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 these podcasts, Health Literacy Out Loud. In these podcasts, you get to listen in on my conversations with some amazing people.

Today, I’m talking with Dr. Joanne Schwartzberg, whose interests and accomplishments are many. This includes her current work as scholar in residence for the Accreditation Council for Graduate Medical Education, or ACGME. It also includes her many years of teaching, writing, researching and creating healthcare policy.

In my opinion, it’s thanks in large part to Dr. Schwartzberg’s leadership at the American Medical Association that the field of health literacy has flourished and grown.

I first met Joanne at a conference in the early days of health literacy. We’ve stayed in touch mostly by email ever since.

I was delighted to see her again in person at a recent conference where Joanne was presenting about creating patient-friendly medication labels. I thought, “That’s a great topic for our podcast today.”

Welcome, Joanne.

Joanne Schwartzberg: Thank you so much. I am so happy to be here and looking forward to a wonderful discussion.

Helen Osborne: I am too. It’ll be great. Let’s get started on medication labels and making those patient friendly. When you say medication label, are you talking about that little piece of paper that goes on that round, brown bottle, or are you talking about something else?

Joanne Schwartzberg: No, we’re talking about the little piece of paper that goes on the round bottle.

Helen Osborne: I wanted to be really clear. What are the problems with those? Why are you and others spending so much time on this?

Joanne Schwartzberg: We’ve learned that just about everybody has difficulty reading the label and trying to figure out, when they have to take a medicine, how they need to do it.

Helen Osborne: Can you give us an example?

Joanne Schwartzberg: One of the studies that was done on medication labels done by Mike Wolf, whom I’m sure you’ve had on these programs, and Terry Davis just looked at common ordinary medication labels to find out how people read them.

That’s because we know that patient errors in reading medications cause very serious problems, maybe 700,000 serious errors a year.

Helen Osborne: Really? There’s only a sentence or two on the label when it talks about what to do. Can you give us an example?

Joanne Schwartzberg: The what-to-do pieces of it, I think first you have to understand how people read labels. They tried five very simple labels and asked hundreds of people to read them and said, “What does it mean? How do you do it?”

Take one tablet once a day or take one teaspoon three times day. Simple kinds of instructions. Almost 50% made a mistake on at least one out of the five lables.

Helen Osborne: Really? Whoa.

Joanne Schwartzberg: For your health literacy people, to me the important thing was that 38% of people who read at adequate literacy level, which means above 10^th grade, many of them college educated, made a mistake out of the five labels.

Helen Osborne: Oh my goodness.

Joanne Schwartzberg: This health literacy is not just people with difficulty reading. All of us can have difficulty when we’re looking at labels, and I think probably that’s the most important piece of it.

Helen Osborne: Joanne, I know when I look at a label, sometimes it’s open to interpretation, like, “Take with food.” How much food and when? What if I don’t feel like eating? Is one cracker enough? Is the problem the judgment stuff or is it the basics, like “Take one pill one time a day”?

Joanne Schwartzberg: It’s both. Remember, we get “take with food” because we don’t have much space on this tiny little container or this tiny little label. We try to make it simple.

Those are very simple words, but how much food? Are you talking about a glass of milk? Are you talking about a couple of crackers? That is open to interpretation unless somebody’s explained it to you, which they probably haven’t. There’s that kind of a problem.

The one out of five making an error on a prescription label, the most common error is “Take two tablets twice daily.” You say to somebody, “How many tablets do you take during the day?” and they say two instead of four.

Helen Osborne: Really?

Joanne Schwartzberg: Something about the word twice makes people think time of day, not doubling the dose.

Helen Osborne: That’s really interesting.

Joanne Schwartzberg: It’s a very simple word. It’s a word we learned to read in second grade or third grade. It’s a one-syllable word. It’s not hard, but it’s what we mean by it.

English is a fascinating language and we use it in many fascinating ways. It’s the assumption that because it means something to you it’s going to mean that to somebody else.

I was giving a conference and talking about this at the conference. A person in the audience came up afterward to introduce herself. She was a professor of English at a community college here in Chicago. She said, “I can parse that word to mean only time of day.”

