by Cameron Young Sweeney, PA-C
He hummed quietly to himself and tapped his fingers on the wooden cane propped between his knees as I rolled the stool from under the computer desk and sat next to him. His gray hair, shiny with Brylcreem, was smoothed back from his high forehead. His blue eyes twinkled as he stole a look sideways at the badge that dangled from the left lapel of my white coat.
I introduced myself and began, “Your primary care doctor sent you here because he was worried that the hemoglobin in your blood was too low, making you anemic. But your blood transfusion and the iron pills he told you to start last month are already fixing the problem. Has your energy level gotten any better?”
“Oh, I am fine, fine.” His Mediterranean accent sounded musical. “I feel very good.”
To hear him tell it, he had no health problems at all. He denied fatigue, shortness of breath on exertion, tachycardia, palpitations. He had no pica symptoms. No headaches or dizziness. His olive skin was surprisingly smooth for his age, save a few crinkles at the corner of his eyes, but his palms were paler than mine.
“Papa,” the middle-aged woman in the corner interjected, “You know you’ve been more tired than usual. Right? Haven’t you?”
“I am okay, I am good.” He denied any bleeding.
“Well, he hasn’t had any bleeding since he had… the procedure… last month,” she stammered. “But he lost a lot of blood before that, leading up to the transfusion.”
I showed her the flowsheet that revealed his chronic iron deficiency and anemia dating back several years and pointed out the low point at the time of the surgical procedure. He had been given 2 units of blood during his hospital admission, and now his hemoglobin, iron saturation, and ferritin continued to climb from the nadir. He was responding well and would not require parenteral iron.
While I reviewed this information with his daughter, the patient spoke up. “I like living here between the mountains and the sea. I came to this country when I was a teenager.” He was proud to tell me how he had worked steadily since that time until more than 15 years past typical retirement age. “I only stopped working when I fell last year… I would like to go back to work now. I want to drive again. I miss living on my own.”
“Papa, she doesn’t need to know all that,” his daughter protested.
As I scanned the remainder of his chart, I noticed that his blood pressure was alarmingly high. When I asked if he had missed a dose of his usual anti-hypertensive medications, he laughed. “No, I haven’t taken any blood pressure medicine at all since I got blood in the hospital. The new blood fixed all my blood problems, no?” He beamed.
His daughter looked worried. “My sister takes care of all his medicines. I don’t know what he’s taking.”
It had not occurred to me that someone might associate blood transfusions with blood pressure medication, and I tried to correct the misunderstanding. I recommended that he continue all his usual prescriptions and keep a blood pressure log. I asked his daughter to schedule an appointment with his PCP if his blood pressure did not normalize by week’s end. When the visit concluded, he stood, hiked his pants over his belly, and bobbled down the hall, cane in one hand, with his daughter at his other elbow, humming all the while.
About one in eight American adults have “proficient health literacy,”1 defined by the Institute of Medicine as the ability “to obtain, process, and understand the basic health information and services … to make appropriate health decisions.”2 People at risk for low health literacy include the elderly, members of racial or ethnic minority groups, the poorly educated, people from lower socioeconomic groups, and those who speak English as a second language. 3 This patient was the center of the bulls-eye.
Health illiteracy can lead to both financial and emotional costs, increased hospital admissions, infrequent primary care follow up, and poorer overall health and compliance with medical advice.4 The exchange with this family reminded me not to assume knowledge of health concepts or terms that may seem fundamental and to check frequently for understanding. “Teach back” can confirm the effectiveness of communication, including any changes to the medication list.
Within a few days, the patient’s blood pressure returned to a more age-appropriate range. His hemorrhagic bleeding did not return. Within a few months, his ferritin had been replenished and anemia resolved. We returned him to the care of his PCP.
1 Kutner, M, Greenberg, E, Jin, Y, and Paulsen, C. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006–483) [Internet]. U.S. Department of Education. Washington (DC): National Center for Education Statistics; 2006 Sep [cited 2018 Jun 24]. Available from: https://ncapa.org/wp-content/uploads/2018/06/2006483.pdf
2 Report brief: Health literacy: A prescription to end confusion [Internet]. Washington (DC): National Academies Press; 2004 Apr [cited 2018 Jun 24]. Available from: http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2004/Health-Literacy-A-Prescription-to-End-Confusion/healthliteracyfinal.pdf
3 Fact sheet: Quick guide to health literacy: Health literacy basics [Internet]. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. [cited 2018 Jun 24]. Available from: https://health.gov/communication/literacy/quickguide/factsbasic.htm
4 Hartsell Z. Health care illiteracy implications for providers. JAAPA [Internet]. 2005 May [cited 2018 Jun 24]; 18(5):41-7. Available from: https://journals.lww.com/jaapa/Fulltext/2005/05000/Health_care_illiteracy_Implications_for_providers.6.aspx