INTRODUCTION

Only 12% of Americans are considered to have proficient health literacy, and low health literacy is associated with multiple adverse health outcomes, including increased mortality.1–5 Patients are at increased risk of adverse events in the period following hospital discharge.6–8 Ineffective transitions of care can be a significant source of health disparities, and for patients with low health literacy, communication failures during this time increased the risk of poorer health outcomes and readmissions.9–12 Despite the prevalence of low health literacy and the associated risk of significant morbidity and mortality, health professionals are often not trained in communicating with this vulnerable patient population.13

Medical school initiatives, including longitudinal curricula on effective communication techniques and Objective Structured Clinical Examinations (OSCEs), have attempted to address this gap in provider training.10 , 11 , 14–16 The majority of structured health literacy learning opportunities are offered during the first three years of medical school, with fewer than 15% occurring during the fourth year.13 A fourth-year student is poised to become an intern. In the inpatient setting, interns shoulder the responsibility of communicating with patients about their diagnoses and ensuring safe hospital discharge. However, published health literacy curricula have not focused on this high-risk period for patients or on the skills needed to ensure that patients with limited health literacy are safely discharged from the hospital.

This evidence-based initiative for fourth-year medical students includes two components: 1) an interactive workshop on screening tools and communication techniques to care for patients with low health literacy, and 2) an innovative OSCE that assesses the application of these skills during transitions of care such as hospital discharge. This OSCE is innovative for several reasons. First, it targets fourth-year medical students as part of their preparation for residency. In addition, it specifically focuses on the discharge process, because effective communication during such a transition is critical for patient safety and is an important skill for all future interns. Finally, it allows learners to apply their knowledge and practice their skills in a safe and simulated yet realistic environment.

SETTING AND PARTICIPANTS

The workshop and OSCE were integrated into the Introduction-to-Internship Clerkship, a mandatory learning experience during the spring semester of the fourth year. One hundred and one fourth-year students participated in the workshop and OSCE between January and April 2014. Fifty-seven students (56%) completed the workshop, followed by the OSCE 1 week later, while the remaining students (44%) completed the OSCE first, providing a natural comparison group in the study, as allocation was based solely upon availability of the OSCE center (Table 1). Gender and specialty choice were recorded for all participants. Twenty-seven students in the fourth-year class were unable to participate because they were in residency interviews or were ill at the time.

Table 1 Student Characteristics: Students Pursuing Residency Training in Primary Care had Similar OSCE Scores Compared with Classmates Entering Non-Primary Care Specialties (p = 0.5)
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PROGRAM DESCRIPTION

Goals

The primary goal of this project was to develop an OSCE for fourth-year medical students in order to demonstrate oral and written communication skills to be used during the hospital discharge process with patients of low health literacy.

Educational Methods and Rationale

The interactive health literacy workshop is modeled on Kripalani and colleagues’ workshop for medical residents.15 Its objectives are to prepare students to apply knowledge and techniques in the clinical assessment of health literacy level, and to communicate medical information to patients for whom low health literacy is a barrier to care. The OSCE assesses learners’ ability to apply the knowledge and demonstrate practical skills from the workshop in the context of hospital discharge involving a patient with low health literacy.9 , 17

Implementation

We developed an original OSCE scenario, including a clinical case for the students and standardized patients (SPs) (Appendix 1). We piloted the OSCE with a group of four students who had completed all core third-year clerkships and were on scholarly leave before fourth year. Pilot data was used to clarify OSCE instructions for students, ensure that time allotted was reasonable, and improve SP case portrayal. We developed an SP training session in which actors participated in the health literacy skills workshop and watched supplemental videos of patients with low health literacy interacting with the healthcare system. They rehearsed and provided feedback on sample scripts. The SPs were blinded as to which group the students were in. The study was reviewed and deemed exempt by the institutional review board.

Workshop

The student leaders of the health literacy group (KBF, DC, LS) taught the workshop to their peers. Although the workshop is PowerPoint-based, it was designed to be interactive, with many opportunities for student participation and role-play. The workshop emphasizes the importance of health literacy, teaches ways to actively assess health literacy, and allows for the practice of communication skills such as the use of plain language, teach-back, and the method of limiting key information to three major points as outlined in the Ask Me 3 campaign.18 , 19

OSCE Scenario

The OSCE tasked students with preparing a patient for hospital discharge. Students were instructed to screen the SP for low health literacy and to provide education regarding diagnosis (pulmonary embolus), management (warfarin), and follow-up (international normalized ratio [INR] monitoring). Following completion of the SP encounter, students were directed to write discharge instructions appropriate for the patient. Students received 15 minutes to complete the patient encounter and 15 minutes to complete the written discharge instructions.

Checklist

Our 17-item checklist (Table 2) includes behavioral statements linked to health literacy assessment and discharge planning described in the literature.19–24 It assesses performance in health literacy screening, the use of plain language, delivery of a focused message regarding diagnosis and management, and the use of open-ended questions and teach-back, among other evidence-based communication techniques. English proficiency is not evaluated. The trained SPs completed the checklist immediately following each student encounter.

