 combining your relationship with your doctor. But they don't listen to what you're saying or they go so quick that you don't understand what it is all for. The doctor is going to spend enough time with the patients that come in. Just in case. It is the end point. You've got to be quick. I think they always explain to the patient in the same way that the patient would understand. From what we've done so far everybody is not the same level and sometimes I think they're the same. They go to college, they went to work, so much school and they imagine that they can have a son. Does anybody think that Spider-Man has kind of a focus over a baby? So these are the objectives to divine health literacy, discuss the scope of the problem and how it impacts health outcomes and then at the end we'll talk about a little bit of tools and skills to make our practice patient better. So now this is... I think to make this session this is a very small group more interactive than anything. So what I'd like for you to do is to read this paragraph out loud so that I know when you finish and some of these words are still the backwards. Let's start with the national action. Alright, so I'll stop you there. I'll stop you there. I'll look at what I can tell you and you'll understand the context. And so I just kind of want to give you a flavor of what some patients might go through that maybe they're going to a few years of school and they can actually read but at the end of the day they understand what they're reading. And that's what they may know because they may have known the words but they're trying to concentrate on reading the words that they don't get the meaning of it. And so this is... Yes, go ahead. This is a time magazine from 2006 and I think this is really outdated but unfortunately the information is still very similar. And so it's telling us about the dropout nation that one out of three public high school students will not graduate and if you are a African-American or a Latino background the numbers are going to be worth about 50% if you're not graduating. And this is a website that I like to follow in terms of looking at the America's most literate cities and these are the larger cities more than 250,000 in the population. And is anybody here from Oregon? So a few years ago I read that they actually closed down their last bookstore maybe two or three years ago so I suspect that if there were these bigger cities that would be really at the bottom of that list. But they're looking at newspaper circulation of course, library resources education attainment and then they have Iraqi cities and I just want to share with you where we are in San Antonio out of 77 cities, 77 is the worst and we are 71. Only El Paso is worse than that in Texas. Austin usually writes higher and I suspect because they're a college town. Washington D.C. was number one and the most recent numbers was I think Minneapolis and Edom and I think it's still the most recent one is 70. So it hasn't really moved a whole lot. So this kind of just kind of gives you the ranking that essentially if you go from 2005 to the most recent we're in the 60s, 70s they need to miss getting the worst so it's not getting any better so there's a lot of work for us to do. So in 2004 the Institute of Medicine realized that there should be problems and they published this book called Health Literacy and Rescription to End Confusion and so that's actually when the Center for the Health Literacy Initiative also was born out of this this book and this awareness and so we've been in place, I think this is another pull up I can tell what that says. So these are the Health Literacy Basics Literacy and Health Literacy are different so you may read those words over just a bit but you don't really understand and I can think about it as a chemical engineer who might be a very right person but not only in the context of cancer and health he's going to hear words like test cancer, chemotherapy all these words that he may have to be familiar with in the same way if you talk to me about mechanics I wouldn't know anything about mechanic literacy so even though I can read it I wouldn't know anything about that the same thing in health literacy so there are some patients at higher risk but just because you know that it's a very common problem it's also a particular health status it's a famous major barrier so a lot of times you may not know that the patient has a literacy problem because they're not telling you they have an issue or you can't tell we do know that it's associated with health care costs and I'll just have some slides to share that with you you can't tell by looking and we have providers nurses, doctors, dentists all across the board but I've learned to train in health literacy but slowly but surely we're changing that in fact this morning from 9 through 11 myself and my colleague we actually taught a health literacy and day exact same one to our medical students in the first year just across the street at the Health Science Center but this is after 20 years of this so this is the definition by the Institute of Medicine health literacy is a degree to which individuals have the capacity to obtain to process and understand basic information and services needed to make appropriate health decisions so first can they get the right information can they process it, can they understand and can they act to actually make the right decisions for their health and use it in one of my favorite videos low health versus a hidden epidemic in America it causes needless suffering to millions of patients and their families which translates into billions of dollars in unnecessary health care costs fortunately this problem is starting to get national attention next is world leaders you're both taking a closer look at something that is vastly made into Americans how to make their way to the second instruction the direction and the guidelines given to them by their doctors now 40 million