A 21-year-old man comes to the office due to recurrent ear drainage. He is accompanied by his girlfriend. He speaks in English. On examination, the patient has purulent otorrhea, a tympanic membrane perforation, and a pearly white mass behind the tympanic membrane consistent with a large cholesteatoma. He is told that he will need an operation on his ear to remove the mass. After listening to an explanation of the procedure and why it should be done, the patient nods briefly but does not ask questions. He is also given information sheets with a written description of the procedure and instructions on how to schedule surgery that he immediately hands to his girlfriend, who begins to read them. Review of the medical records shows he has been to the emergency department several times in the last year with this same concern and has not had a flu shot in the past 5 years. Which of the following is the most appropriate course of action?

Question

A 21-year-old man comes to the office due to recurrent ear drainage.  He is accompanied by his girlfriend.  He speaks in English.  On examination, the patient has purulent otorrhea, a tympanic membrane perforation, and a pearly white mass behind the tympanic membrane consistent with a large cholesteatoma.  He is told that he will need an operation on his ear to remove the mass.  After listening to an explanation of the procedure and why it should be done, the patient nods briefly but does not ask questions.  He is also given information sheets with a written description of the procedure and instructions on how to schedule surgery that he immediately hands to his girlfriend, who begins to read them.  Review of the medical records shows he has been to the emergency department several times in the last year with this same concern and has not had a flu shot in the past 5 years.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

11ec160b_3683_eee2_9249_4572956e6241_MD0001_00 This patient's cholesteatoma requires surgical intervention; lack of definitive treatment has led to multiple emergency department visits for the same condition. During today's office visit, although the patient seeks medical care, he does not appear to engage with the physician (eg, nods briefly but asks no questions) and does not read the written health information sheets but instead hands them to his companion. This presentation raises suspicion for low literacy, a diminished ability to read and write. Low literacy has been shown to correlate with many adverse health outcomes, including increased hospitalizations and emergency care use, decreased adult vaccinations (eg, influenza), poorer self-reported health status, and increased mortality. Low literacy may be difficult to detect because known risk factors (eg, low level of completed education, history of incarceration) may not be present. In addition, adults are often ashamed and may try to conceal low literacy, sometimes with apparent noncompliance or refusal to cooperate. Screening reading tests (eg, asking the patient to read the information sheet aloud) are typically discouraged because they may induce anxiety and/or shame (Choice C). However, questions such as "How often do you have other people help you interpret medical documents?" or "How confident are you in filling out medical forms?" may reveal low literacy in a supportive fashion. If a physician suspects that low literacy is contributing to poor patient outcomes, alternative forms of communication such as visual resources (eg, illustrations, videos) should be used. (Choice A) Although adults with low literacy may require additional educational strategies (eg, visual aids) to gain appropriate understanding before making health care decisions, it should not be assumed that they lack decision-making capacity. This patient is likely a capable adult; therefore, further communication should be directed toward him rather than a family member. (Choices B and E) Explaining the condition again or verbally reviewing instructions for scheduling the procedure is unlikely to improve the outcome because many individuals with low literacy experience challenges in both written and spoken communication. Using an alternative mode of education that includes visual learning is more likely to improve comprehension. Educational objective: Low literacy can be a significant barrier to appropriate treatment and may be difficult to identify. For patients with suspected low literacy, alternative methods of communication (eg, visual resources) should be used to improve understanding.

A 21-Year-Old Man Comes to the Office Due to Recurrent