Helen: 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 with some truly remarkable people. You will hear what health literacy is, why it matters and ways all of us can help improve health understanding.
Today I’m talking with Professor Joseph Kimble who is a long-time champion of plain language. For more than 25 years he has taught legal writing and drafting at the Thomas Cooley Law School in Michigan.
Joe Kimble is a prolific writer. He is the editor of an international journal about plain language and author of numerous articles and books, including Writing for Dollars, Writing to Please. Joe Kimble has worked on many plain language legal projects, including a redraft of The Federal Rules of Civil Procedure and The Federal Rules of Evidence. He’s won a lot of awards for his plain language work.
I first spoke with Joe several years ago. I was interviewing him for a column about regulatory legal language in healthcare. We more recently met in person at an international plain language conference. Welcome, Joe.
Joe: Thanks, Helen. It’s nice to be here.
Helen: Your work is all about plain language. You’re a long-time champion. Let’s take this from the beginning. When you say plain language, what do you mean?
Joe: At bottom, it’s about clear and effective writing for your audience.
Helen: Is it only about writing or is it about speaking too?
Joe: It’s about writing, speaking or communicating with your audience. It is about putting your audience first. It’s interesting that right now there’s an international plain-language working group, which is a collaboration of several organizations. They are working on a definition of plain language.
Helen: Thank you. The definition that I’ve been using, and I’ve probably taken it from one of the many organizations you’re involved with, is that plain language is essentially using words and terms and communicating in ways the other person can understand.
Joe: Yes. It’s wording, structure and design as well. The definition will probably come out something like this, Helen. A communication is in plain language if its wording, structure and design are so clear that the intended audience can easily find what they need, understand what they find and use it.
Helen: That’s clear. I hope they use that one.
Joe: It’s a little longer than we would like, but we do have to make it clear that plain language is about more than just words. It’s also about structure and design. It’s about testing too, although that isn’t a part of the definition. As you know, it’s about testing documents on typical readers to make sure they work.
Helen: I love your book, Writing for Dollars, Writing to Please and I have highlights all over. You have a quote in there at the beginning that to me really captures it.
You’re talking about plain language and saying, “As for achieving it, that’s never easy. Anyone can complicate matters. It’s much harder to simplify without oversimplifying.” Can you tell us a little bit more about that? What’s hard about being simple?
Joe: It is a skill like any other, and it’s one that needs to be practiced, learned and worked on. I think in that same area of the book, I quote Jacques Barzun, who was one of my early heroes. He says, “Simple English is no one’s mother tongue. It has to be worked for.”
You can’t buy it at the store. You have to learn it. It requires practice, reading and training. Yes, it’s a real art and skill to come in at the right level of simplicity, as simple as possible but no simpler.
Helen: I love how you phrase that. Why go to all this bother if it is a new skill? As a lawyer or a health professional, all of us out there have other things to do with our lives. Why should we spend the energy to learn how to write in plain language?
Joe: You only do it if you care about your reader, especially if you write for the public.
Helen: Tell us more about that.
Joe: It’s your job to make yourself clear.
Helen: You do this for the law. That sounds like the absolute other end of the scale. When I think of legal language, I think of the most bureaucratic, multisyllabic terms. How and why did you bring this to the law?
Joe: Unfortunately, we lawyers inherit a long history of poor writing.
Helen: I agree.
Joe: One of my favorite quotes is from a law professor at Temple named John Lindsey (now deceased). He said, “Lawbooks are the largest body of poorly written literature ever created by the human race.”
Helen: Oh dear.
Joe: It’s true. I didn’t realize it in law school. You’d think I would have known better. I was an English major, and I did a lot of writing before law school.
You go to law school and most students don’t think twice about what they read. They read opinions written by judges who many times weren’t very good writers, and they start to think that this style of writing is all perfectly good and normal. It may be normal, but it’s not good. It hit me after law school that there’s something terribly wrong with legal writing.
Helen: I think my interest in this came about because my world is health and my listeners are probably all involved with some form of health communication. I, like you, am a real advocate and a champion of it. “It’s worth mastering those skills,” I say as I’m teaching those skills. Somebody always asks, “What about all of that regulatory and legal language we have to deal with?”