This is a convention that we use and there’s sort of a general assumption that we’re going to mean doubling it, but it isn’t necessarily in that word.

That’s like the general assumption about food that you just mentioned.

Helen Osborne: It takes our interpretation. Another point is you’re talking about twice, and thank you for making clear what that problem is. It’s an aha for me, a scary aha.

I sometimes talk about problems with the word “once.” In my presentations, I often ask everybody, “If you’re told to take a medication once a day, how many times do you take it?” People are wondering why I’m asking and I say, “It means one time, but the word ‘once’ in Spanish means 11.” People truly are taking 11 times the amount of medication because of our word choice.

Here we have examples of once and twice, both easy words, both open to huge errors.

Joanne Schwartzberg: One of the things is the way we read. We learn to read when we’re children and we read all the time and we tend to try to read as fast as we can. Because there’s so much going on in our lives, we’re trying to be fast anyway, so we skip over. Maybe these are the kinds of problems that you can’t skip over.

The once and twice thing, you’re talking about people who are bilingual. Yes, you can read in both languages. You’re reading very quickly. It’s very easy to switch back from one to the other without even being aware that that’s what you’re doing.

Again, how do we slow down and pay attention? Then is there a way in what we put on the label and the way we design the label that can help people slow down and not make mistakes?

Helen Osborne: You talked to people who can and cannot read very well, but it includes all of us. We’re talking about language, culture or being rushed or in a hurry.

People taking medication might have a dreadful headache at that moment too, or their baby is screaming in the background. So there’s even more reason to have trouble paying attention to that little tiny piece of paper.

You started talking about design issues. Let’s move into what are we going to do to help? I’m feeling to my core. I get it. There’s a problem. What are the efforts going on to make this better?

Joanne Schwartzberg: The way the effort started was that it was an organization called the United States Pharmacopeia that took on this challenge. It was raised at one of the Institutes of Medicine health literacy roundtable discussions. Roger Williams, who was the EVP at USP at that point, was in the audience and said, “We’ll take it.”

United States Pharmacopeia, if you see that little USP label, which you’ll see on a lot of over-the-counter products as well as on prescription medications, USP has been around for almost 200 years, since 1820.

It was created, basically, to try to standardize the medications. Even at that point, there were roots and leaves and things that people were taking.

Helen Osborne: We’re back to roots and leaves too, but that’s another issue.

Joanne Schwartzberg: We’re back to that now again. If it has a USP label, somebody has checked it in a lab. A pill has the same quantity and the same strength, the same purity, etc. That’s really what you get when you have a USP label. What it takes to do that, of course, is a lot.

Helen Osborne: They took on this issue of labeling? It’s great. A 200-year-old institution taking this on is amazing.

Joanne Schwartzberg: They are responsible for the labeling, the standardization, for all of our drugs and all our manufactured drugs. They have a process that they go through and they invite people who might have any information.

You will have the researchers, the academics, the clinicians, the local pharmacists and the industry and manufacturers. For this issue, we brought in a lot of literacy and design people who had looked at how people read and understand it. It was a fascinating group to be part of and to listen to what really makes a difference.

What size font do you need to have to be able to read it easily? With that tiny little piece of paper on a tiny little container, six-point font or eight-point font, which many of them are using, is really hard for older people who are beginning to have to hold it out a little bit further than their arms.

Helen Osborne: Furthermore, the bottle is round anyway.

Joanne Schwartzberg: The bottle is round, you’re right. And you’re on a lot of different meds. It gets harder and harder.

What they said to us was it has to be a 12-point font. It has to be that large. How are you going to get anything that large on this little piece of paper?

How does the information get identified? What are the important things that have to be there? Are there some things that perhaps are less important?

Helen Osborne: I’m just curious. I just have a question for you right now. We talked about this little tiny piece of paper. Was there any initiative to make it a bigger piece of paper?

Joanne Schwartzberg: There was a wonderful initiative out of Target.

Helen Osborne: The big-box store chain?

