title: Closing the loop: physician communication with diabetic patients who have low health literacy.
abstract: BACKGROUND
  Patients recall or comprehend as little as half of what physicians convey during an outpatient encounter. To enhance recall, comprehension, and adherence, it is recommended that physicians elicit patients' comprehension of new concepts and tailor subsequent information, particularly for patients with low functional health literacy. It is not known how frequently physicians apply this interactive educational strategy, or whether it is associated with improved health outcomes.
  
  
  METHODS
  We used direct observation to measure the extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts during outpatient encounters, using audiotapes of visits between 38 physicians and 74 English-speaking patients with diabetes mellitus and low functional health literacy. We then examined whether there was an association between physicians' application of this interactive communication strategy and patients' glycemic control using information from clinical and administrative databases.
  
  
  RESULTS
  Physicians assessed recall and comprehension of any new concept in 12 (20%) of 61 visits and for 15 (12%) of 124 new concepts. Patients whose physicians assessed recall or comprehension were more likely to have hemoglobin A(1c) levels below the mean (< or = 8.6%) vs patients whose physicians did not (odds ratio, 8.96; 95% confidence interval, 1.1-74.9) (P =.02). After multivariate logistic regression, the 2 variables independently associated with good glycemic control were higher health literacy levels (odds ratio, 3.97; 95% confidence interval, 1.09-14.47) (P =.04) and physicians' application of the interactive communication strategy (odds ratio, 15.15; 95% confidence interval, 2.07-110.78) (P<.01).
  
  
  CONCLUSIONS
  Primary care physicians caring for patients with diabetes mellitus and low functional health literacy rarely assessed patient recall or comprehension of new concepts. Overlooking this step in communication reflects a missed opportunity that may have important clinical implications.
authors.affiliation: Primary Care Research Center, Department of Medicine, University of California San Francisco, San Francisco General Hospital, 94110, USA. dean@itsa.ucsf.edu
authors.forename: Dean
authors.initials: D
authors.lastname: Schillinger
authors.forename: John
authors.initials: J
authors.lastname: Piette
authors.forename: Kevin
authors.initials: K
authors.lastname: Grumbach
authors.forename: Frances
authors.initials: F
authors.lastname: Wang
authors.forename: Clifford
authors.initials: C
authors.lastname: Wilson
authors.forename: Carolyn
authors.initials: C
authors.lastname: Daher
authors.forename: Krishelle
authors.initials: K
authors.lastname: Leong-Grotz
authors.forename: Cesar
authors.initials: C
authors.lastname: Castro
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Bindman
mesh_terms: D000328:Adult; D000368:Aged; D003142:Communication; D015986:Confounding Factors, Epidemiologic; D003920:Diabetes Mellitus / Q000188:drug therapy; D004522:Educational Status; D005194:Family Practice; D005260:Female; D006779:Hospitals, Public; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage; D007388:Internal Medicine; D008297:Male; D011939:Mental Recall; D008875:Middle Aged; D009819:Office Visits; D010045:Outpatients / Q000706:statistics & numerical data*; D010353:Patient Education as Topic; D012107:Research Design; D012495:San Francisco; D013637:Tape Recording
chemical_list: D007004:Hypoglycemic Agents