Helen Osborne: Welcome to Health Literacy Out Loud. I’m 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 about health literacy with some pretty amazing people.
Today, I’m talking with psychologist Mark Hochhauser, who is a readability consultant in Golden Valley, Minnesota. Mark is also a longtime health literacy champion.
Among his many accomplishments, Mark has researched the readability of consent forms, HIPAA notices and patients’ bill of rights. He’s given more than 100 presentations and authored over 200 articles.
Mark has also taught undergraduate and graduate courses in topics including Adulthood and Aging, Human Learning and Memory, Motivation and Emotion and Abnormal Psychology.
Mark and I have known each other at a distance as health literacy colleagues for many years. In fact, he’s my go-to person when I want to know more about the psychology of health understanding.
Mark Hochhauser: Thank you, Helen. It’s good to talk with you again.
Helen Osborne: Someday, we will meet in person.
Mark Hochhauser: I hope so.
Helen Osborne: Mark, I’ve been reading a lot of articles lately about older adults and health literacy and health understanding. More and more I’m noticing references to issues of cognition with terms like “executive functioning” and “processing speed.”
You’re a psychologist. Tell us more about these terms that we have to be thinking about in terms of cognition and health understanding.
Mark Hochhauser: I think that the research and the understanding on health understanding has been changing and for the better.
I like the lifespan approach. When you look at human abilities across the lifespan, you find that often some abilities, like our cognitive abilities, attention, and working memory, tend to decline with aging. The older people get, the harder it will be for them to remember pieces of information, to think about it, integrate it, and make decisions.
Helen Osborne: That’s depressing news, but that aside, tell us what these terms mean. You talk about working memory. I’ve heard executive functioning, processing speed, abstract reasoning and logic. Can you just briefly describe those terms so we all have the same understanding?
Mark Hochhauser: Yes, I will try to do that. The key point to this is to recognize that all of these terms relate to what’s going on in your brain at a given age. These are all brain activities and these are not things that people have very much control over voluntarily. It’s what our brain allows us to do.
When you’re talking about something like selective attention, which is important in healthcare, what is your ability to filter out the noise or the distracting information in a situation and focus on what’s most important?
Another one would be working memory, which is how much information your memory can hold that you can work on while your memory is holding it.
Let me give you one concrete example. If you’re driving, you get lost, you ask for directions and someone starts explaining how to get to where you want to go. After about two pieces of information you get lost.
Helen Osborne: Or one, in my case.
Mark Hochhauser: That’s because our brains can only process or hold in working memory a limited amount of information. Typically, it’s about three to five pieces of information.
Helen Osborne: Mark, for something like that, as far as listening to directions or remembering phone numbers, I’ve never been good at that. Is that just a factor of aging?
Mark Hochhauser: I think a big part of it is aging. Working memory tends to get better in childhood and adolescence and peaks in adulthood, and I hate to say this, but after 30 or 35, our working memory tends to decline.
In some people, it’s much worse than others, and it is also unfortunately affected by things like illness, prescription drugs, drug interactions, head injuries and all the things that happen to us as we get older.
Helen Osborne: This is not a rafter of good news, but it’s the reality. I just jotted down some of the terms. You talked about selective attention, working memory and the factors of illness, drugs, injuries and all of that. Are there other important key terms we need to be aware of when we think about health literacy?
Mark Hochhauser: In terms of health literacy, sure. One of the things that people need to become more aware of, and I think you mentioned this, is processing speed.
How long does it take you when you’re dealing with working memory or you’re trying to retrieve a memory? How long does it take you to process that information? Younger people tend to have better or faster processing skills than older people.
I’ll give you an example. A TV quiz game like “Jeopardy,” if you’ve ever watched that, it is amazing how quickly people can process the information and arrive at the correct response to it.
As you get older and you watch “Jeopardy,” you think, “I know that, but I can’t remember it in five seconds. I need a little bit more time.”
