Developing a new focus on communicating with patients

Even as a chemical engineering student at UCLA, Darren DeWalt was interested in health care. At the time, he was keenly aware of two things: that he wanted to help people and that he had no desire to spend his life in a lab.

Developing a new focus on communicating with patients click to enlarge Darren DeWalt, MD, MPH

This story was originally published here in the University Gazette.

After working for a year with a pharmaceutical company, he attended medical school at Vanderbilt, where his passion for studying the relationship between socioeconomic status and health deepened.

“I never would have guessed at the time that I would be doing what I do now,” said DeWalt, assistant professor of medicine in the Division of General Medicine. “I was very much a basic scientist, an engineer, but I had this notion of wanting to help people, especially poor people.

“I was very interested in why poor people were always sicker than rich people and understood that it wasn’t just a question of access to care. There were other things going on, which we needed to understand, and that is how I got started.”

During a combined residency in internal medicine and pediatrics at Carolina, DeWalt came across the concept of health literacy – how well people understand their doctors’ instructions and other health information and services key to their care.

Studies conducted nearly two decades ago showed a correlation between people with low literacy levels and poor health outcomes, he said, but there was no intervention to fix the problem. Doctors around the country, including DeWalt and his colleagues at Carolina, began making patient materials easier to read and developing ways to care for patients that did not require advanced literacy skills.

At the same time, the researchers realized that everyone, regardless of literacy level, was struggling to understand health-care issues. In general, people tend to remember only about half of what their doctors say and the part they remember is often not entirely correct, DeWalt said.

“So we realized we needed to think about how patient care in general is designed,” he said. “Could we make everything we do more user friendly?”

Tools for practitioners

Fast forward to this past March when the “Health Literacy Universal Precautions Toolkit,” developed by School of Medicine faculty members for the federal Agency for Healthcare Research and Quality (AHRQ), was released.

DeWalt was the lead author for the toolkit, which includes 20 tools to help primary care doctors and their staffs communicate more effectively with all their patients, not just those who might need extra assistance.

The researchers worked with nine different community practices around North Carolina to develop and test the toolkit in a variety of health-care settings.

These community practices and many hospitals now are using the toolkit, and a health-care system in Maine is adapting it for teaching medical students, DeWalt said.

Within the first month of its release, the toolkit received 15,000 hits online. (It can be downloaded at


Universal precautions

Because a person’s reading level alone is not an indicator of whether he or she understands information and instructions, DeWalt said, the toolkit was designed to minimize the risk of misunderstanding among all patients.

“If I’m trying to explain to you how to take care of your blood pressure or diabetes, the only way I can know if you understand is to ask you to teach it back to me, to tell me what you’re going to do when you get home and how you’re going to take these medicines,” he said.

Doctors do not always assess the patient’s level of understanding, he said. “I mention lots of information during the visit and I assume you have it because you seem to understand what I’m telling you.”

Then, doctor and patient go their separate ways. When they meet or talk again in several months, he said, “It’s astounding what communication actually didn’t occur.”

Practices that tested the toolkit gave the same feedback. “They came back and said, ‘We had no idea patients weren’t getting this,’” DeWalt said.

Testing another tool, the brown bag review of medications, where patients bring all their prescription medicines with them for the doctor to review, also showed surprising results, he said.

“The practices said three of five patients they tested had inconsistencies in what was in their bag with what the doctors thought they were taking, and should be taking. And that’s kind of scary,” he said.

Long-term research has shown that helping patients become better informed and take an active role in managing their health actually leads to better outcomes, DeWalt said.

That is where communication comes in. It is not essential that patients with diabetes understand how the pancreas makes insulin, for example, but they need basic information and understandable instructions for keeping their blood sugar levels in check, he said.

“As a doctor, you have to ask yourself if the patient really understands what they need to know and to do,” he said. “To me, that changes the whole conversation.”
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