Furthermore, marginal functional literacy has been associated with poorer physical health, psychological health, and higher health care costs. [4][5][6] The implication for physicians is that at least one-fourth of our patients may not be able to discern prescription bottles, understand patient education materials, or use written directions to find a lab or get a mammogram. Identifying patients with potential literacy problems is important if physicians are to attempt to combat the adverse effects literacy has on health care. Because many illiterate patients will attempt to hide this disability from their physicians and because people with more schooling may still be functionally illiterate, physicians cannot merely ask a patient if they can read or what their educational achievement is. search attempting to identify a shorter literacy screening instrument was unsuccessful. We designed the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), a shortened version of the REALM. The REALM-R was designed as a rapid-screening instrument to assess how well primary care patients read words that they commonly experience and are expected to understand in the course of interacting with their physician. This pilot study was conducted to determine whether the REALM-R could be used as a screening instrument to identify patients with potential literacy problems. METHODSWe set out to revise the REALM, a well-validated and reliable instrument, but one that is still too long to practically administer in busy clinical settings. The 66-item REALM was administered to 50 patients in the Internal Medicine Clinic at the University of Kentucky. We examined 2 item characteristics of the 66 words from the full scale REALM. First, we identified items with an item-whole correlation of greater than 0.40, and then selected those that maximized discrimination by being as close as possible to a 50 / 50 correct / incorrect split. The new 8-item REALM-R demonstrated a Cronbach's α of 0.91. The part whole correlation between the REALM-R and the REALM was 0.72.

Resident physicians overestimated the literacy abilities of their patients. A significant portion of these residents' patients may not have the skills to effectively interact with the health care system and are at increased risk for adverse outcomes.

Better nonverbal communication skills are associated with significantly greater patient satisfaction in a variety of different types of clinical encounters with standardized patients. Formal instruction in nonverbal communication may be an important addition to residency.

Residents' communication practices may stem from their attempt to balance an informed choice model of decision making with their interest in providing appropriate care for the patient. Physicians' beliefs about mandatory autonomy may be an impediment to improving communication about patients' choices for life-sustaining treatment. Redefining the role of the physician will be necessary if a shared decision making model is to be adopted.