Americans are functionally illiterate which means they read at a below the fifth grade level they have an impossible time but even littering Americans can be overwhelmed here's a piece you have to find it's estimated that one of three Americans struggles with what is called low health literacy many can't read but many others are simply overwhelmed by the direction they're given from doctors and pharmacists it used to be when you went to the hospital and stayed so you got better but with different drugs and technology and the never ending push to cut costs patients are often sent home before they understand what they have to do to take care of themselves average Americans are struggling with modern health care it's hard to be a patient these days what's it like to be a patient what challenges do they face they'll show us just how complex and overwhelming health care can be so I'm going to pause right there because I want to hear from you because I suspect that you already went into this and that's why you're here because you want to learn more about it what to do about it so let me hear from you what challenges does your population think you might not be in an health field but something really did to that's what they think think about it the low income by medications and they can't go to the doctor okay good what else they don't have things in Spanish yes in the language issue and I always say this mother that went to California had a daughter that had epilepsy so they prescribed dialysis for her and the bottle said take once daily dialysis is a pretty powerful seizure medicine and so this is a little girl that said take once daily the mother only knew how to raise Chinese so once in the English is so that's 11 the mother gave the child 11 captures of the dialysis so the story was that the child you mentioned you didn't apply because of the orders because of the miscommunication that was written in English but she left on sick and it was just a harmful mistake so that's a language issue can you see in your your clients your potential yes yes you cannot be so I'll show you a video that this is longer she's very eloquent but she says I want out of that that doctor's office I hope I remember everything and he just told me because he doesn't know that I know and don't read so yes changes the communication so we need to make sure that we make it okay for them to share that with us and at the end of the day when I explain to them I'm hearing how good it's okay if you don't but if I don't know that then I can't tell you one more? yes the favorite way of learning maybe it's by reading, maybe it's by video maybe it's by computer so just knowing that okay these are just some examples well I'm here to transplant transplant for about 15 and a half years but I've been sick forever okay well I'll take a baby aspirin that's something to do cyclosporine, regizones and when I make the doctor's appointments I have to be sure that it doesn't interfere with his doctor's appointments my doctor's appointments are their doctor's appointments so you don't like to go to the hospital where they give you a lot of papers paper work why is that you can't read that well what does it feel like when somebody hands you a lot of paper work and you can't read still like in another controversy when you enter a doctor's office the first thing that your first time patient in they're going to give you a clip for it sometimes that is very discouraging for a patient who cannot read I'm really embarrassed to worry about things ringing or worried about my child being all upset I would not be able to read things I know wouldn't read every day some of the words that the Sanjeev Ramplasty and all of that is that several things or one thing or it's just a language that I'm not permitted with if the patient was transferred to that facility and to any and all insurance companies or other book parties or anything or obligated to play this is this is not like in any sense do you have any idea what a normal blood pressure is there's no no, it's not normal it's high have you or anyone ever had to sign with a symptom? yes I have hereby all for a conference seeking others to know all education and reading levels and one thing in common low health literacy it's so easy and I clumply and costly out of the space just to listen to what they have to teach us so what you do, you come out of that room, that examination room with this intelligent woman or man thank you God, I hope I don't make a mistake of my medicine because I did not understand anybody, who you're seeing what do you usually get? a motion or a normal motion because that's what the doctor recommended she gets more I would get her the 4 to 5 a table spoon and a half so you get a table spoon and a half can you find great coffee how many in the UK? the dosage? three in a day take three to two no leaders and I don't actually read this because I know what it says so if I had to sound it out it was where I knew it because I've heard it so many times I would not be able to read that every three to four hours as needed for pain what's the other meaning? the medication that was giving to her was not boring what would you use it? she ran out of her blood pressure most she didn't like it she didn't call me to tell me to do it so finally I found out that she had not been having it I said mother you can't do that you have to keep taking the blood pressure most and then it says just continue what does that mean? no how many times do you take being star world close? once a day and you take one of each of these so you take two star world close no I take one but I've got a lot to go out and mess with and I got revealed and then are these stickers out there? don't even look at them they just put them through and you tell them I am not the baby love out there they didn't even find any of the rubles that they made the longer the longer they did how many milliliters is in the table 15 in the table and a