In Response

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					234     April 2008                                                                                 Family Medicine

Letters to the Editor

                                         Joseph Scherger, MD, MPH
                                     Editor, Letters to the Editor Section

      Editor’s Note: Send letters to the editor to or to my attention at Family Medicine
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      preferred. We publish Letters to the Editor under three categories: “In Response” (letters in response
      to recently published articles), “New Research” (letters reporting original research), or “Comment”
      (comments from readers).

In Response                              physician from the less-developed       only one young family physician
                                         countries has to acquire will differ    from the institution present. All
                                         from those in the West in many          the others were senior consultants
Country-centered Family                                                          from various departments, some
                                         ways. Faculty in other specialties
Medicine                                 in my institution have expressed        of whom were supportive while
                                         their concern about the relevance in    others had doubts and questions.
To the Editor:                                                                   The absence of senior consultants
                                         India of the family medicine model
   The breadth of diseases, clinical                                             in family medicine in teaching
                                         practiced in the West. Though I do
skills, patient/family problems, and                                             hospitals is a factor that should be
                                         not completely agree with them, it
a clear focus on patient-centered                                                reckoned with.
                                         is a reality that the needs of India
care make family medicine exciting
                                         and other less-developed countries
and challenging. However, the care                                               (3) Attempt to transform rather
                                         will be different from those of a de-
of people in the context of different                                            than transplant
                                         veloped Western country. Here are
cultural and socioeconomic back-                                                    It is tempting to reproduce a
                                         some suggestions to those working
grounds, health delivery systems,                                                model that has worked quite effi-
                                         to develop family medicine in the
political situations, health policies,                                           ciently in the West. However, it may
                                         less-developed countries:
disease patterns, trends in medical                                              not be practical and acceptable in
education, and changing demo-                                                    the less-developed countries.
                                         (1) Be country centered
graphic patterns makes the prac-
                                            Just as we practice patient-cen-
tice of family medicine unique in                                                (4) Influence the government
                                         tered medicine, we need to be will-
each part of the world. The article                                              and policy makers
                                         ing to envisage “country-centered
“Balance of Trade: Export-Import                                                    Influencing those in authority
                                         family medicine,” recognizing the
in Family Medicine”1 addresses a                                                 who make health policy decisions
                                         fact that each country has its own
critical issue that is faced both by                                             is strategic for the development of
                                         unique factors that affect the prac-
the teachers of family medicine in                                               the specialty. With the trend toward
                                         tice of medicine.
the developed world and those in-                                                subspecialization that is happening
volved in the development of fam-                                                around the world, there will be an
                                         (2) Begin with the existing
ily medicine in the less-developed                                               increasing demand for generalists
countries.                                                                       from the public, and it is the role
                                            Working with family physicians
   The expertise and experience                                                  of family physicians to influence
                                         and other specialists of the coun-
of teaching and practicing fam-                                                  stakeholders in health policy to
                                         try simultaneously is essential to
ily medicine in the West for more                                                recognize and respond to this.
                                         making progress. In most places,
than 50 years is valuable for the
                                         the academic decision makers
development and establishment                                                    (5) Be patient!
                                         will be from other specialties who
of the specialty in the rest of the                                                I personally know people from
                                         need to be taken into confidence.
world. Although the foundational                                                 the developed world who have been
                                         In a discussion last week on the
principles of the specialty remain                                               frustrated at the pace at which at-
                                         introduction of family medicine as
the same throughout the world, the                                               tempts to develop family medicine
                                         a specialty in a teaching hospital
knowledge and skills that the family                                             in India have progressed. The
                                         that I was invited to, there was
Letters to the Editor                                                                                   Vol. 40, No. 4         235