Table 2 Checklist for Health Literacy OSCE: This Checklist was Designed to Represent Core Competencies in Health Literacy, and Completed by Trained SPs to Assess Students’ Performance. The Mean Score was 14.4/17; Students who Completed the Workshop Prior to the OSCE Outperformed Peers (15.1 vs. 13.4, p < 0.0001)
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Feedback

Each student viewed his or her scored checklist the day after the OSCE, thus allowing for use of the OSCE not only as a means of assessment but also as a learning tool for participants. After the workshop and OSCE, 65 students (64%) completed a voluntary ten-item anonymous survey (Appendix 2) to assess perceptions of the OSCE and workshop effectiveness, the importance of health literacy, self-assessment of effective communication with patients of low health literacy, and relevance of the skills taught in the workshop to providing patient care.

PROGRAM EVALUATION

Checklist

The mean score on the OSCE checklist across the entire group of study participants was 14.4/17 (range, 8.5–17). The Student t test was performed to assess the relationship between workshop participation prior to the OSCE and the final performance score on the OSCE. Chi-square analysis was utilized to assess the relationship between workshop participation prior to the OSCE and each checklist item. Students who completed the workshop before the OSCE outperformed peers, with an average checklist score of 15.1 (range, 10–17), compared to 13.4 (range, 8.5-17) among those who completed the workshop after the OSCE (p < 0.0001). This relationship remained statistically significant after controlling for intended career in primary care (defined as family medicine, internal medicine, or pediatrics) versus non-primary care specialty (p < 0.0001). The most commonly missed item was question 2: only 33/101 students asked a validated health literacy screening question. However, 51% (29/57) of students who completed the workshop before the OSCE asked a validated screening question, versus 9% (4/44) of students who completed the workshop after the OSCE (p < 0.0001). Students who completed the workshop first were also more likely to use (p = 0.03) and normalize teach-back (p = 0.0003). Among the entire group, students pursuing residencies in primary care had scores similar to those of their classmates entering non-primary care fields (p = 0.5).

Discharge Instructions

We used the Flesch-Kincaid readability score, the SMOG [Simple Measure of Gobbledygook] index, and the Gunning Fog score to assess the reading level of the students’ written discharge instructions. The average score among all students across readability tests was a tenth grade reading level (range, grades 7–16).25–28 On average, the written discharge instructions of students who completed the workshop before the OSCE were at a grade reading level of 9.9, versus 10.6 among those who completed it after the OSCE (effect size 0.7, p = 0.01).

Survey Results

After completion of the workshop and OSCE, 87 % of students reported confidence (agree or strongly agree) in assessing health literacy, and 82% felt confident (agree or strongly agree) in effectively communicating with patients of low health literacy. Ninety-seven percent of participants agreed that health literacy was important to consider in patient care.

DISCUSSION

The Health Literacy in Transitions of Care OSCE focuses on imparting communication skills necessary to optimize safety in transitions of care. The OSCE and skill-based workshop were successfully integrated into the existing fourth-year curriculum. The OSCE allowed students to put health literacy theory and communication strategies into practice in a safe yet realistic environment.

Our data indicate that the workshop was effective in improving students’ ability to communicate with patients with low health literacy. There was statistically significant higher performance on the checklist among students who completed the workshop prior to the OSCE than among their peers who did not. Workshop participation was most closely associated with improved communication skills in asking validated screening questions and in employing and normalizing teach-back, all clinically important techniques for effective communication with patients with low health literary. With regard to the written task, although there was a statistically significant difference between the two groups, the effect size was less than one reading grade level, and both groups wrote their instructions at a level above which most adults can read, which suggests that we may need to bolster the portion of the curriculum focusing on competency in writing skills for communicating with patients of limited health literacy.

Our educational experience was built on existing curricula in the literature. Kripalani et al. developed an interactive health literacy workshop, filmed SP encounters, and created a feedback opportunity and survey for medical residents. The trainees in this study found the experience meaningful, and noted that it would influence their clinical practice.15 Like Roberts et al., we included an emphasis on teach-back as a tool for health literacy communication.11 We also used a concept similar to the curricula described by Harper et al., designing our OSCE both as a method of teaching health literacy and as a tool to assess curricular efficacy.29 However, our OSCE is innovative in that it targets fourth-year medical students preparing for internship, and unlike existing OSCEs, our encounter focused on the high-risk period of hospital discharge. Our targeting of fourth-year students is especially timely given the growing need for fourth-year assessments that document competencies in entrustable professional activities.30

There are several limitations to our study. We were unable to control for variance in educational exposure to health literacy prior to the clerkship. In addition, due to limited resources, we were only able to present students with one OSCE station. In the future, implementing multiple cases would provide more reliable data. Though we attempted to standardize the OSCE with rigorous SP training, the uniformity with which different SPs assessed students was not measured. Our results would be enhanced by having more than one rater per student encounter and by assessing inter-rater reliability. There was no significant difference in specialty choice or demographics between students who completed the workshop before versus after the OSCE. However, because the groups were not randomized, other differences between the control and intervention groups may have influenced performance. Additionally, there may have been sharing of OSCE materials between the two groups. Finally, we were unable to assess the efficacy of the workshop and OSCE in changing future clinical practice.

Transitions of care are a vulnerable time for all patients, but particularly for those with low health literacy. The Health Literacy in Transitions of Care OSCE is an innovative tool for training future interns and interprofessional learners to identify and better communicate with patients of all health literacy levels during the hospital discharge process. Approximately 50% of US medical schools with health literacy curricula already use simulated patient encounters, which suggests that our curricular design could be easily applied at other institutions.13 Our hope is that widespread health literacy training in medical school will lead to less miscommunication and to improved outcomes for vulnerable populations.