It seems to be the intersection of your world and my world when it comes to how we communicate. What about all of that pushback we get and people saying, “Why bother? We have to say all of this in exactly this way.”
Joe: You don’t have to say all of that. I ran into this fairly often when I was working on The Federal Rules of Civil Procedure.
Helen: Can you explain what that is? I’ve heard that it’s an impressive document that you’re working on.
Joe: I was involved in redrafting The Federal Rules of Civil Procedure and The Federal Rules of Evidence. These are the federal court rules that govern procedure in the United States federal district courts, the federal trial courts.
Many times when we were redrafting or restyling them, as we called it, I would hear the argument, “We’re just following the language of the statute.” The language of the statute, the federal law, isn’t the model for good drafting. We can improve on that. We can do better than that.
Helen: I know that was a colossal project. As you go forth in doing that, thinking about healthcare or either world, sometimes I know I get pushback. People say, “Why are we doing this?” or that phrase that I hate, “Isn’t this dumbing down?” What do you do about pushback or those myths that people may be saying about plain language?
Joe: One of the big myths is that plain language means dumbing down or baby talk, but it’s not. It’s about writing clearly for your audience, writing to communicate and writing to be understood, not to impress or enthrall. After all, most of us are not writing poetry or literature. We’re writing for the general public, for consumers and customers and patients.
The public is impatient to get the goods. They resent your wasting their time, and we ought to make a point of making it as simple, direct and easy as possible for the reader to get the goods.
Helen: In healthcare when I try to put complicated information into plain language, sometimes I hear the pushback from scientists or other professionals. They say, “You’re leaving this out and you’re leaving that out.” What about that and the letting go of some content?
Joe: Plain language does not leave out.
Helen: It doesn’t leave out?
Joe: It doesn’t leave out. The idea is not to change the substance. The idea is to make the substance as accessible and clear as possible. It doesn’t change the meaning.
At some point, after all the demonstration projects we’ve done around the world, one after another, we have shown that this can be done without changing the meaning, as we did with The Federal Rules.
You can convert to plain language. You can convert to at least plainer language without losing the substance or nuance. Even if you occasionally make a mistake, that doesn’t mean you have to revert to legalese or officialese.
Now people will say, “What about technical terms?” Yes, there are technical terms, but in law there are far fewer technical terms than lawyers would like to think.
We’ve studied this. We’ve actually taken legal documents and tried to assess how many true technical terms there are in a document. They are a small part of most legal documents, and I expect it’s the same thing in health.
Helen: That’s right. When I think of legal, I think of those words like heretofore, hereunder and things like that. Those aren’t technical terms.
Joe: Those aren’t technical terms. “Pursuant to” is not a technical term.
Helen: In healthcare, we have the equivalent. There are words we tend to just fall back on that the other person may not understand. When I’m teaching this, sometimes we have to hang on to those technical words, but then we can explain it more clearly. An example is the word “metastases” if we’re talking about cancer.
Sometimes we need to use a complicated term, but I always advocate that it is our job to then explain that clearly and simply. Do you agree?
Joe: I do agree. If you absolutely must use a technical term, then you ought to explain it for a lay audience.
Helen: Another myth I hear is that people think plain language is always shorter. What do you think of that?
Joe: It will usually be shorter. It will be shorter on the whole. In a particular sentence or in a particular part it may take a few more words to explain, but it will almost always be shorter overall.
Helen: Are there any other myths you hear about a lot for plain language?
Joe: Maybe the biggest myth is the myth of precision.
Helen: What is the myth of precision?
Joe: It is the argument that you can’t write in plain language and still be precise or legally accurate. Here again, in one demonstration project after another, we have shown that’s not true. In fact, we’ve shown that the reverse is true.
When you convert a document into plain language, you will tend to make it more precise and more accurate. That’s because when you shine a light, you will uncover all the uncertainties, inconsistencies and ambiguities that you never realized were in the old document because they were covered over by the dense surface.
