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 really remarkable people. You will hear what health literacy is, why it matters, and ways every one of us can help improve health understanding.

Today I’m talking with Dr. Candace McNaughton, who is an emergency room physician at Vanderbilt University Medical Center, and also a fellow in the Vanderbilt Emergency Medicine Research Training Program.

Dr. McNaughton also completed a VA Quality Scholar Fellowship focusing on issues of quality and patient safety. Her research looks at patients with heart failure, hypertension and other chronic diseases who seek care in the emergency department.

My first contact with Dr. McNaughton was when I read a research paper that she and others wrote. It was called “Lower Numeracy is Associated with Increased Odds of 30-Day Emergency Department or Hospital Recidivism for Patients with Acute Heart Failure” and published in the journal Circulation.

I was so intrigued by the combination of concepts in that article that I contacted the lead author and, ta-da, Dr. McNaughton agreed to be a guest on Health Literacy Out Loud. Welcome.

Dr. McNaughton: Thank you. It is so nice to talk to you.

Helen: You cover so many timely topics in that article. You cover numeracy and chronic disease. The red-hot issue of today is about people coming back to the emergency room within 30 days or being re-hospitalized within 30 days. Can we take these one by one and then see how you put them all together?

Dr. McNaughton: Yes.

Helen: Let’s start with numeracy, which is an ongoing issue of intrigue for me, and I’m glad it’s getting much more attention. Why did you pay attention to numeracy and how do you frame numeracy?

Dr. McNaughton: We have an interest in looking at literacy and numeracy and their impact on a patient’s ability to care for themselves outside of the hospital setting. I’m lucky to work with several colleagues who have focused on literacy and numeracy over the past several years, Dr. Russell Rothman and Sunil Kripalani.

Helen: I know them both and have certainly read their research. You are in great company. How are you framing numeracy? Is it high-level math, like statistics? Is it everyday math, like weighing yourself? What do you mean?

Dr. McNaughton: Numeracy in this case is just the ability to work with and understand numbers. We looked at general numeracy as opposed to health literacy, for example, which looks at how patients read and understand information directly as it relates to their health.

Some of the colleagues that I work with have developed more specific measures of numeracy that relate to health, but we wanted to look at general numeracy and how people use and understand numbers. It’s not all higher math and statistics. It’s really how you use it in your daily life.

Helen: How do you use numbers in your daily life? I can think of a zillion instances where that can happen. What about framing this in terms of chronic diseases, which does seem to be your special focus?

Dr. McNaughton: This is why we included literacy and numeracy in this paper. This paper focused on patients with heart failure. The reason that we included literacy and numeracy is that we recognized patients who have heart failure have a lot of things to manage at home.

Patients with heart failure are supposed to weigh themselves every day. If their weight goes up, they are supposed to do something about that. A lot of times they are supposed to take extra medication.

Helen:  I see two numbers right there. There is figuring out the weight and remembering what it was yesterday or seeing incremental differences, and then doing something about it. There are also a lot of numbers in there.

Dr. McNaughton: In addition to that, they are supposed to monitor their salt intake and figure out, “I’ve eaten this much salt. That means that I only have this much salt left in the day that I can drink or eat safely before I’m going to start gaining water weight.”

Helen: That is both addition and subtraction. How do people even know what their salt intake is? Salt is in everything we eat these days, like ketchup, isn’t it?

Dr. McNaughton: Yes, you are exactly right. You are supposed to be able to read the nutrition label on the back of the packages. This usually involves multiplication because sometimes the nutrition labels are a little bit tricky. Let’s say you get a bag of food. Sometimes they will have two servings in there.

Helen: That is division too. You’ve got addition, subtraction, multiplication and division, and we’ve only gotten through one day at home.

Dr. McNaughton: We haven’t even talked about the fact that a lot of folks who have heart failure also have diabetes and high blood pressure. In addition to everything they are already doing for their heart failure, they are supposed to watch their blood sugar, count carbs, calculate insulin doses, measure their blood pressure and all sorts of things.

