Simplicity: Using the Power of Plain Language to Encourage Patient-Centered Communication

Patient-centered communication includes understanding the aims of the patient by elevating their perspective of their health conditions and treatment goals.1 The characteristics and skills required of health care professionals, including physical therapists, for successful patient-centered communication include empathy, active listening, and asking open-ended questions.2,3 For effective patient-centered communication, physical therapists must understand their patient’s health literacy and their capacity to communicate about their health needs. Health literacy is defined as the “ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”4 It is more than reading comprehension—it encompasses all the knowledge and skills needed to identify and apply health information. Many factors contribute to health literacy (Figure). Patients who have higher levels of quality education, higher income, and greater socioeconomic status tend to have higher health literacy.5,6 However, the use of medical jargon by health care professionals may impede any patient’s understanding and utilization of health information, even among those who are well-educated.7 For people with chronic conditions, health literacy also can be affected by cognitive dysfunction, mood disorders, and low quality of life.8 Consequences of poor health literacy include reduced patient self-efficacy to manage their condition, reduced participation in the treatment plan, worse engagement with available health resources, and worse health outcomes.9 Low health literacy is associated with increased hospitalizations, greater use of emergency care, and among older adults, poor health status and increased mortality.10 Factors contributing to individual’s health literacy. Language and culture discordance between physical therapists and patients are common challenges to health literacy and may result in negative health outcomes.11,12 Communication about the causes and consequences of illness and decisions about management may be affected if the health care professional and patient do not share the same language and cultural background.13,14 Using the COVID-19 pandemic as an example, factors such as poor proficiency in English and the lack of culturally appropriate health care contributed to a 3-fold higher COVID-19-related mortality rate among people from culturally diverse backgrounds as compared to the general population in Australia.15 Effective communication requires the use of appropriate written and verbal language as well as nonverbal language. Health literacy is often viewed as an individual characteristic, with attention focused on strategies to increase the health literacy of patients. However, organizational health literacy is also necessary, as articulated by Broder et al,16 it is “the way in which services, organizations and systems make health information and resources available and accessible to people according to health literacy strengths and limitations.” In essence, it acknowledges the responsibility of the health care system, and the health care professionals within that system, to adapt their communication to the health literacy levels of the people they serve. Having written materials pitched at the right level to support an individual’s health literacy is an essential part in the delivery of equitable health care. The frustration experienced by patients attempting to decipher health care jargon has been part of the driving force behind a plain language “movement.” Proponents of this movement advocate for the use of clear and concise communication understood by all individuals—a position supported by US legislation, which mandated all government bodies to use plain language when communicating with the public, including within the health care sector.17 Physical therapists need to ensure that care for patients with different levels of health literacy is delivered in a safe and respectful manner.18 This includes being “culturally responsive”—a process in which the therapist is continuously aware of the cultural differences, reflects on their own individual values and beliefs, and perceives how such values and beliefs may impact on their communication with patients from a different health literacy and cultural background.19,20 This not only challenges the physical therapist to develop a set of strategies to address the patient’s health literacy needs, but this also acknowledges the therapist’s preconceived values and beliefs. Unfortunately, while cultural competency training is widely delivered across various health facilities and is embedded into the physical therapist curriculum, the translation of the learnings from these trainings into clinical practice to support the health literacy of patients remains poor, with many therapists adopting superficial strategies when delivering care.21 How can physical therapists address the health literacy needs of their patients and meet the legislative requirements for plain language? First, physical therapists should be aware of the signs of potential limited health literacy of their patients. These signs include difficulties with verbal communication, missed appointments,22 and not following through with exercise or self-management programs. Next, therapists could formally assess their patient’s health literacy and not assume that their patients are understanding the therapist’s verbal and written communication at the levels needed for effective care. Including a formal assessment in the intake process would also normalize the process of identifying patients with reduced literacy, yet it is not routinely done.23 Standardized measures are available—Griech et al24 and Ennis et al25 summarized the properties of several validated health literacy assessment tools, many of which take <5 minutes to complete. For example, the Newest