An Intervention to Teach Physicians to Use Plain Language for After Visit Summaries

Setting and Problem

Program directors must ensure that trainees achieve competence in key domains. An important skill that relates to patient care, interpersonal and communication skills, and professionalism involves the ability to provide information to patients in a language they can understand. Although the Centers for Disease Control and Prevention recommend that information for patients be written in plain language, many physicians write personalized patient instructions at a high school or collegiate grade level, even though the United States Department of Education, in a national adult literacy study,¹ found that one-fifth of US adults read at an approximately fifth grade level or below.

In keeping with “universal precautions” for health literacy, we sought to train residents and faculty to write patients' personalized information and instructions in the after visit summary (AVS) in plain language at a sixth grade reading level. To meet this aim, we designed an intervention that incorporates personalized feedback, including (1) a reading grade level to work toward; (2) a comparison of their work to that of their peers; and (3) periodic feedback aimed to maintain skill development.

Intervention

We designed and implemented this educational intervention in a community-based internal medicine residency program with 24 categorical residents and 8 clinic faculty. After expedited approval from the Institutional Review Board, we reviewed the physician-entered, patient encounter–specific portion of the AVS for 5 consecutive patients for each of the 8 faculty and 24 residents in our residency training clinic as a baseline. We ran the writing samples through the Fry Graph Readability Formula embedded in software from Health Literacy Innovations (Bethesda, MD). This gave us a reading grade level for each sample as well as highlighted complex words and medical jargon.

Then, we staged a 50-minute educational intervention. Physicians were first introduced to the concept of health literacy and its impact on patient outcomes, costs, and patient experiences of care. After this introduction, each physician was given a sample of his or her own AVS statements to review, along with the Fry-based grade level and highlighting of complex words and medical jargon in each statement. They also were presented with their own average grade level and a chart of average grade levels of all other clinic physicians stratified by training level. Physicians then were directed to rewrite 1 of their AVS samples into “plain language,” and then share the rewritten summary with the group. Physicians who did not attend the conference were personally briefed by the investigators about the project and their performance relative to their peers.

Six weeks later, we took another sample from each participant. Shortly thereafter, they received their data, including new Fry-based grade levels of 3 of their writing samples. Physicians also received 1 sample that was rewritten by the investigators with a grade level analysis applied to the revised sample to help learners see how use of plain language produces grade level improvement. They could also compare their progress to that of their peers.

Finally, at both 3 months and 6 months after the initial intervention, we again analyzed the grade level of AVS samples for each physician.

Outcomes to Date

As illustrated in the figure, prior to the intervention 30% (7 of 23) of the physicians were writing at an average of sixth grade or below. Over the course of the 6-month follow-up period, that number increased to 68% (15 of 22).

Figure.

Percentage of Physicians With Average After Visit Summary Grade Level 6 or Below

The time required for the training was a 50-minute conference. The majority of the cost for the intervention was administrative time. Our electronic health record has easily searchable patient instruction notes. The process of cutting and pasting those into a Microsoft Word document and applying the readability formula for 5 samples for each participant took about 20 minutes. This can be done by a clinic staff member. The cost of the software from Health Literacy Innovations to run the readability formula and highlight medical jargon and complicated words is approximately $500 per year. A survey of participants 1 month after the workshop showed that 10 out of 10 respondents would recommend the training to colleagues or future trainees.