Published 10/1/2016
Dwight W. Burney III, MD

Health Literacy and Patient Safety

As orthopaedic surgeons, we are often frustrated by patients who have trouble understanding our advice, continue to have questions, or are “noncompliant.” We need to consider that the average American reads at a fifth-grade level and may have difficulty understanding prescriptions, appointment cards, and consent documents.

Even patients with college degrees may not be sufficiently “health literate” to understand our written or verbal messages. These facts have major implications for verbal and written patient education materials, shared decision making, informed consent, and the completion of advance directives.

Physicians have a unique vocabulary. We learn an estimated 13,000 medical terms during our training. And we use them. According to one study, we use an average of four undefined medical terms (medical jargon) per office visit. Our patients may not understand many of the terms we use in the same way that we do. Thus, avoiding medical jargon to prevent confusion is a good idea.

In addition, patients with limited health literacy and/or limited English proficiency are at increased risk of adverse events and harm from surgery. Fortunately, we can take precautions to reduce this risk, starting with learning the level of a patient’s health literacy. And that’s not as difficult or time-consuming as you might think.

Assessing health literacy
A single-question, valid tool for assessing a patient’s health literacy is “How confident are you in filling out medical forms?” A response of “somewhat” for native English speakers or “a little” for patients who have a different first language reliably identifies patients with inadequate or marginal health literacy.

The “Newest Vital Sign” test can be administered by staff in a few minutes. This test uses a nutritional label and six questions to measure a patient’s understanding. A score of three or less indicates possible limited health literacy.

The Agency for Healthcare Research and Quality has a useful “Health Literacy Universal Precautions Toolkit” that can be downloaded for free. This toolkit describes two “universal precautions” for dealing with patients with limited health literacy. First, practices should assume that all patients and caregivers may have difficulty understanding health information and should communicate in ways that anyone can understand. It includes 21 different tools that can be used to improve spoken and written communications and empower both staff and patients.

Addressing health literacy
For example, patient education materials should be written at no higher than a fifth-grade reading level (based on the Flesch–Kincaid Grade Level [FKGL] Index). The FKGL is calculated by many document programs such as Microsoft Word using the “Spelling check” function. FKGL is based primarily on sentence length. (This article has an FKGL score of 10.1, and a reading ease score of “difficult.”)

Routine use of the “teach-back” technique to assess patient comprehension is also recommended. Patients want to know what they need to do and why doing it is important, in addition to the diagnosis. “Ask–Tell–Ask” is a useful teach-back tool, taught in AAOS Clinician-Patient Communication courses.

The technique begins with the question, “What do you know about [your condition]?” Then, listen to what the patient tells you. Assessing the patient’s prior knowledge of the condition allows the surgeon to craft a message with three key points. (Human factors research has shown that people can reliably handle only three concepts in short-term memory.)

The second ask can be phrased as follows: “We’ve talked about a lot of complicated information today. To make sure I’m doing a good job, would you please tell me what you will tell your [significant other] about our visit today?” The patient’s answer enables the surgeon to assess understanding and correct or clarify it, if needed.

Patient-centered care requires that we translate our knowledge into a form our patient can understand and use. These simple tools should result in better outcomes—and a much more satisfying visit—for both our patients and ourselves.

Dwight W. Burney III, MD, heads the section on safety education of the AAOS Patient Safety Committee.


  1. Agency for Healthcare Research and Quality: Cifuentes M, Brega AG, Barnard J, et al: Guide to Implementing the Health Literacy Universal Precautions Toolkit. (Prepared by Colorado Health Outcomes Program, University of Colorado Anschutz Medical Campus under Contract No. HHSA290200710008, TO#10.) AHRQ Publication No. 15-0023-1-EF, Rockville, MD. January 2015.
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