teaspoon is five so he has three times in those what else? that gentleman with the high blood pressure it was always that he knew his numbers this is a three of eight he said three because I was not even close to what the instructions were and these are actually real patients they were coming to Atlanta Atlanta Georgia many years ago can you see if any of these videos are so powerful? does anybody recognize the newscaster Peter Jennings the older of us so he was actually a high school drama and he kind of wanted to be a newscaster do you have a question or a problem? just that a little bit more entirely they don't want you to cook they don't want you to cook they don't want you to cook the table yes you're not computer literate so other issues that just a patient this issue of communication medication instructions that's on the pharmacist so I see that all the time they do this they follow up appointments they use to be in a clinic or they have to sign in for their appointments so I was walking through the lobby today and gentlemen I think he must have been in a 70 he takes out this IU card he gives it to me and says can you sign in for me or the follow up pharmacist they give him a piece of paper and they see the words but they don't know what it is they have to highlight and write for them health information pamphlets you know I think we spend so much effort in translating English to Spanish that I like to know whether that really helps any because even the great ones in English sometimes are not helpful I see many of them are written such highly that they're not useful a form consent when you guys are working you have to get a form consent or even if you're a patient you always have to sign these SIPA forms patients giving it to the history public health training directions to clinic we have a clinic where they have 3 buildings and they only connect on the 2nd floor to build within the 3rd floor and the 3rd floor but they didn't connect so it was really confusing for the patients to get around this is one of our own clinic signs so here is the sign by the elevators it says auto-rival radiology clinic on the 3rd floor that's the sign right there and then it kind of made it easy in English it says gear goes and goes so that they understand that auto-rival radiology means gear goes and goes what do you think it says in Spanish auto-rival radiology okay which is probably not useful to most of our either English or Spanish patients so I took a picture this is literally our own clinic but thankfully we now have a new clinic and this is one of our initiatives that's why I can share that so this medicine said that they have a framework actually that health literacy is actually impacted by several different things we are in the healthcare system most of us are but it's also impacted by 1812 education so those types of students that I talked about earlier that I drop out eventually become my patients eventually get medications and they make mistakes so the patient system actually affects the health literacy the social issues in society so as we mentioned about low income we have patients that have insurance what are the social issues sandwich language or whatever other language we have refugees from other countries as well culture yes, just a different culture so different issues and they all have an effect on health literacy and then at the end the health outcomes and costs we'll talk about that later so this is a graduation rate in 50 cities the average is 53 but I looked at this a few years ago but again just to reiterate San Antonio at that time was about 47% so it was about 38 out of the 50 cities so not very good and this is a question locally this is a data poll that is very similar still 40% of the population in Salter County does not have a high school education so yes 45% and this is the information from the health collaborative and the loss assessment and so you can tell these are the real numbers and this is 2010 now that the south is 45% and they've lived there in our north central it was 6.9% 7%, big difference and the most recent health collaborative assessment also tells us that not only is education different but how long you live also depends on where you live so low health literacy is common and this is on the survey that was done in 19,000 adults looking at literacy on the silly health literacy where they get adequate health literacy questions so they divided into low basic basic intermediate and proficient where do patients need to be to navigate the health system for that, for the efficient so this is what we want them to be in the grade and this that he tells us that only 12% of the population who are in the proficient which is more than one of our patients to be but below basic they basically ask if you're a patient so she's a paper and they said start with the date of their appointment and 12% or 14% would not do that so what percent of America enjoys is considered below basic considering this national health and resources this is a recall test of 5 seconds it's almost been attention yes that's the right one so we go back the below basic is the worst so 14% or what should be in the proficient so if you have the basic and the below basic gets 36% that's a lot of patients if you consider the old United States population more exactly it's about 89, 90,000 or 90,000 people with the below basic and basic and we actually did not exactly the same but we just wanted to know what the health literacy was in San Antonio so we went out to Walmart and we did basically a test of functional literacy and the bills and we tested them and we found something very similar that patients I think was 12% in our 14% was like 12% below basic but when you consider the population that ends up being like 250,000 San Antonio literacy level these are the patients at highest risk think about what you have in the area the elderly persons with limited education they have members of ethnic minority they do not