Vital Sign tool, developed by the pharmaceutical company Pfizer, asks 6 questions to evaluate literacy and numeracy, which may be helpful in the physical therapist practice where we use text and numbers for exercise programs (https://www.pfizer.com/products/medicine-safety/health-literacy/nvs-toolkit). However, no single tool assesses all aspects of health literacy, and there has been little research to identify the best tools for physical therapist clinical practice. Finally, physical therapists should evaluate any documents intended for patient use to ensure they are written in plain language. Medical jargon should be replaced with plain language, and the addition of pictures and illustrations may improve comprehension. In addition, to support the development of plain language communication, the US government created a website (www.plainlanguage.gov) that provides several resources to help convert complex communication into plain language. There are detailed checklists that you can use to evaluate your written documents, answering questions such as: “Does this document use ‘you’ and ‘we’ where possible? Does it have less than 15–20 words per sentence? Does it use the same term for the same concept throughout?” The website also provides examples, including companies and institutions that have won awards for their plain language documents. A comprehensive list of words and phrases to help create plain language communication is also available (see the Table for examples). Suggestions for Simple Words and Phrases to Support Plain Language Communication Physical therapists should consider involving patient groups to review any written materials to ensure that the content can be easily understood and is appropriate for the condition. For people who prefer communicating in a language apart from English, written materials should not only be translated into the preferred language but should also reviewed by people from the cultural group for content and presentation of the written materials. For example, while the use of horizontal rating scales are common in Western cultures, the use of vertical rating scales are more common in Chinese cultures.26 Involving people from the cultural group and language experts in the translation of written plain language materials can ensure that the information is appropriate and is presented in a way that is easily understood by people from similar cultural groups. In addition, the use of professional interpreters, where available, during physical therapist interventions will also facilitate a smoother communication process with patients from diverse cultural groups.27 In the absence of available professional interpreters, a friend or family member may help with interpretation with the patient’s permission. Of course, ensuring plain language in physical therapist care extends beyond the individual therapist’s responsibility. The Agency for Healthcare Research and Quality has developed numerous resources (https://www.ahrq.gov/health-literacy/publications/ten-attributes.html) for health care organizations to improve their organizational literacy, including toolkits, implementation guides, and checklists. They also identify 10 attributes of health literate organizations28 that could be applied to any physical therapist clinic, department, or program. These include having leadership, which makes health literacy integral to its mission; integrating health literacy into evaluation and quality improvement, among other things; and specifically addressing health literacy in high-risk situations, including care transitions. Despite the plain language legislation of 2020, many organizations struggle with incorporating plain language in their materials. Nine years after the 2020 legislation, Paige et al29 analyzed the content on various government, commercial, educational, and not-for-profit physical activity websites and found that, in each studied sector, only half of the websites were using plain language techniques in their communication. However, technological innovations could support organizations that aim to increase plain language communication.30,31 For example, natural language processing is a form of artificial intelligence that can be used to turn complex medical terminology into simplified plain language. Research shows that patients found artificial intelligence–generated plain language useful.30 Using artificial intelligence tools, such as ChatGPT, to create plain language information may reduce the burden on the clinician to be a “plain language expert,” but the risk of disseminating misinformation is substantial,32 and regulatory bodies have not yet provided guidance on the use of natural language processing tools in clinical practice. Further research is needed to evaluate the feasibility and validity of artificial intelligence tools to create plain language communication that is relevant in physical therapist practice. Using plain language communication with patients helps build relationships. The use of plain language communication can help patients gain agency over their own health and improve the relationship between clinicians and patients. Governments have mandated the use of plain language and have provided guidelines on techniques to follow. Artificial intelligence software may enhance the ability for clinicians to use plain language communication by translating complex medical terminology. Maryke Peter (Conceptualization, Writing, Project management), Stacy Maddocks (Writing), Clarice Tang (Writing), Pat G. Camp (Conceptualization, Writing, Project management, Providing facilities, Providing institutional liaisons) There are no funders to report for this study. Data sharing is not applicable to this article as no data were created or analyzed in this study. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

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