When you peel back the layers, it happens every time. Every project that I’ve ever been involved in, when you peel back the layers, you find all kinds of uncertainties and inconsistencies.
Helen: That’s really interesting. The first plain language redo I ever worked on was an informed consent form for a hospital. There was a committee of us with doctors, lawyers, administrators, risk managers and me. We worked on that informed consent form for general admission, and every single patient signed it.
We thought it was way too difficult, so we tackled that as our first collaborative project to make it a bit easier for people to understand. While doing that, we realized that huge concepts and ambiguities were hidden behind all of those syllables. When we stripped that clean, we really knew what was in the informed consent form.
Joe: That’s exactly right.
Helen: I’m glad you’re talking about that and precision.
Joe: That’s something to remember, Helen. Plain language improves the substance.
Helen: How do you know when your job is done with plain language?
Joe: That’s a good question. You test it on your audience if possible. You test it on your audience to see whether they can understand it and use it. If not, then you go back and try again. This only makes sense, right? This is part of what the book is about, the kinds of benefits that you can realize from plain language.
Helen: That’s your book, Writing for Dollars, Writing to Please.
Joe: That’s right. If you are writing a document that goes out to thousands or millions of people, why wouldn’t you test it, even informally, on a small group of readers before you send it out to try to discover what the flaws are and what parts of it readers might not understand?
If you can improve the error rate on those kinds of documents by even small margins, like 5%, 10% or 20%, think of the savings. Some of the savings are just astounding and staggering.
Helen: You’re talking about time and money spent. You’re very quotable, and there’s another quote in your book for the chapter that is actually headed “Saving Time and Money.” In there, you wrote that two themes stand out.
You said, “First, a small saving on a single act produces huge numbers when the same act is performed repeatedly on a high-volume document.” Then you write, “Second, an investment in plain language will repay itself many times over.” Would you give us some examples?
Joe: If you send out a document that goes to thousands or millions of people and you have an error rate on that document where people fill out the form wrong, for instance, or they don’t understand the document and have to call into the call center: if you have an error rate of 20% on that document and you can improve your error rate to 10%, the savings are huge.
One of the studies in the book is about a letter that was sent out by the Veterans Benefits Administration. I don’t have the numbers right in front of me, but this was just one call center and they were getting about 1,100 calls a year. This was just on one letter.
Helen: Did they send out a letter telling people what to do about their benefits?
Joe: It was how to get some benefit, some medical documentation that they needed or something like that. I can’t quite remember.
Helen: By the error rate, do you mean the people who didn’t quite get the written instructions and were calling in?
Joe: That’s right. They didn’t understand the instructions, and they called into the call center. They were getting about 1,100 calls a year from people who didn’t understand the letter and had follow-up questions. After they revised the letter, the calls to the call center dropped to about 200 a year. That’s just on one letter.
Think of all of the letters, forms, pieces of information and brochures that are sent out by every department of every government agency every year. Those are the kinds of improvements and savings that you get from plain language. In many of the studies, the savings are in the millions and even billions.
Helen: That’s what you mean by making a small difference over and over again. Is that how people might justify the time it takes to learn this skill or put it into policy where they work?
Joe: That’s right. That’s why I say that a small investment up front will repay itself many times over in the long run.
Helen: I’m thrilled that in your book you make about 50 cases for why this matters. There are very real examples. Some are in healthcare, and others are in law, government and other parts of our life. You make a really compelling case.
Joe: Thank you.
Helen: As I said, our listeners are all somehow interested in health communication. What would be on your wish list that you would like us to do?
Joe: Commit to plain language, learn about plain language, read about plain language and join the organizations devoted to plain language. There are several of them.
Helen: We’ll have those on our website. It’s learning the skills and strategies and putting them into practice.
Helen: You’re an inspiration to us all. I think that if anyone can do this in legal documents, there is plenty of space for all of us to be doing this in healthcare.
Thank you so much, Joe, for sharing your passion, advocacy and talents about plain language with Health Literacy Out Loud.
Joe: Thank you, Helen.
Helen: I learned a lot from Joseph Kimble, and I hope that you did too. 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.