speak English before starting school they are unemployed or they are provided with Medicare Medicaid who works for this population I know I do anybody else? yeah so I think most of us do have the low health literacy so there is a way to measure how literacy these are more formal the most that we use at the Walmart survey was the first one test of functional health literacy in adults and there is others but basically I just want to share that there is a way to measure that I'll show you but you can actually get to that point with just a couple of questions this is a question that I would like to answer what is the strongest predictor of a person's health status is it age income, literacy skills employment status, education level and all so the word is strong guest I agree that the album should be I asked another student this morning and said what kind of class is this students so how kind is the class so C is the answer which was surprising to me when I first read that as well you know like when you say all of them contribute but the strong guest according to the Gemma1999 article was literacy skills so we know that health literacy is a predictor of health status and that's why we're really interested in this because it does affect health so we know that the links between education and outcomes are strongly established so again literacy is one of the strongest predictors more than income, employment status and educational rates this is just an example of where well health literacy affects just your knowledge so this was studies done in cases that had diabetes and hypertension they had an inadequate margin or adequate literacy and that's a question about their diabetes and as you would expect in cases that had higher literacy levels knew more knowledge about their diabetes and knew more about their hypertension those that knew less health literacy skills so this is kind of what we would expect we also know that in general the lower the health literacy the poorer the health status the lower the health literacy the poorer their blood sugar control the value of this is less control we also know that they also have less healthy behaviors so they don't get the vaccines, they don't get their colonoscopies, they don't get they don't use their suitcases all those things that we consider healthy behaviors they are less likely to be those things and we also know that if they have lower health literacy they have more hospitalizations what does that do for a system? more hospitalizations, more consciousness and even more importantly that the worst health status is you died on the road if you died more higher mortality if you have lower health literacy so this was a study done in 2007 2006 in the elderly so they looked at the elderly and their literacy levels and what they found was that if they had adequate health literacy the mortality rate was about let's say around 20% those that had low health literacy rounded up 40% so 20% versus 40% in mortality then someone said well maybe they are just sicker or they have lower socioeconomic status so they said let's control for all those things and they did and what they found is that there is still an azure ratio for increased mortality in 1.52 so there are still 50% higher in terms of the mortality we had lower health literacy so if I don't want this to affect outcomes it also affects mortality so that's why this is really important medications so people again this is my area people with basic and below basic health literacy were 5 times more likely to misinterpret prescriptions and those would have a good scale and I'm going to show you just the data that I like well sometimes doctors make mistakes and I need to try twice as hard to fix them are you using your inhaler? all the time, go through one a week are you sure you are using it right? do I look like an idiot? no let me see how your killer works we think it's funny but unfortunately I see this all the time and it's amazing what the patients can do we don't understand how to use their inhalers or medications whatever is an insulin I have a patient that has diabetes and I started her out on insulin so the nurse part of her use a pen it's an insulin pen so she showed her how to use it they were like 300 normal is less than 120 and so they kept on being at 300 so I kept on increasing the dose and so I kind of had to start around another insulin and so the patient received an insulin from the pharmacy with a pathway and she was reading the instructions and she called me and she said I think I know what I did wrong and I said what? she said well the nurse didn't tell me to push the pen so she was just poking herself with a pen every day poking herself so the blood for the insulin was not being injected into her skin and so of course once she started using it right then her blood sugar just came down and it's just amazing I'm sure the nurse she even injected herself in front of me but somehow she was going that up and she was just poking herself every day and her blood sugars were not going up and she was getting injected into her skin so it's just amazing but if you're a mom and you get this prescription you have one teaspoon full by now through times daily you go home this is what you get to see in your kitchen which one is a teaspoon can you even know? it's a strict question because you have to know which one is 5 milliliters and you have one teaspoon of 5 milliliters but they can be 5 milliliters it can be non-milliliters there was a little study that but they just measured adding this as a longer health release workshop but the point is that if you don't have the exact measurement and you have a tiny baby you're giving them 2 milliliters or 9 milliliters instead of 2 we can over dose them easily we need to make sure that the patient understand the correct dose and maybe give them a syringe with a sharpie marker for the correct doses 4% of patients forget that the doctor tells them as soon as they may be on