One-third of patients who walk into your surgical clinic will have basic to poor health literacy—a health disparity that is often overlooked or misunderstood by the majority of health care providers.¹ Prior work has shown that improving the health literacy of the population as a whole could save the health care system 25 billion dollars a year and reduce annual health care visits by 1 million.² By definition, health literacy is the ability to obtain, comprehend, and act upon basic medical information for oneself or others, and is critical in order to make well informed decisions regarding medical and surgical care.² Unfortunately, it has been well documented that poor health literacy is a positive predictor of worse health care outcomes in various disease states (see Figure). Among numerous surgical subspecialities, low health literacy has been associated with higher rates of readmissions and emergency department visits, increased health care costs, longer hospital stays, and increased morbidity and mortality.^1,3 Within urologic oncology, patients with lower health literacy were found to have increased rates of prostate cancer treatment regret, as well as higher rates of utilization of discharge services, complications, pathological tumor stage at the time of surgery, and malnutrition amongst those undergoing radical cystectomy.^4–6 Although sparse, emerging data within reconstructive urology demonstrate that lower health literacy has been associated with decreased patient satisfaction following male prosthetic surgery and a lower likelihood of accepting female anti-incontinence surgery (see Table).^7,8

Poor health literacy can affect patients of any age, gender, race, or socioeconomic background. While patient education level is often used as a surrogate marker in practice for a patient’s ability to understand and act upon health care information, this has proven to be an inappropriate assumption, as educational attainment has been shown to have a nonlinear relationship with health outcomes and health literacy.^7,9 Failure to recognize an individual patient’s health literacy during surgical counseling can thus lead providers to overestimate a patient’s understanding of medical discussions, an increased use of medical jargon, and a failure for patients to set realistic expectations.

Table. Studies Within Urological Surgery Evaluating the Impact of Health Literacy

So why should reconstructive and prosthetic urologists care about the nuances of health literacy? Reconstructive and prosthetic urology revolves around the credo of improving a patient’s quality of life (QOL) through medical and surgical therapies. With QOL as the principal outcome, despite any seemingly positive objective surgical outcomes, patients often define success based on meeting their preoperative expectations and improving their overall QOL. However, QOL is highly subjective and variable from patient to patient. For example, while one patient may be satisfied with managing their urethral stricture disease with a suprapubic catheter, another may only be satisfied with the ability to void while standing through the urethra. As such, it is our responsibility to decipher, understand, and ultimately work towards identifying patient goals, their understandings of their options, and their expectations regarding potential surgical outcomes. As patient satisfaction and expectations are dictated by a myriad of factors, perioperative counseling and education play a critical role. With shared decision making at the core of reconstructive surgical management, adequate health literacy is necessary for patients to actively participate in their care and to understand the potential outcomes of the decisions they make.

Health literacy is an easily identifiable demographic variable that can be incorporated into standard perioperative evaluation and counseling. There are numerous validated screening tools that can be used to measure health literacy including: the Brief Health Literacy Screen, Rapid Estimate of Adult Literacy in Medicine, and Test of Functional Health Literacy in Adults. Implementing such screening tools can help identify patients with low health literacy prior to surgical decision making, thus allowing for individualized counseling and education. Once identified, utilizing techniques such as avoiding medical jargon, referencing visual aids, requesting patient feedback, clarifying expectations, and summarizing key discussion points can be effective clinical tools to ensure that those with lower health literacy are fully informed.¹⁰ The integration of patient health literacy within one’s daily practice can ultimately lead to higher patient satisfaction and overall QOL.

Unlike basic literacy and numeracy, poor health literacy is very easy to miss in a standard clinic setting. As previously noted, education and socioeconomic levels do not clearly correlate with the understanding of medical conditions and surgical care, just as achieving a doctorate in medicine does not prepare one to play the stock market. It is the responsibility of the surgical team to ensure that this often-overlooked issue is not marginalized, leading to further gaps in health disparities, and that information and counseling are provided in a comprehensible and equitable fashion.