Helen: Welcome to Health Literacy Out Loud. I am Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.
In these podcasts, you get to listen in on my conversations with some truly remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.
Today I’m talking with Dr. Dean Schillinger, who is professor of medicine in residence at the University of California, San Francisco and chief of UCSF’s Division of General Internal Medicine at San Francisco General Hospital.
Dean Schillinger is a practicing primary care physician who not only sees patients, but also teaches in the primary care residency program and conducts research about healthcare for vulnerable populations.
Dr. Schillinger is widely recognized as an expert in health literacy, health communication, and chronic disease prevention and management. He has written well over 100 scientific manuscripts and won more awards than I could possibly count.
I have known Dean Schillinger for many years. He is also a super-nice man. Welcome to Health Literacy Out Loud, Dean.
Dean: Thank you, Helen. It’s my pleasure to be here.
Helen: I’ve heard you speak many times. One of the recent times, you added a concept that is near and dear to my heart about jargon. I would love to get your take on jargon. Why is this an issue that you are looking at as a communication concern? First of all, what do you mean by jargon?
Dean: It is funny. When we sought out to study jargon, the first thing we had to do was to find a working definition of jargon. Let me share that with you because I think it has some very important concepts imbedded in it.
Jargon has been defined as technical terminology or characteristic idiom of a special activity or group often employed with a tacit assumption of common understanding.
If you think about doctors or nurses talking to patients, doctors and nurses have been highly technically trained. Part of that training has included the acquisition of new technical terminology that is unique to special activities, like taking care of patients, or unique to those groups, like doctors and nurses.
We often employ those very same words without recognizing that they are a second language we just learned. We tacitly assume that our patients understand those words as well.
Helen: Absolutely. I see that all of the time. The longer we are in school, the more of that language we learn. I love that phrase “the tacit assumption of common understanding.” Can you explain a little bit more about what tacit assumption means?
Dean: It is an obvious assumption that you would understand what I’m talking about because we are speaking English to each other.
The metaphor that I used when you and I last talked to each other was about when I go to the computer guys in my IT department with a problem on my computer. They start to speak English to me, but it is an English that I don’t understand. It is computer speak.
I am obviously a highly-educated person with over 21 years of education, but I don’t understand a thing about what they are saying. They are tacitly assuming that I understand their computer speak because it is English.
Because they are so acculturated to that language because they tend to speak to each other, they couldn’t possibly assume that I wouldn’t understand what they are talking about.
Helen: In healthcare, I know we have a lot of jargon. One question I get from people is, “How do I recognize jargon? I am so deep into this all of the time. How would I even know I’m using it?”
Dean: Do you mean that clinicians are saying that?
Dean: There are two forms of jargon that clinicians can recognize and flag. One is when they are using words that can only be found in their medical, nursing or pharmacy textbook. If it can only be found there, that is going to be jargon.
Helen: Can you give me an example?
Dean: Sure. Hemoglobin A1c is a big one in diabetes care, or a glucometer. That’s the machine that checks your blood sugar. That is one form. It is easy for people to recognize because they know they only know that word from their training.
A tougher one is jargon that has one meaning in the healthcare context and a distinct meaning in lay context. The example that I could give there is the word “stable.”
A nurse may weigh a patient, look in the chart and say, “Oh good, your weight is stable.” The patient may not understand that stable means no change over time. They may think of the word stable as the place where the horse sleeps.
The tougher one is for clinicians to recognize when words have a clinical meaning and a distinct, different lay meaning.
Helen: One word I use as an example is the word dressing, as in “change a dressing.”
Dean: That’s right.
Helen: Does that mean oil and vinegar, or cornbread instead of regular turkey dressing? What does that have to do with that wound on my arm? Those are hard to recognize.
Dean: That is a big one in surgical context. Negative and positive is another great one. “Your test results came back negative. That’s great.” The patient is thinking, “Negative? That’s horrible. I have breast cancer.”
Helen: I know. We do this all of the time. There are two other forms of speech that interest me a lot, but I don’t know if you consider them jargon. One is what I refer to as an idiom, which is more regional language or nonliteral use of words such as, “Are you feeling blue?” or, “Let’s draw some blood.”
Dean: That’s right.
Helen: There are all those different uses of words.
Dean: They’re phrases. Once you’re a patient for 20 years, you understand what they mean.
Helen: That’s right. What are we going to do about this, other than assuming everyone will be a patient for a long time and finally learn our language? You said that you are doing research on this. Are you learning what we can do, or are you just learning that we do it all of the time?
Dean: One thing I learned in the last study that we should not do is to use jargon and then explain it. We did some very in-depth interviews with patients who were exposed to unclarified jargon and clarified jargon.
I may say, “I want you to go get the glucometer. That is the machine that helps you check your blood sugar level.” It turns out that the clarification after the jargon does not lead to higher rates of understanding of the jargon term.
In other words, it is all well and good that we want to teach our patients, but they are not in a place to learn about glucometer, hemoglobin A1c or whatever. In fact, it is not entirely clear that they need to know those words.