I think with patients who are getting older in the healthcare setting, it is easy for healthcare providers to not realize when they’re talking with a patient and the amount of time in the visit is limited, you may be giving the patient more information than their working memory can hold. It may be given to them in a way that they really can’t process it quickly enough.
Helen Osborne: As you’re talking about that, I’m thinking about what I do with crossword puzzles. I’m a big crossword puzzle fan. If I come up with a really hard puzzle, like the Sunday New York Times, sometimes I can get just so far on that day or at that time. I put it aside for an hour or two and when I come back, it’s clear to me and I can complete the whole puzzle. Is that processing speed?
Mark Hochhauser: I don’t think it’s processing speed as much as it is your subconscious memory working on things when you’re not aware of it.
I think this is a common experience that people have. You see a performer on television and you know that you know their name, but you cannot remember it at that time, and you decide you’re not going to cheat and go online and look it up.
Then you find yourself going to bed and maybe after you’re in bed or you wake up in the middle of the night, the name suddenly hits you.
Helen Osborne: That happens over and over. It’s like I got it at the most inappropriate time to remember what you were trying to remember before.
Mark, I am relating to all of these, and the articles I’m reading may not even be about folks like you and me. It might even be people with greater levels of difficulty with this.
This podcast, Mark, is for folks who care about communicating health information in ways others can understand. You’ve clarified some of the problems. What are some of the solutions? What can we do better to improve health understanding?
Mark Hochhauser: Certainly, communicating health communication in plain English helps a lot. People can become really overwhelmed with medical jargon, abbreviations and acronyms that healthcare providers use every day, but are completely incomprehensible to the patient.
What I think patients often do, and this typically happens when you get older, is you have someone go to the visit with you who can write down information for you or ask the questions that you forgot to ask.
That’s because, as a patient, you can sometimes be so incredibly stressed out and fearful that you’re focusing on the fear and the anxiety and maybe not on the questions that you should be asking or even paying attention to the answers.
One of the things that some providers are doing now is giving patients a printout of what took place at the visit. I think that’s tremendously helpful.
Helen Osborne: Mark, I actually did a podcast on that, about the after-visit summaries. I’ll have a link on your Health Literacy Out Loud web page.
That has a lot of advantages. It’s not perfect yet. The problem is that it’s written really for the provider, so it doesn’t incorporate all those principles of plain language necessarily, but we’re moving along. I appreciate that.
Have a written summary of what just transpired. Bring someone with you to appointments. We as clinicians or providers can encourage someone to bring someone with them to appointments. Is that appropriate?
Mark Hochhauser: I think it absolutely is.
Not every patient is going to have somebody who can be with them at that day at that time. I did some consulting with a physician who used to have a health educator in his practice. The health educator was there to help the patient actually work on changing their health behaviors from unhealthier to healthier.
I thought that was a terrific idea, and this was in the ’90s, because it went beyond just the prescription of “Here’s what you need to do. You need to exercise more and you need to eat better,” or, as an aunt of mine was told, “You need to watch your diet.” I have no idea what any of those things mean in real life.
Helen Osborne: How do you watch your diet? That can be interpreted all kinds of ways.
Mark Hochhauser: It can be. It sometimes helps to have someone other than the provider, because healthcare visits sometimes don’t last very long. I think the average is about eight minutes.
Helen Osborne: I was just going to ask you about that. Some of the cognitive factors you were talking about have to do with issues of time, whether you retrieve that actor’s name two hours later or I do my crossword puzzle later, the processing speed and the selective attention.
Our appointments are finite in length and it’s not very long. As both providers, communicators and also as patients and family members, what can we do given the fact that appointments are short?
Mark Hochhauser: They’re often short because that’s what insurance will pay for, or you have a certain number of patients that you have to see in a day, so extending the length of the visit may not really be possible.
Helen Osborne: Let’s talk about alternatives other than that. I don’t think that we’re going to change our whole healthcare system immediately. Given the reality of short appointments, what can all of us do to improve health communication?