Joanne Schwartzberg: Right, Target Pharmacy, which did a flat bottle much larger than the usual little bottle, probably about four inches by two inches wide. It was flat, so you had two flat surfaces, front and back, that you could write a great deal on. That was a very successful bottle, but it was expensive.

When Target got bought by CVS, CVS figured that it wasn’t worth the money to do that. Instead, they are trying to extend the paper label. They make it stiff and it sticks out flat.

Helen Osborne: I’ve seen that on my new scripts. It’s like all of a sudden this thing is sticking out. What is that all about? Now I know.

Joanne, I am just delighted to hear that great minds, diverse minds from all perspectives, are working on this. Do you think it’s getting better?

Joanne Schwartzberg: I think that there are several things that are really important that have been taken up on the standards. One of the things is when USP sets standards, they’re voluntary standards for the retail pharmacies. It’s the local state board of pharmacy that makes the decisions.

A lot of work has gone into “Does it make a difference in the way we use the language?” It makes a difference design-wise in the print, so you don’t want all caps. The reason they used all caps was that was the only way, if you had eight-point font, that you could make it large enough for people to read.

Helen Osborne: That’s an interesting point.

Joanne Schwartzberg: If you really make it larger, then you should have it in sentence structure, just the way we’re used to reading. The capital is the first letter and then the rest are small letters.

You would look to say things like, “Take one tablet in the morning and one tablet in the evening,” to be clear. That takes up a little more space on the label, so you have to give up some other things.

If it said, “Take one tablet three times daily,” and they asked people “Tell me how you would take it,” only 44% got it right.

Helen Osborne: Yikes.

Joanne Schwartzberg: Then when they said, “Take one tablet in the morning, take one tablet at noon and take one tablet in the evening,” it went up to 91% understanding.

Helen Osborne: Wow. It sounds like they’re not just coming up with some good ideas and trying them out, but it sounds like they’re also testing them, which is really good.

You’re reassuring to me that something’s moving forward to make these labels a little bit better, though we’re not there yet. In the few moments we have left on this podcast, what would you like listeners to be doing?

Our podcast listeners all care about health communication. What would be on your wish list for us and what can we be doing now?

Joanne Schwartzberg: I think it’s paying attention to this issue and talking to the pharmacies in your area to encourage them to become part of the effort to improve the label. I really think that we need a groundswell of interest in this.

When you and I were at the conference in Wisconsin, here you have the pharmacists in Wisconsin on the ground level, 53 different pharmacy programs, some of them are chains with 10 or 15 different pharmacies, but not the big ones. Not CVS or Walgreens. These were the small local pharmacies.

Helen Osborne: I remember hearing one man who just was very much part of his community talking passionately about his specific needs for where his pharmacy is. It was obvious he cared a lot about making things better.

Joanne Schwartzberg: This is the way change is going to happen, and they’re working together. I talked about the design. The design piece is really where the problems are. How big is this little white label? What kind of computer software can print it out? Can it leave enough space between the lines so that you can really read it?

Helen Osborne: Wow. All of those are technical issues. They’re design issues. My guess is they’re also financial issues.

Joanne, thank you so much. We didn’t cover all that’s going on, but this could go on and on. What’s so reassuring to me is that great minds like yours and others have acknowledged that there is a problem with that label and then are working on systems, committees and all kinds of forums to start making it better.

I think there’s room for all of us in that. Thanks for getting us started and thanks so much for being a guest on Health Literacy Out Loud.

Joanne Schwartzberg: Thank you for inviting me. This has been, obviously, a passion of mine and I enjoy talking about it. I want to encourage everybody listening to start thinking about what could be done. We’re just beginning the process, even though it’s a good many years down the road. We can all make a difference.

Helen Osborne: Thank you, Joanne Schwartzberg.

As we just heard from Dr. Joanne Schwartzberg, it is so important to communicate clearly in all the ways we do that, including on that tiny little piece of paper that’s attached to our medicine bottles.

Communicating clearly 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, please sign up for the free monthly e-newsletter, What’s New in Health Literacy Consulting.

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Did you like this podcast? Even more, did you learn something new? I sure hope so. If you did, tell your friends and tell your colleagues. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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