Mr. M was a typical new patient: 74, with diabetes, hypertension and elevated cholesterol. He had some prostate enlargement and back pain. His bag of pill bottles was depressingly bulky. I spilled the bottles out at our first visit, sorting them by disease.
A thick shock of white hair spilled over most of his forehead, framing skin that was weathered from a lifetime of outdoor work — farming as a teenager in Mexico, construction as an adult here in the United States. His smile was bracketed by concentric rings of creases. Mr. M didn't remember the names of all the medicines, but he did know that the white pill was for "pressure" and that there were two pills for diabetes. Something also for cholesterol and prostate.
The visit took nearly an hour as I painstakingly explained each medication, matching the names on the bottles to the pill inside and the disease it was intended for. I cleaned up his medication list in the computer, purging expired or redundant meds and then printed the list for him to take home —clear, organized and, most important, legible.
Despite running over our scheduled time, I felt gratified that I'd brought some clarity to my new patient's medical conditions. Plus I was meeting one of the patient-safety goals mandated by our hospital.
At our next visit, I plucked out the bottle of lisinopril, the one new medication we'd started last time. "How does the new blood pressure pill feel?" I asked.
"Is that the one I take twice a day?" Mr. M asked.
"No, it's once a day," I said, pointing to the label. "The metformin for diabetes is the one you take twice a day."
He unscrewed the top of the next bottle and peered in. "I take these before breakfast."
I reached for the bottle and squinted at the label. "This is the one for your cholesterol. You have to take it at bedtime."
Mr. M was clearly still confused about his medicines, a not uncommon occurrence in this age of poly-pharmacy. Patients routinely juggle 7 to 10 medications, many of which change at each visit.
And a low level of health literacy, which the national report Healthy People 2010 defines as "the capacity to obtain, process and understand the basic health information and services needed to make appropriate health decisions," is surprisingly common among older adults. It is especially common in those who have the most diseases and the fewest resources.
For the next few visits, I spent all our time assiduously reviewing his pills and medication list. I referred him to an eye doctor to ensure that the diabetes was not affecting his vision. I arranged for a weekly visiting nurse to help him prepare a week's worth of medications in a pillbox.
In short, I did all the things that are recommended to assist a patient with low health literacy.
It was a year into our relationship when Mr. M finally told me the truth. I was typing up yet another beautifully manicured medication list to help keep him organized.
"Doctor," he said, his voice faltering, "you don't have to keep giving me those lists." He looked down at his lap for a moment. "The truth is that I can't read. Not in English, not in Spanish. Nothing at all."
Despite knowing that true illiteracy exists, I was still shocked to come upon it in real life. No wonder Mr. M couldn't keep his medications straight. He smiled faintly, then shrugged.
I recalled my travels to countries where I didn't speak the language; I'd felt so handicapped. To imagine that situation complicated by illness was frankly terrifying.
Watching Mr. M fumble with his bottles, unsure which pill was twice a day, which once, unnerved me, as I envisioned mix-ups and overdoses. That he'd succeeded this far was a testament to his resourcefulness and perseverance. But I worried about his future, his ability to juggle multiple chronic illnesses and to navigate a complex medical world.
Most patients don't offer up that they have low health literacy – let alone the fact that they can't actually read. Many expend great effort to compensate or hide it. Nevertheless, it is a powerful detriment to good health, and we in the medical world need to be on the lookout for it.
Mr. M and I opened up his pill bottles. We extracted a pill from each and taped it onto a piece of paper. I drew a sun next to the ones that needed to be taken in the morning, and a moon next to the ones for nighttime. He left my office with sheet of brightly colored pills, a rainbowlike guide that I hoped would offer him access to the quality medical care he surely deserved.
My kindergarten-age daughter is just beginning to read, and she is taken aback with delirious joy each time a few random letters suddenly form a word that matches real life. It's a painstaking process for her, but as I watch her I think about how this skill has powerful ramifications for her health and longevity. It's a gift, really, one that I'd long to transfer to Mr. M if I could.