I had an extraordinary hour- long conversation with about 35 medical residents and attendings in an inner city teaching hospital last week. I was invited to present not-a-lecture on health literacy at their Grand Rounds*. I met them in their beautiful auditorium, which was elaborately equipped and designed for lectures.
I decided to model what I teach. I took on the role of a home visitor. I resolved to empower this “family” to move toward their best possible desired outcome by asking reflective questions that would lead them to formulate their response to health literacy in their institution and their practices. As home visitors point out, this is scary; who knows what might happen?
I set my intention to be fully present with them, especially if things got dicey. I reminded myself to avoid “duct tape moments”. Those happen when a visitor needs duct tape on her mouth to resist giving advice, answering questions families can answer themselves, or telling them what to do.
I told the physicians I would like to engage them in a reflective conversation. The intent of the discussion would be to think together about what health literacy means to them, their hospital, and their patients; about how would they know if they were addressing health literacy thoroughly and well; what's supporting them and what's in the way or missing. By the end of the hour, if we were good, they would name action steps that they are willing and able to take next week. They were game.
One ‘burning question” from the group was What IS health literacy? So we started with the storyof my Dad’s fall in the driveway last summer and my family’s experience with him in the ER and the hospital (not their hospital). I asked them to listen for three perspectives of health literacy. 1) “Low health literacy” as clinically defined (inability to understand (read) basic information needed to make health decisions); 2) health literacy as a personal and community asset that people use to manage their health and healthcare and to build healthy communities; and 3) “hyper health literacy” - a term I coined to describe extreme levels of medical knowledge and familiarity with healthcare documents which can leave health professionals unable to communicate effectively with those outside the professions.
Doctors feel disrespected and unappreciated, too
The physicians were engaged, participative, thoughtful, reflective, and at times, defensive. Generally a tough, stressed, brilliant group. It was not an easy conversation. The doctors revealed feeling unappreciated. “They treat us like waiters. They say, ‘I want this and this and that,” one attending said. “The respect is gone,” said another.
Some thought my dad had low health literacy and probably could not read well since he did not know if he had a kyphoplasty* and did not know whether his testosterone and prostrate had been checked. (He’s an avid reader - but not of medical journals) A few defended the doctor for asking Dad to repeat what happened, although he had told the story many times already that day, his injuries made it difficult to talk, he was on a pain cocktail, and it was recorded in the chart, which the doctor did not read. “We hear something new each time, she said.” Fair enough. How could you do it differently to save the patient some of the difficulty and save yourself some time?
The Chief Resident chided me for not being more assertive. He said when the doctor burst into the room late at night, woke us up, pointed at me and asked Dad, “Who is she and what is her relationship?”, I could have stood up and asked him who he was and what was he doing there. Good point. It reminded me of quote attributed to Melvin Belsky, M.D: It’s not enough for the doctor to stop playing God, you have to get off your knees. Next time.
What do you want and how will you know you’ve got it?
The doctors said they would know they are addressing health literacy fully and well when patients are more compliant; and they acknowledged that an informed patient might reasonably choose not to comply. Another sign: patients would ask more questions. Good one.
Things supporting them in addressing health literacy were good training and good policies. In the way, no surprise, was limited time with patients. More troubling was some attitudes about patients. A young woman resident said, "they are just irresponsible, you give them info and they leave it on the bed". The group suggested several reasons why that might happen - they thought they were going to get the same information from the pharmacist; they were overwhelmed with info and instructions; no one discussed the information and its importance with them. One physician complained that his patients search the Internet and come in with information. He considered that a time consuming problem, rather than a sign of an engaged patient,
Moving to Action
The reflection lead the doctors to name steps they will take in the next week to address health literacy. For example, instead of asking the patient to repeat their story for each provider, they might read the notes and say something like "I understand this is what happened... “ and ask for specifics as needed. At discharge they might talk with the patient about how they will apply instructions to cope and recover at home. They might encourage patients with a new diagnosis to make a list of questions for the follow-up visit, and then be sure to ask them for it. A simple suggestion was to look the patient in the eye when talking with them. My best lecture could not have generated this collaborative action planning.
The Power of Reflection
This conversation demonstrated the power of reflection and reflective questions to engage people, bring them to their own solutions, and move them to actions that they are willing and able to take. These doctors showed that they are response-able for health literacy in their institution. Hear me applauding.
Notes & Reference
The reflective process described here is part of TED* - The Empowerment Dynamic described by David Emerald. Visit powerofted.com/. Order the book The Power of TED* or the new TED* and Diabetes. s
*Kyphoplasty is a surgical procedure designed to stop the pain caused by a spinal fracture