so yes, 80% and I told this to this morning the side part is that 20% of them remember half of it is wrong so they only understand about 10% of what you tell them and so one of the things to do is actually that doctor in the house and he actually did what he was supposed to do he said show me show me how you're using the inhaler so that's a key skill okay, I'm going to show you how to use it and you show me that I can make sure I talk you well okay, so on the onus is on us and on the patient so shameless stigma associated with limited literacy skills or major barriers to improvement health literacy and this is what we're talking about whether you're embarrassed or ashamed it stings to someone and really it paralyzes your thoughts completely to think that you may say something or something is putting it for you to read and you can't read I mean you live with that on my daily basis so I try to make sure that the patient know that it's okay I don't want to read but just trying to pull that out of there this far so I usually ask them where you're from from San Antonio what high school did you go to they tell me where I'm from so then I ask them where did you go to they tell me I just went to the surgery where I dropped out so they tell me so then I ask them are the letters easy for you to read or too small for you and then they eventually tell me why can't I read or I'm reading my glasses so I said I just want to make sure that you understand how to read because reading instructions is important and I want to make sure that I'm here to help you so I want to make sure that whatever I give you that you can understand so eventually they know that you're there to help them and they're okay telling you but sometimes when the doctors they don't feel like really interpreting the doctor because they're busy, they've got something else to do they're reducing to make sure that in whatever area we're working that they feel comfortable telling us okay I'm not sure I understand limited health literacy has been associated with higher healthcare costs so those of you in administration are probably interested in this or any of those of you that are taxpayers so this is a study that was done by Dr. White so this is actually the end of our after medicine department a few years ago and because those patients that are in the Medicaid we're a close system so we can actually look at how much they spend in their health so he took pregnant women and they can measure their literacy skills and then look at how much they cost to help their system so those with lower literacy skills were costing more almost $100,000 or $10,000 in 16 days with those with adequate skills and so about $3,000 so $3,000 versus almost $11,000 so big difference in cost the only difference was just the received level we also know again in my studies that up to 6% they have 6% more hospital visits and those that are hospitalized tend to stay in the hospital longer approximately maybe 2 days longer then they have more literacy skills where they get hospitalized more often and they stay in the hospital longer so again that translates to more cost and just to give you an idea some people do just all these models and projections that the economic impact is about up to $238,000,000 70% to 70% of all personal health care expenditure and they say this is enough to cover all of those people that are under insurance more than $7,000,000 and if you don't do anything about this then this is going to add up to $2,000,000 and that has been in this morning they say no it costs so much and we know people are making mistakes why don't we just hire people to do this what we think about this so it's kind of hard to inspire someone to do just one thing but I think it's all of our tasks to help in whatever area because you know we were thinking more of pharmacy and pharmacists are supposed to counsel on the medications but when the doctor prescribes it about the medication how to use it when the nurse dismisses it that's also their job and the pharmacist prescribes it that's their job too and that's just medications and there's also what to do about your diabetes what to do about your surgery your procedure there's so many things that we can make mistakes as patients so it's not just one area but it's just such a big task that's allowed you to continue to it so you can't tell by looking at the state's study that 50% of patients with reading difficulties have never told their spouses although some of you that are not here you know if your spouse has ever been in difficulty or in this nation so that was interesting so they never told their spouse about it and decisions could only identify 20% of their patients who are at the lowest and worst level so if the doctor goes into the office they can't tell, okay this patient has low literacy this one has high literacy and they're very eloquent in their speech and they're real patient and this is Ms. Walker talking about high units and that's what we can't tell one of the things that most of us know how to do is to hide it sectionally well because it's a terrible embarrassment you know and the shame that goes with it is death savings so the last thing to worry you want an intelligent doctor to know that you have any kind of problems other than the ones that you dare to see them about so how first and basic number 7 health professionals and staff have limited education, training CE, practice opportunities to develop skills for the health literacy so we've been doing health literacy through the salaries in 12 years and I've been doing this problem longer than that in 20 years and this is now just the second year that we're teaching this class to the first year medical students and so I know that pharmacists really tend to constitute a little bit more in the dental schools and the physical therapy schools and the every health professional schools that we have so health literacy basics again literacy and health literacy are different