Mark Hochhauser: From the provider’s standpoint, for example, there’s research showing that, in the examining room, once a patient starts talking they get maybe 30 to 45 seconds before they’re interrupted by the provider. Some patients take longer than others to get to the point.
I think one of the problems, which is a selective attention or a focus problem, is patients may have a hard time focusing on what’s most important. You may have three or four things you want to talk about and the doctor is thinking that she can only deal with two things in an eight-minute visit, so there is this communication disconnect.
How do we talk with our healthcare providers about what we think is important, and how do they get the information that they need to make a diagnosis and to help us do the things we need to do?
I think there are probably changes in the medical curriculum now that weren’t there years and years ago. Given the pressure on the whole healthcare system in terms of visit length, reimbursement and whether you’re going to see a physician assistant or an M.D., I don’t know that there’s a lot that patients can do other than maybe before the visit, prepare for it and write down two or three things that you feel have to be discussed during that visit.
Helen Osborne: I actually do that, Mark. As I’m getting ready for an appointment, especially if I know it’s going to be about something particularly scary, major or icky, I will be thinking of my questions way ahead.
I take an index card and I jot them down, even when I think of them in the middle of the night. Then, right before my appointment, I take my list of questions and I prioritize them.
I bring that little index card, and it’s specifically little so that it doesn’t have much information on it. I bring that plus a pen to the appointment so I can make sure to ask the doctor or provider those questions in that order. The pen is so I can take notes and don’t have to remember it all.
Mark Hochhauser: You are very well prepared as a patient.
Helen Osborne: I’ve learned.
Mark Hochhauser: However, a lot of patients aren’t that organized, or maybe they’re at a point in their life where, in terms of their own cognition, they just can’t think through all of that. It’s easy for those of us who can do it. We think everybody can do what we can do.
Helen Osborne: That’s true. What I do is I encourage others to do this or I help people, family members perhaps, who don’t have the wherewithal to be able to do that. I’ll go over it and say, “What are the questions? What do you want to know more about?” I’ll help them do that.
The other thing, Mark, you talked about, and I can certainly relate to, is that retrieval where you have to come up with that factor, name, clue or word for your crossword puzzle hours later.
I would hope for our listeners out there that there’s some way to build in some follow-up system that one appointment is not the only encounter to exchange information. There are ways to learn more later on.
I would love it if people can offer those opportunities, be it written information, a follow-up phone call or another visit. Continue that learning in not just one big burst.
Mark Hochhauser: Exactly. One of the new technology procedures is that many physicians, clinics and practices have a patient portal in which you can email. You probably won’t get to talk to the physician, but maybe the physician’s nurse and sometimes it gets passed on.
My wife and I have both used these. It’s a way if you’re not in a rush and it’s not an emergency that you can ask questions and get them answered. It may take three days for the processing to take place.
For a variety of reasons, especially among older adults, they don’t use patient portals very much. Part of it is the technology, the complexity, having to remember a login name and a password or maybe having half a dozen different providers, and they’ve all got fragmented pieces of your healthcare.
They may be able to work that out down the road, but there are ways for patients to contact providers to get questions answered.
Helen Osborne: I’m so glad you addressed that because what we’re talking about is the reality of now and the realistic changes that happen over time.
You’re talking about the future and as you’re talking about it, I see hope, opportunity and tools that help us, and I think that in part that has to do with technology.
Even when you talked in the beginning about not remembering directions, or I talked about not remembering phone numbers, we now have devices that can help us with that.
Mark, I thank you so much. I am so glad you are my health literacy colleague and my go-to person about this psychology part, because we need to consider that in order for all of us to help improve health understanding.
Thanks for being a guest on Health Literacy Out Loud. And Mark, thanks for doing all you do.
Mark Hochhauser: Thank you so much, Helen.
Helen Osborne: As we just heard from Mark Hochhauser, it’s important to consider cognition and those lifespan changes that happen too. But doing so isn’t always easy.
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Until next time, I’m Helen Osborne.