struggles of the founders of the spe-         each interview. A study investigator     felt that health literacy screening is
cialty in countries like the United           offered to read all consent forms,       worthwhile, 73% believed it is the
States will be faced by those who             including a simplified “short form,”     patient’s responsibility to initiate
pioneer in less-developed countries.          to ensure comprehension. Each            a discussion about health literacy
It is my hope that they will persist          participant received a $20 gift          with his or her physician, and 91%
with sensitivity and patience.                card before the interview. Next,         stated they would not be embar-
Sunil Abraham, MBBS, Dip NB (Family           a series of four validated health        rassed if asked about their health
Department of LCECU
                                              literacy screening questions1 was        literacy.
Christian Medical College                     read aloud:
Vellore, Tamil Nadu                              (1) How often do you have some-       Discussion
India                                         one help you read hospital materi-          The four health literacy screen-
                                              als?                                     ing questions examined in this
                Reference                        (2) How confident are you filling     study were generally acceptable to
1. Pust RE. Balance of trade: export-import   out medical forms by yourself?           participants, with the exception of
   in family medicine. Fam Med 2007;39(10):      (3) How often do you have prob-       the potentially embarrassing phrase
   746-8.                                     lems learning about your medical         “how often” (which may imply reg-
                                              condition because of difficulty un-      ular difficulty with health literacy)
                                              derstanding written information?         and the word “help.” An unexpected
New Research                                     (4) How often do you need to          finding was that most participants
                                              have someone help you when you           believe it is the patient’s responsi-
Understanding the Role                        read instructions, pamphlets, or         bility to initiate a discussion about
of Shame in the Clinical                      other written materials from your        health literacy. This sentiment may
                                              doctor or pharmacy? 2                    reflect the growing emphasis on
Assessment of Health                             Par ticipants commented on            patient autonomy.
Literacy                                      whether each question might po-             This study has several limita-
                                              tentially elicit shame, as well as the   tions. Participants were assembled
To the Editor:                                appropriate context for screening.       as a convenience sample from the
   At least 20%–25% of the US                 This study was approved by the           primary care setting. Non-English
population has inadequate health              Memorial Hospital Board for the          speakers and those with auditory or
literacy, which may be defined                Protection of Human Subjects in          visual disabilities were excluded,
as the diminished capacity to un-             Research.                                and 81% were female. There may
derstand written, verbal, and nu-                                                      be a selection bias, since patients
merical information in health care            Results                                  with inadequate health literacy
settings. Inadequate health literacy             Eleven participants completed         might have been too embarrassed to
is a major predictor of health care           interviews. All participants were        enroll. Finally, we did not measure
outcomes. It is unclear whether the           English speakers age 18 or older         the health literacy level of each
process of screening for inadequate           (average age 55, range 24–78) with-      participant and thus could not cor-
health literacy induces shame. The            out significant visual or auditory       relate health literacy level with our
primary goal of this study is to              disabilities. Nine of the 11 partici-    findings.
investigate patient preferences for           pants were female. Seven patients           Additional research is necessary
the content and context of screen-            attended at least some college, three    to determine whether modifications
ing for inadequate health literacy            patients completed at least some         to the four health literacy screening
in primary care, with particular              high school, and one patient com-        questions in this study might de-
emphasis on factors that minimize             pleted middle school only.               crease shame among patients with
shame and embarrassment.                         The four screening questions          inadequate health literacy.
                                              listed above were acceptable to          Timothy W. Farrell, MD (research com-
Methods                                       most participants (81%, 73%, 91%,        pleted while a PGY-3 family medicine
   We recruited 11 participants               and 81%, respectively). The phrase
from an urban, underserved family                                                      Rabin Chandran, MD
                                              “how often” and the word “help”          Robert Gramling, MD
medicine residency population in              were identified as potentially em-       Family Medicine Residency Program
the winter of 2007 for enrollment             barrassing. The optimal format for       Brown University
in qualitative, semi-structured               screening was felt to be periodic        Memorial Hospital of Rhode Island
interviews lasting 30 minutes                 interviews in the privacy of the         Acknowledgments: This project was supported by
each. Recruitment continued until             examination room and not the ad-         a Health Resources and Services Administration
saturation (ie, no new perspectives           ministration of questionnaires in        Grant #CRS EIN1050259004A1.
emerging from interviews). Written            the waiting room. All participants
consent was obtained to tape-record