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“I learned one of my first lessons on the importance of clear health communication when I was a Special Forces Medic in Vietnam delivering care to the indigenous people of a small Montagnard village,” US Surgeon General Richard Carmona, MD, told Neurology Today in a phone interview. “Before I was allowed to see any patients, the village chief invited me to his thatched hut, asked me many questions, and wanted me to share a meal and drink the local wine.”

“Only after that did he allow me access to his people. I was brought to see the chief's daughter, who had skin infections on her arm. I thought I would look brilliant because I knew how to treat impetigo. I gave instructions that I thought were clear – wash with Phisohex at the river several times a day and take these penicillin pills four times per day. The little girl got better, and the villagers wanted to express their gratitude, so when we sat at the next reception ritual, they brought me gifts – a crossbow and a bracelet.”

“Then they brought out a ceremonial box containing a necklace with 28 Pen VK pills strung on it. Each day, they had put four pills on the string and since that time, they had been placing the ‘beads’ around the neck of any villager who became ill.”

Although Dr. Carmona's story is 30 years old, the experience still holds true. As neurologists, we recognize the value of engaging our patients in thorough discussion of medication use, as well as disease management and prevention. But perhaps what we fail to recognize is that our attempts to get the message across are often unsuccessful.


Dr. Richard Carmona: “As we look at the messages we send that we think are clear, we see that there are in fact many barriers, including variances in cultural attitudes and customs.”


See the sidebar, “Resources for Health Literacy,” for online sources and publications to help health care professionals address inadequate patient education.


Over the past decade, the concept of health literacy – the ability to read, understand, and act on basic health information and services needed to make appropriate health decisions – has begun to receive considerable attention. Furthermore, studies have shown that poor health literacy may have profound adverse health effects by limiting patients' abilities to communicate with physicians, understand health information, and follow written medical instructions. Neurology patients in particular – often elderly, cognitively impaired, confused, or anxious – are at even higher risk for poor health literacy.

Working as a trauma surgeon, Dr. Carmona said he witnessed many consequences of poor health literacy including cases where patients came to the emergency room with bowel obstruction having swallowed suppositories wrapped in their aluminum packaging. Dr. Carmona has made health literacy a principal focus of his tenure as the 17th US Surgeon General.

Dr. Carmona believes that awareness is the first step in addressing the challenge of low health literacy. “As we look at the messages we send that we think are clear, we see that there are in fact many barriers, including variances in cultural attitudes and customs,” he said.


Dr. Orly Avitzur is a neurologist in private practice in Tarrytown, NY. She holds joint academic appointments at Yale University School of Medicine and New York Medical College.

“From my perspective as a surgeon doing critical care in Tucson, AZ, my approach to a Native American patient needed to be different from my approach to a highly educated, affluent patient,” he continued. “It extended beyond the use of language into an understanding of cultural influences. In many cultures, such as the Native American, patients do not question a physician.”

In addition, he pointed out, many patients feel embarrassed about asking questions. “If the doctor stops for one or two minutes, makes eye contact and asks for feedback, the patient can be placed at ease. We often forget that for many people there is a sense of intimidation; patients feel they need to accept our information at face value despite the fact that they may not understand how to take their medication or follow other instructions.”

The Surgeon General noted that one area of the hospital where communication is at high risk is the ICU environment with critically ill patients. “Imagine how the average person who walks into this setting feels seeing multiple intravenous and central lines and several monitors. In order to give them the information they need, you have to have the sense of who the family is, and you have to spend enough time to respond to their needs and concerns.”


Inadequate patient education may also lead to poor outcomes in neurological conditions such as stroke. “We need to a better job at making our patients understand the role that risk factors play in stroke prevention and of informing them of the symptoms to watch out for,” said Larry B. Goldstein, MD, Director of the Duke Center for Cerebrovascular Disease and Head of Duke's Stroke Policy program, the Center for Clinical Health Policy Research.

Dr. Goldstein noted that many studies have shown that the public's knowledge of stroke symptoms is poor, a situation believed to contribute to the observed delays between stroke onset and a patient's contact with the medical care system. Merely developing effective new stroke prevention and acute interventions will have a limited impact on stroke associated morbidity and mortality if they are not optimally incorporated into practice, he said.

“As we have learned from a report from the ACASS (Asymptomatic Carotid Artery Stenosis Study) investigators, it is also the way that we present essential information that affects patient actions. For example, if you tell a patient that an intervention will decrease their risk for stroke by half, their response to the information may be quite different than if you say that their risk will be reduced from 1 percent to 0.5 percent,” he explained.


Steven R. Rush, AAN's Practice and Patient Safety Manager, suggested that there are various strategies neurologists can use to gauge communication with their patients. For example, neurologists could conduct a pre-exit interview, saying, for example: “Your family may be interested in what we discussed during our visit today. Can you tell me what you will say to them?”

Other experts suggest inquiring if there is someone who helps the patient take their medicine in order to explain the instructions to that designated person. In addition, physicians can ask their patients, if they, like many others, have trouble remembering health care instructions.

Last May, neurologists Gloria Galloway, MD, and John A. Schafer, MD, attended the AMA Foundation's health literacy train-the-trainer program along with Mr. Rush. The AAN was the first medical specialty organization to receive training in the AMA Foundation's new health literacy initiative.

Dr. Schafer said the AMA program offered techniques for identifying “red flag” behaviors which may betray a patient's low literacy level, learning how and when to assist patients in completing forms, reviewing medications with patients, and providing written and spoken information appropriate to the reading level of most patients. The “show me” and “teach back” techniques, in particular, greatly increase patient comprehension of explanations and instructions.

The Surgeon General's office is preparing a report on health literacy for HHS Secretary Tommy Thompson, which will be available later this year to physicians and the public at: “As we get busier and we have far too many patients, and our lives become more complex, we stick to the medical side and we forget the importance of communicating,” Dr. Carmona said. But, if you stop to ask the questions: ‘What's on your mind? Do you understand what I have said? Can you repeat back to me what you have understood’, you will discover that it makes a great difference.