Noncompliance critical side effect of patients not understanding M.D.s' directives

National report - Though dermatologists deal with the body's most visible organ, they face the same challenges as other physicians in addressing patients' varying levels of health literacy, experts tell Dermatology Times.

These challenges involve communicating clearly with patients of all ages, cultures, ethnicities, functional capacities and education levels.

Crystal clarity

One recent article says survey results indicate that nationally, more than one-third of English-speaking patients and more than half of primarily Spanish-speaking patients at U.S. public hospitals have low health literacy (Marcus EN. N Engl J Med. 2006 Jul 27;355(4):339-341). Consequences of low health literacy can include noncompliance and increased emergency room usage and hospitalization, the report continues.

As for dermatology, this specialty contains "no unique health literacy challenges," says Fred Kobylarz, M.D., M.P.H., associate professor, Department of Geriatrics, Florida State University College of Medicine, Tallahassee, Fla. "The bottom line is, it's all about communication, and should not depend on the specialty," he says.

Accordingly, Dr. Kobylarz says healthcare providers must collaborate with their patients and/or caregivers, partly by asking questions such as what patients believe may be causing their symptoms. It's also important to learn how the problem impacts daily functioning, he adds.

Overall, "The message delivered to the patient should be understandable - no jargon," he adds.

Nonverbal elements such as eye contact and body language also are extremely important, Dr. Kobylarz says.

To ensure that patients understand their doctors' messages, Dr. Kobylarz also recommends using teach back techniques, whereby patients explain what they understand, and "show me" techniques, through which they demonstrate a skill such as how to use medications.

One program that stresses thorough patient education is Harvard's dermatology training program, says Papri Sarkar, M.D., a third-year resident there.

For all patients, she says, "We use layman's language and ensure that they repeat directions back to us. For dermatology, it's also important to get down the order in which (medications) are used," such as when a patient must apply a cream on an open wound and a steroid on top.

Experts share the following communication tips:

But if one fails to ratify patients' understanding, he says, "There's a huge gulf between one's degree of education and the patient's profound lack of knowledge."

Dr. Beer, director, Palm Beach Esthetic Institute and clinical instructor in dermatology, University of Miami, says that while his private-practice patients frequently bring Internet information, a high level of functional illiteracy among indigent and nonEnglish-speaking populations served by the University of Miami means these patients rely almost entirely on their physicians' words.

In such instances, he says one must "really be a doctor."

It takes longer, he says, "But typically that extra effort is rewarded because the patients will be more compliant" and tolerant of problems like occasional lateness.