You can see that if you have a hard time with numbers, it would be really difficult to manage all of that. Honestly, even if you have really good skills with numbers, that is still a lot to manage under the best of circumstances.

Helen: I know. I’m thinking about that. I can do everyday things with numbers in my life, but that’s a lot. I can almost see this as a spreadsheet. That’s not an everyday skill for a lot of people.

You are outlining the problem. There is general numeracy, and we know that is a problem in society, and now you’ve got all of these chronic diseases. How does that fit in with return visits to the emergency room and/or return hospitalizations?

Dr. McNaughton: We have been recruiting patients with acute heart failure who have come into our emergency department for the past several years. As I was thinking about this, I started wondering, “Are patients who have a hard time with numbers more likely to come back to the ER or the hospital within 30 days?”

It seems like it would make sense that if you have a hard time managing numbers, it would be a lot more difficult to manage heart failure, diabetes and high blood pressure all by yourself at home.

It seems like they would be more likely to be at risk for having what we call an acute exacerbation of heart failure, which is where your heart failure gets out of control and you get a lot of water weight gain and shortness of breath.

Helen: You need to go see somebody. This isn’t just because you’re thinking, “Maybe I have a problem.” You need to be seen.

Dr. McNaughton: Exactly. Sometimes if people get bad enough heart failure exacerbations, they can have heart attacks. They’ll be unable to breathe. When they come in and they’re sick enough, we have to put them on ventilators and things like that. It can rapidly get severely bad for these patients at times. They can get really sick very quickly.

Helen: What did your research find? Obviously from the title of your research paper, there is a connection. Can you tell us about what you discovered? You got me at the title. Lower numeracy is associated with increased odds, and then it goes on from there. Can you just frame this a little bit for all of us?

Dr. McNaughton: What we found was that when patients came into our emergency department with acute heart failure and we measured their literacy and numeracy, they were more likely to have to come back to the hospital within 30 days if they had lower numeracy.

Helen: It was not literacy. It was more a factor just of the numeracy.

Dr. McNaughton: That is correct. That was an interesting and surprising finding. They tend to go together, although it is not unusual to find patients who have high literacy who do not have high numeracy. I have taken care of a couple of English professors who were very literate but had great difficulty with numbers and managing their medication.

We suspect that maybe there are different scales. Maybe being able to read your medications is not as important as being able to go up on your medication, weigh yourself or, for patients with heart failure, calculate your salt intake.

The disclaimer we always have to say in anything like this is that just because we didn’t find an association or relationship between literacy and coming back to the hospital doesn’t mean there isn’t one. It just means we didn’t detect it.

We did detect a difference if you had lower numeracy. If there is a role for literacy as far as when people come back to the hospital, it may be less of a role.

Helen: The way you are explaining it to me makes it very clear. We often talk about health literacy as a subset of skills that deals with reading, understanding and acting on information.

I can see where reading and understanding falls into literacy, but it sounds like the math part, or numeracy, has to do with the doing part more than anything else. You have to understand it, but it sounds like it is very action oriented.

With all of the examples you are giving, you are really asking people to add, subtract, multiply, divide, make decisions and act on them in a timely way, or they are going to be extremely ill.

Dr. McNaughton: That is actually a really good way of looking at it. We have learned over time for example that having knowledge doesn’t necessarily translate into doing, so that is an interesting way of looking at it. You are probably exactly right.

Numeracy frequently is the nitty-gritty, day-to-day thing that you have to do to take care of your chronic disease at home. Literacy is absolutely required, but if you don’t have the numeracy, literacy may not be enough.

Helen: I’m glad we are both framing this in a very interesting way. Now I want to push it a little more.

You talked about the nitty-gritty and what people need to do every day. What can listeners, health communicators, and all of us as professionals, patients, the general public or systems be doing in a nitty-gritty way to make this a little better?

Dr. McNaughton: The bottom line that I would like clinicians and providers to take away from this is increased awareness. There is some talk in the literacy and numeracy circles about universal precautions.

Helen: I love universal precautions. It is not just looking at, “Can this person do it and maybe that person can’t?” It’s assuming we have to basically communicate with everybody.