it's common, could they sell status change the major barrier associated with higher cost we can't tell other people and we have limited training so some of the recommendations in general first recognize that it is a problem and how do we recognize it I just know that it is very common in the widespread and just some clues at least in the clinical area patients may be routinely late to the refills they may be frequent medication terrors so and I see that all the time that patients are just making mistakes so when I see that when I start getting more I realize okay the patient doesn't know how to read or they may not understand or they're just afraid of something or they actually have to sign some forms a lot of times they will just fill out their name and the rest of the behavior can't read it or they don't understand and so I mentioned earlier about economic status well at least as a patient that needs to fill out has to fully write on their page and care for their exchange programs and that's just very complicated so that's how we need to help fill these things out other patients if you ask them to read something they say oh I forgot my glasses can you read what the lady wants medication says oh I forgot my glasses could probably aid me on how to read or if I know something they'll say like I'll read it when I get home or their husband or wife can just give it to them and they're there with them or they just show a lot of interest because they're just not understanding what you're telling them anything else that you guys can think of of people that you work with clients, customers where you say somebody has a low literacy skill somebody need more help if they come to Mexico so first language maybe or they may not read it anybody else anybody else anybody else should ask them what about your language whatever do you work with what about yourself what about yourself well the answer to that is to make sure it's exactly my time anybody else what ever do you work with I'm definitely better at speaking okay professor I know you're one of my primary students anybody else right there what about minister he's going to find more of our helpfulnessy educators good anything else right there go ahead is that again you're just saying it's okay if you're going to are you a mom and a case manager or a tutor with patient navigators okay so you need more patient navigators to help the patient but I'm going to do that what's your name I'm Ziek you need more assistants I had many runs with a type of sort of infection, where she wasn't even writing her results. She was a doctor. She was a regular medical case engineer. And as I helped her to get her, they sent her back to me so we could kind of figure out what the result was for her. And she had a language barrier. I kind of, I'm not going to ask her about the pill box. I'm going to use it as a tool. I'm going to ask her to show me how she was using it. And she couldn't make out what the result was like. And it was a tool that she had. And I started talking on the station there. And then she opened the camera. And so then she did not come around to me. The doctor was not getting the results after months of progress that she was going to have in the case. She actually ran. I started the second night. I was in her night. It was me. And the second night was very nice. But the communication was good. And then I was just working for months prior. So she had me in the open room. There was no fear of taking it. Yes, that's a good way that we should find out. So I looked at the prescription bottle. Today is October 6th. And the prescription is still in January 5th. And it's set for 30 days. So this is good. What happened? She said, well, we can do this with you. This is like five pills in there. Or the idea of getting them not to be there. You better not try. Another example. I had a lady that I actually didn't know. Maybe also children. She was very busy. And so she was there. The doctor asked for a few minutes. And she was like, try and go. Right on by. It was very interesting. And there is a little bit there. I tried to, I don't know how to advocate for this. And the doctor gave us a few minutes, right? A few words that would kind of get the doctor's attention. But they were invested, right? And so we had another issue with the answer. They sent her back to me. She only did it in our agency. As we planned. We took her there. And we started to get her to attend. I think on the third visit, it took me an hour. She was very guarded. But we figured out that it was going on. And she was taking medication with food. The doctor had sent a ticket to get food. This particular lady was going to have to be taken on her about the exact same time of day. And we had already got the bed at the time of the medication. So she was taking it in the morning with food. And we took it in the next day of the week. One day in the morning. So she was taking it sporadically. So we never got the end result. And we got her to kind of pick it up. Yes. It's amazing what patients understand. We had a gentleman that he saw the label and said, take good food. He had a picture of the hamburger. He says, I can afford to buy hamburgers three times a day. Every day. And so, but yeah. So, you know, I was telling the students they were happy to spend the whole day story after story. Because it happens every single time I'm in clinic. But we're just kind of continuing. So another recommendation is to create a shape for your environment. So that the patient is free to actually admit to you what you're looking for. This limitation is fine. So be helpful. Answer films in person if possible. Help complete the forms. Like our nice navigator would probably use. We do the instructions. Encourage questions. So, does anybody have any questions right now? Do you have any questions? No. So the answer to be there, yes or no? Right. So that's a close ended question. So we probably do not want to do that. But what