The Authors' Reply: Your article highlights the important role that good patient education can play in the care of an orthopaedic patient.
As you note, more patients are turning to the Internet for medical information. A recent study conducted by the Pew Research Center shows that 62% of smartphone users access health information on their mobile devices. At OrthoInfo, we try to bridge the gap between the information a patient gets at a doctor's office and what he or she ultimately understands.
In your study, you use readability software, such as Flesch-Kincaid, to assess the reading level of articles on OrthoInfo. You correctly note that over time, our readability scores have come down. In fact, your data indicate that the average Flesch-Kincaid score in the articles you reviewed was between an eighth and ninth grade level. You conclude that these reading level scores are higher than the nationally recommended eighth grade level and therefore too difficult for the average patient to understand.
Here at OrthoInfo, we recognize that we must continue to improve the information we develop for patients, including the reading levels of our articles. We contend, however, that reading level scores should not be the only factor considered when determining whether written material is clear, effective, and understandable.
Readability scores are computer-based formulas that count the number of syllables, words, and sentences within a text. The formulas assume that longer words and longer sentences are harder for readers to understand.
You suggest that complex words that are longer than six letters or three syllables should be avoided in patient education. But even the simplest patient information article includes words such as diagnosis, examination, surgery, recovery, therapy, and exercise—not to mention common orthopaedic terms such as arthroscopy, scoliosis, and osteoarthritis. By your definition, all these are complex terms. Using them makes it difficult to reach a lower grade level based on any formula.
Just because a word is complex does not mean that a reader cannot read it or understand it. Substituting a shorter word does not automatically make it more readable.
The readability of an article is much more than a computer formula score. It is based on the visual presentation, formatting, writing, and flow of the article. If the article is interesting and flows logically, a patient is much more likely to grasp the main points. If that article is also concise and well illustrated, the patient is much more likely to understand the concept presented.
We continue to enhance OrthoInfo with more illustrations, videos, and animations. Our view is that visual presentations and illustrations make health information more readable and easier to understand. We have used Flesch-Kincaid as a tool when we develop our articles and will continue to monitor readability scores in our ongoing efforts to improve our content.
We appreciate the emphasis that your article places on patient education. At OrthoInfo, our goal is to publish the best and most accurate orthopaedic information on the web. Articles such as yours in JAAOS Global Research and Review and other journals can stimulate practicing surgeons to think about how they can best provide information to their patients.
Thank you again for leading the discussion of this important topic in patient education.