Dr. McNaughton: Even if you have a highly-educated patient, they may be under even greater social pressure or feel more pressure when they talk with doctors to act like they have no questions.

Helen: Like that English professor you were talking about?

Dr. McNaughton: Yes, exactly. As providers of health, we should probably focus on very clear, simple communication as much as we can, regardless of what we think the patient has skill-wise as far as literacy and numeracy go.

Helen: Can you give us an example? Heart failure is your focus. How can you explain some of those concepts clearly? They’re hard.

Dr. McNaughton: Particularly in the emergency department where communication can be very difficult, probably the first step is just opening up the lines of communication. Often when I see patients, it is the first time I have met them and they are very sick or they wouldn’t have come into the hospital.

From an emergency medicine standpoint, the first thing that I want people to take away from our findings is that we should be aware that a lot of times people are having issues related to numeracy and we should ask in a very nonjudgmental way. Over time, I have changed the way I ask patients about their medications.

I say things like, “It is really hard to take medications all of the time. I frequently forget some of my medications. You’re on a lot of medications.” I will go down line by line on the medication list and ask, “When was the last time you were able to take this medication?”

If they are not able to take their medication, I am hopeful that I’m framing the question in a way so that they don’t feel guilt or any shame.

Helen: Thank you. You just really normalized it by saying that even you have trouble with this sometimes.

Dr. McNaughton: Yes. You have to be a little bit careful about that. Everybody responds to questions differently. What I want patients to understand is that I know it is hard to take care of all of these medications and to get them right. I say, “I am just trying to get accurate information about what brought you in. What could have happened to trigger you becoming sicker?”

Sometimes they had a ham sandwich yesterday. Sometimes that is, “I forgot to take my Lasix.” That actually makes me feel a lot better as a clinician if I can say, “Aha! I have figured out why you’re in the emergency department, and I can fix it.”

Helen: You really need to do the problem solving with the patient. You can’t do it alone. There is no clue you would have that someone ate a ham sandwich yesterday.

Dr. McNaughton: Exactly, and it changes a lot of the workup. If I can’t figure out what changed, that is actually a lot more concerning. If I know they weren’t able to refill their medication, they forgot, or they got confused and took only one pill instead of two, it is really helpful for me.

It makes me feel more reassured that after they go home, they are probably going to be okay as long as we can clear up whatever the issue was. If they come in and keep getting worse and I can’t figure out why, that is harder for me to fix.

Helen: If I ever have an emergency, I want you as my doctor. Even just listening to you, you are so calm and affirming about this. Thank you for doing what you do.

Can we move to the patient-public side of this?

Dr. McNaughton: Yes.

Helen: We are all patients someday, and you see a lot of patients. What do you see that people can do that makes things better and easier?

Dr. McNaughton: From a patient perspective, it would be helpful for everybody if patients were able to tell me exactly what they are having a hard time with. Sometimes it is hard for me to know what really is bothering them or what they are having a hard time with.

I would love for patients to feel comfortable telling their clinicians exactly what is going on. There is no sense of judgment. Life is what it is. I really just want to get to the bottom of what is going on so we can fix it.

As I said before, clinicians need to be aware of these issues. We need to let patients know we don’t expect them to be perfect and that we really are interested in what is making it difficult to take care of their diseases at home. As difficult as they sometimes feel it is to share that information with us, I realize they are human beings and that life is what it is.

Helen: If somebody forgot to take their pill yesterday or couldn’t afford to take their pills and renew it and stopped a few days ago, you want to know that.

Dr. McNaughton: Yes, or if they have a family member who was trying to be helpful and said, “I heard some stuff about this medication. Just stop taking it or cut your dose in half.”

This happened just before I came in. I was listening to someone who was changing their blood pressure medications at home without talking to the doctor because it was a sense of, “I don’t want to bother my doctor with this.” He wants to be bothered with that information. It is really important information.

No matter what the question is, feel free to ask us. Let us know, “I don’t like that medication. I have this side effect from it. I’m not going to take it. What else can we do?”

