When Health Care Is Lost in Translation

“Health literacy is a two-way street,” says Sabrina Kurtz-Rossi. “It’s not only the skills the patient brings to the clinical encounter, but the skills of the health-care provider and ability of the system to communicate health-care information.” Photo: Alonso Nichols

When some Tufts dental students were learning how to communicate better with their patients, one repeatedly used the term “caries” to describe a common oral health affliction. The teacher kept correcting him.

“Who uses the term ‘caries’ for ‘cavity’? No one. Only dentists,” said the instructor, Sabrina Kurtz-Rossi. “They were so involved in their own field and their own learning that they had forgotten how people outside the field talk.”

The use of discipline-specific language isn’t limited to dentistry. For health-care students and practitioners, there is too often a gap between what the provider is intending to say and how their patients interpret and act on that information. Bridging that terminology gap is one goal of the growing field of health literacy, a movement designed to increase communication and understanding in health care.

“You’d think it would be so obvious, but health literacy has only recently been recognized on a national level by the surgeon general and the Institute of Medicine,” says Kurtz-Rossi, an adjunct clinical instructor who teaches a seminar on health literacy as part of the School of Medicine’s health communication program. The course, one of only a handful on the topic taught at medical schools across the country, draws students from the medical and dental schools, the Friedman School of Nutrition Science and Policy and other students in public health.

The U.S. Department of Health and Human Services defines “health literacy” as the ability to read, understand and act on health information. “Within the field, we see it as much broader than that,” Kurtz-Rossi says. “Health literacy is a two-way street. It’s not only the skills the patient brings to the clinical encounter, but the skills of the health-care provider and ability of the system to communicate health-care information.”

The consequences of poor communication go far beyond confusion. “Miscommunication is one of the top causes of medical errors,” Kurtz-Rossi says. Patients who don’t understand hospital discharge instructions for home care or dosing instructions for their medication are also more likely to be re-admitted.

The Risks of Miscommunication

Within the past two decades, assessments of adult literacy in the U.S. have revealed that nearly 50 percent of the population has basic or “below-basic” literacy skills, according to the National Institute for Literacy. “That was a wake-up call to the health field,” Kurtz-Rossi says. “If millions of people have limited literacy, that raises questions about the ability of a large part of our population to navigate the health-care system, and our ability to reduce health-care disparities.”

At the same time, researchers have documented the mismatch between the written health information that is being given out and the reading skills of patients. “We’ve built a lot of evidence documenting that we’re not doing such a great job communicating health information with patients and the larger community,” she adds.

The patients at greatest risk of miscommunication include the elderly, those with less than a high school education, the poor and those who don’t speak English as a first language, Kurtz-Rossi says. But they are not the only ones. “If you have a Ph.D. but know nothing about heart disease, and your doctor starts talking about angioplasty, you may not understand,” she says.

That leads to another element of expanding health literacy: promoting a shame-free environment when communicating with patients. “You don’t know who doesn’t understand and may be too embarrassed to say so,” Kurtz-Rossi says. “We talk about establishing an atmosphere of helpfulness, encouraging questions and engaging all staff.”

Learning New Tricks

During the past decade, more medical schools and schools of public health have recognized health literacy as a core competency for students. That wasn’t always the case. “One physician told me that 20 years ago when he was in training, he got marked down for using common language, rather than medical terminology” when talking to a patient, Kurtz-Rossi says. “That’s changing now, but doctors need to almost unlearn what they’ve learned in terms of communicating with people.”

It’s all about how we offer medical education, she says, which often has its own language. “In medical school, you communicate with your students and colleagues in one way; when you’re working with patients, you need to speak about health in ‘living-room language,’ also known as plain language.”

It isn’t as simple as it sounds. “Sit down and try to write in everyday living-room language about a health-care topic—it’s not so easy,” Kurtz-Rossi says. “Students are often surprised; they’re challenged by it.”

For example, she says, “think about communicating risk. It’s a fairly complex concept. When you’re counseling patients about cancer treatment or other treatments, we expect people to understand the concept of risk and make life decisions based upon the information provided to them. Communicating the concepts is just as important as communicating the vocabulary.”

“Health literacy is also dependent on cultural factors,” Kurtz-Rossi says. There are times when health-care concepts and vocabulary literally don’t translate. “For example, in Navajo there is no word for chemotherapy,” says Kurtz-Rossi. “If you’re working with an interpreter, not only the word, but the whole concept has to be explained.”

Kurtz-Rossi teaches her students about working with interpreters, and stresses the importance of using professional interpreters, rather than family members.

“Students need to know how important the interpreter’s role is and how complex when it comes to facilitating patient-provider communication,” she says. She stresses that the communication is between the patient and provider and reminds students to direct their comments to the patient rather than the interpreter. “Don’t say to the interpreter, ‘ask him what his symptoms are.’ Say to the patient, ‘what are your symptoms?’ ” Kurtz-Rossi says. “It’s very easy to fall out of that.”

A guest speaker who addressed Kurtz-Rossi’s class last year was a “cultural broker” from Maine Medical Center in Portland, who helps members of Maine’s growing Somali immigrant community navigate the health-care system and helps the providers better understand Somali culture and health-care needs.

“One of my students recently described to me how a Somali woman missed an appointment at the hospital and had to reschedule because her sister served as the interpreter and confused the location of her procedure,” she says, which clearly illustrates the need and value of trained interpreters.

Helene Ragovin can be reached at helene.ragovin@tufts.edu.