsequently had disciplinary analyses of other services, including plastic surgery, and it turns out theirs are written at just as high a level as ours. So I do believe that this is a generalizable phenomenon and other institutions should ensure that their summaries and the text that they provide, whether summaries or not, needs to be at an appropriate reading level.

Dr. Jones: So what do you think is the biggest takeaway for patients in light of this study and health literacy more in general?

Dr. Zielinski: Make sure you understand what occurred in the hospital and how it affects your health and what you need to do moving forward to make sure that you can be as healthy as possible.

Announcer: Be a part of the conversation that transforms health care. Leave a comment and tell us what you're thinking. The Health Care Insider is a production of TheScopeRadio.com, University of Utah Health Sciences Radio.

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