If we just clarify jargon and don’t specifically call out the fact that, “Right now we are going to teach you a new word. It is really important that you understand it, so I am going to explain it to you,” it doesn’t lead to more understanding.
What can we do? There are three things. One is to eliminate jargon use. As you implied, that requires recognizing when you are using it and trying to pick substitute words that are similar enough.
For instance, “draw your blood.” You don’t have to say “draw your blood.” You can say, “We’re going to take some blood out of your arm.” You don’t lose anything by saying that. One thing is to recognize it and try not to use it and substitute.
The second thing, which I’m sure you’ve had multiple sessions on, is to do the teach-back method. If you are unsure as to whether you have used jargon or you used jargon and made a tacit assumption that the patient understood it, you can use the teach-back method. Have them teach back to you what you what they understood about what you just said.
Helen: Have them put it in their own words. If you are talking about diabetes, maybe the other person will talk about sugar.
Dean: Exactly. Then you can use those words as you proceed as well.
The third thing, which has yet to be fully developed, is for us to be systematically developing living room language around common medical concepts. I talked about hemoglobin A1c. That is a great example. This is a really important concept. None of us, to my knowledge, has a good way of explaining hemoglobin A1c.
We really need to study that. We need to bring 100 patients with diabetes together and have them talk about what worked for them. Then we can have an evidence base of communication skills as opposed to just thinking, “I’m a good doctor. I can do it my way and it works.”
Certainly people who have been in the field for 30 or 40 years have learned to become better communicators over time, but it would be great to build an evidence base around which to work.
The new PCORI, the Patient-Centered Outcomes Research Institute, includes opportunities for people to study risk communication and how we can communicate with patients about risks and benefits of treatments in ways that we just haven’t been able to before.
Helen: You are getting me thinking in so many different directions. I have heard that concept. I have been talking about it too. We need to recognize when we are using jargon and try not to do it. I always thought explaining it was good, but I learned something about that. I am familiar with the teach-back. We were addressing that in some podcasts. There is a lot of information about that.
I hadn’t heard about coming up with what sounds to me almost like a glossary of living room language to use.
Dean: It’s based on real evidence. We field tested 70 different ways of explaining hemoglobin A1c. This is what the advertising people do when they sell their Whoppers or whatever. They field test the stuff and figure out the best way to communicate something to sell their product. We’re not selling a product here. We are just trying to motivate, but the same concepts need to be applied for healthcare.
Helen: I envision that when you go to doctor school, I go to OT school and all of us go to whatever kind of school we go to that we will be learning a new language. It won’t just be those technical terms. It will also be those evidence-based terms.
Dean: That would be phenomenal. One of the reasons we use jargon is because that is how we learned about the disease from our professors. They were talking to us in jargon. It was acceptable to talk to us in jargon because it was the professional school. That is the only way we learned how to talk about the disease.
Helen: Dean, there one question that is lingering. You, me or our listeners may not be thinking it, but others are. They might be saying, “Isn’t this dumbing down?” What would you say to that?
Dean: I think that highly-perceptive clinicians will take cues from their patients about the level of sophistication that they want, need or desire from their visit. Within about three sentences, I can figure out that my patient knows more about cancer than I do. Then I’m in trouble.
I don’t ever think it is a problem to increase sophistication as needed. In addition, most people, even the highly-sophisticated patients, like clear explanations. I have never heard a patient say to me about another doctor, “She was explaining it to me so simplistically that it infuriated me.” I have never heard that.
I have heard people say, “The doctor didn’t seem to care about me when I was crying,” but I have never heard that they have been speaking to them too clearly.
Helen: Thank you for framing it that way. I hate that term. The only thing I like about it is that it finally gets aired if that is what someone is thinking. When somebody says to me, “Isn’t this dumbing down?” my response is often, “No, it is smartening up.”
Dean: I could say to you, “Getting this biopsy will be associated with a 3% chance of bleeding or infection,” or I could show you a little computerized picture that has 100 women with 97 of them in green and three of them in red and say, “Three out of 100 women who get this biopsy will either have bleeding or infection. Look at these three red ladies here.”
Did I just dumb that down? It doesn’t feel like dumbing it down. It is the same concept. It’s just communicated more effectively. Three percent is a mathematical concept that is hard for a lot of people to actually get their arms around.
People who are brighter will understand 3% more effectively than many others, but it doesn’t mean that we are dumbing it down to put the picture in their hands.
Helen: You have always explained things so clearly. Thank you so much for talking about jargon with us on Health Literacy Out Loud. You said you are doing research. Is your paper published yet?
Dean: It is published. It is called “Babble, Babel.” It was babble as in talk and babel like the tower of Babel. It is about all the different languages that humans speak. It tries to convey the fact that we are speaking different languages in a clinical context. I will send you the article.
Helen: That’s perfect. I will put a link on the Health Literacy Out Loudwebsite. Dean, thank you for all you are doing to help us communicate more clearly, and thanks for talking with us on Health Literacy Out Loud.
Dean: Thank you.
Helen: I learned so much from Dr. Dean Schillinger, and I hope that you did too, but health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, sign up for the free monthly enewsletter, What’s New in Health Literacy Consulting.
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Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.