I want them to feel like they have the power to talk to their doctors about whatever their concerns are regarding their medication because we really do want to know. Our place is not to judge. We’re here to help people.

Helen: That is wonderful. Thank you. I think we should do a podcast sometime just looking at how patients can feel comfortable sharing that kind of information that might feel awkward.

What about systems? Today, health literacy and numeracy is not just about what providers, professionals or patients do. It’s about the structures, systems and organizations in which this communication takes place. What would be on your wish list? What do you see that works or doesn’t when it comes to communicating about the numbers part of chronic disease?

Dr. McNaughton: The systems are near and dear to my heart with my background in quality and safety. There are a lot of things from a systems standpoint that I have on my wish list.

I wish for a system in which the easiest thing to do from the patient’s and provider’s perspectives was the right thing to do so that it would be easy to refill their medications and communicate with the patient and other providers about what the medications are, when the patient last refilled the medications, what their side effects were, and to make it so that the most clear and concise way of communication was the most easily available.

Our hospital has been working on this in their informed consents. Several years ago they redid all of the informed consents because they recognized that the reading level was at a 10^th-grade level.

Even if you have a 10^th-grade reading level, when you’re acutely sick and getting an operation, you shouldn’t have to function at the highest reading level that you have available. They have tried to make communication clearer from that standpoint.

Helen: It sounds like I am hearing, “Do it in print.” I have been in some emergency room situations for sure. It is not the time my thinking is the best by any means. I love the way you phrase it that on your wish list would be “the easiest thing to do is the right thing to do.”

That takes everybody working together, including reimbursement, structure, time, quietness, privacy and all kinds of things. I am so glad you are focusing on this and working toward this.

We talked about different perspectives, such as what the problem is, what some ideas might be, and some solutions or ways to go about it. What do you hope would happen? What would it look like if everything worked just right?

Dr. McNaughton: If I was to focus on heart failure and what we could do for the patients of ours who have heart failure to improve their outcomes, there are a lot of simple things that could be done from an emergency medicine standpoint.

It’s helpful for everyone if we can start communication in the emergency department to try to figure out what triggered the acute illness and brought them into the emergency department. It would start the trajectory toward recovery a lot earlier. We think that it reduces hospital stays if we can get to the bottom of things sooner and start getting people feeling better.

For example, here at Vanderbilt, we got a large grant to start helping patients manage their chronic diseases on a much larger scale. We are trying to get better coordination around transitions.

When patients are getting ready to be discharged, we start preparing them for going home before it happens. Then we assist in the transition from hospital stay to going home. Then we check up on them more frequently, especially the high-risk patients, like heart-failure patients, who are likely to come back.

Then we try to have good enough communication so that if they have trouble, hopefully we can get a hold of somebody in the doctor’s office who can maybe help manage self-disease management at home to prevent them from coming back.

Helen: There are a lot of things that you hope for. I hope for all of those too, but let’s have a dose of reality. Do you expect that will all happen pretty soon?

Dr. McNaughton: It is interesting. We are actually implementing something just like that here at Vanderbilt. It is called My Health Team. The federal government thought this was such a high priority that they are doing some innovation grants. They are starting this in some places.

We are going to see if it works. We hope that it works, and we expect that it will work. We have been surprised in the past. We’re really trying to focus on the patients and making sure that the healthcare system doesn’t get in the way of taking care of patients.

Helen: I love how you frame that. Keep us posted. On the Health Literacy Out Loud website, we will have the title of your article. Hopefully people can find it and keep up-to-date with what is going on.

I just want to thank you so much for doing all of this important work that you are doing with the belief that we really can and will get better as providers, patients and systems. Thank you so very much.

Dr. McNaughton: I was such a pleasure to talk with you. Thank you.

Helen: I learned so much from listening to Dr. Candace McNaughton, and I hope that you did too, but health literacy isn’t always so 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 e-newsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, Stitcher Radio and the Health Literacy website at www.HealthLiteracyOutLoud.com.

Did you like this podcast? 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.