kind of questions do you have that I can answer to you? As opposed to do you have any questions in the answer to there yes or no? No. But what questions in that kind of encourage is that? Develop easy to read materials. So we're going to give them 10,000. Make sure they have plenty of white space, pictures, you know, easy to understand words. Clearly more bright and healthy. So accreditation standards. So, you know, the accreditation bodies that have accredited hospitals and clinics, they need to say, okay, we really need to make sure we have clear science, make sure patients understand that we have HMM theaters, health educators and pharmacists. And more of everything to make sure the patients understand. So, recommendation number six. This is one of my favorite, a lot of people have not heard the line, you know, about health literacy, and medication use chapter. And he advocates for this in myself as well. So if anybody has any access to our political and politicians, I really would love to see this incorporated in our pharmacies to make the levels more easily understood. Because generally, it's the pharmacy name, the pharmacy phone number, and the address that is huge. But then the patient instructions are in time to print. So we're advocating that the biggest information need for the instructions and what it's for, and with some pictures perhaps, as opposed to the current levels that we have now. We talked about schools and measuring. So we know that the one, two, three, the fourth one is a 92% and the other 92% accurate. But the fourth one is the schools, that may not be very, when you have a little toddler, they're going to fight you, so you might still love it. So the recommendation is to use the second one, the syringe, and mark it with a sharpie so that they know what the correct person is. Improve your communication skills. Show empathy, be an active listener, use simple language, slow down, avoid information overload, get possible and include family and friends. Tell stories and make sure you understand the cultural context. I know we're in San Antonio, so it's usually the Hispanic population when we have more poor refugees, and then we have a good number of other patients in our clinic that come for me to use a translator. So I ask you English and Spanish when we're in Korea or another language that I have to use that I can see political and trying to communicate with patients. And that's it. Just show it's up, which is possible. We teach that kind of thing. Really important. So Mrs. Lyft, this is how you use your enabler. You shake it well, you pull it this way, you increase, and after you teach them, it's okay. Just so that any share that I explain to you correctly shows me how you can use it. And hopefully it's not like a lady that does. Well, if they do it like a lady, when they do this, it's okay, well, I might be shook, but let's kind of go to it again. And so we kind of keep on going. They call it the teach back loop. So teach them, if they do it wrong, you can teach them again. But one of my physicians are attending. He says, you know, I know that Dr. Maeson Tumas says this, but I'm only good if you have a heart. And I didn't know what he meant and what he explained as he's your physician. So he tried that one time and he saw he explained something to the patient. And the patient got it wrong. So he had to teach him again and he got it wrong. So he says, only if you have a heart to realize that you're not a very good educator to do that. But, you know, the good thing is that we have, and we realize this is a clinic direction, we realize that we need more help. So we have health educators, we have politicians, we have pharmacologists. So we're blessed to have a good team to actually have a good team. So the teach back method is important. So it basically is asked the client to review instructions back to you in their own words. And I'm going to just end with this video because of everything this is telling one of the most important places to actually treat our clients our patients with respect. We didn't choose to do this way. And we would never choose this way. And I don't want to think about that one way or another, but I don't care who you are and how high or how low your IQ is. It's very important for people to be treated with respect. I don't care what your financial wealth is or any of those things. Respect is very important. It's very important. And if you take a person who has a low IQ, a low respect problem, and God knows they have some very little hold on to them at first points. Do you really? Can you imagine how much that person has to diminish when they got that offense? You want to melt it to the floor. So I think we have just a few more minutes for just a question so that anyone has any comments about what we just kind of discovered. And there's so much more that we can talk about. There's a study that came out a few years just to maybe not that long maybe a year or two ago about you know how we the administrators are really so they count the cost the emergency rooms in the hospitals but there's one study that actually looked at 30-day re-admission rates. They found that those patients with lower effectiveness actually got re-admitted to the hospital more often than 30 days. And so that's the, of course, we don't remember to get re-adversed with those patients. So health literacy really has effects again and the health outcomes, mortality in costs and you know, not to mention the quality of life in our patient and patient's appliance. Any other comments, questions that I can clarify? Answer? This was just kind of a, the ABCs, the health literacy 101, there's so much more to discuss but you know, the mirror to this conference we usually try to to have this session so at least you kind of have a baseline background before we go to the other sessions but I hope this was helpful and I hope you enjoy the rest of your conference. Thanks very much for this patient.