Advancing the Science

Mayo Clinic Medical Science Blog – an eclectic collection of research- and research education-related stories: feature stories, mini news bites, learning opportunities, profiles and more from Mayo Clinic.

January 9, 2019

Why doctors might need to go back to 6th grade

By Elizabeth Zimmermann

When you leave the hospital, following an injury, stroke, surgery or other event, you are loaded down with paper. You receive instructions on how to take care of your body. They tell you how to prepare your home and your family. Other pages include directions on what medication to take, when and how. For example, take one in the morning with breakfast; or three times a day, at least one hour before meals. The papers describe any special equipment or supplies you may need, as well as how to use them. Other pages discuss possible side effects, and still more share tips for prevention or better health in the future.

Likely you are feeling tired and sick. Now you are supposed to read and understand all this writing, with its complicated medical language.

Asad Choudhry, M.B.B.S.

Asad Choudhry, M.B.B.S. (@choasad), was a trauma research fellow at Mayo Clinic, when he started thinking about this.

While collecting data for another research study, he noticed that many patients tended to call back for the same few reasons. These reasons largely included clarification of written instructions provided to patients in their discharge summaries.

“After discharge, different patients tended to ask the same questions repeatedly related to instructions given; time and time again,” he says.

Dr. Choudhry and his mentor Martin Zielinski, M.D. (@ZielinskiTrauma), put together a research team to examine this.

Initial findings

Their initial study looked at the readability of discharge instructions, to see what grade level the Trauma Center used when writing the instructions. They were quick to note that it was much higher than recommendations from the National Institutes of Health and American Medical Association. (Both groups recommend a 6th grade reading level). In fact, they found the current instructions were written at around a 10th grade level.

After reviewing the records of nearly 500 patients, they found 27 percent received instructions that were difficult to read. They also found that 65 percent of the patients had reading skills below the level of their discharge summary.

Example Readability Edit

You had an Inferior Vena Cava (IVC) filter placed during this hospitalization: this was done for the prevention of respiratory sequelae of thromboembolic disease which commonly occurs after extremity trauma. (Grade 20.4)

You had an Inferior Vena Cava (IVC) filter placed during this hospitalization.

This was done to prevent the formation of clots in the blood vessels of your lungs. This is common after an injury to your extremities. (Grade 8.3)

Forty patients were readmitted within 30 days, and of those, 65 percent had reading skills below the level of their original discharge instructions.

“At the time there were some guidelines on the appropriate reading level of discharge information,” says Dr. Choudhry. “However, there was little information about the effect of improved readability on patient return phone calls as well as readmissions.”

The research then became a two-part effort. First, to understand the level of information patients received upon discharge, compared to national guidelines. Second, analyzing the effect on patient care outcomes after receiving more readable discharge instructions.

“It was an area lacking in quality data,” says Dr. Zielinski, “and there were outstanding opportunities to improve patient care and understanding.”

Following the trail

The team recently published their findings from the second part of this research.

In this project, the Trauma Center revised the way they wrote discharge instructions. They rewrote the information to a reading level of grade 6. Then they compared 1,072 patients, 493 who had received the old instructions, and 579 who received the new ones.

The researchers found that this change transformed outcomes for patients. Not only were there many less phone calls from patients asking for clearer instructions, but there were less readmissions.

They also found that by improving readability of instructions for pain medication, they reduced questions related to pain.

“Health care systems are trying to find ways to reduce opioid misuse,” says Dr. Choudhry. “By enhancing the readability of pain management and medication instructions, patients are better able to understand how to control their pain. This leads to fewer questions or confusion around pain and potentially better pain control.”

Dr. Choudhry has since moved on from Mayo Clinic, and is in his third year of general surgical training at the State University of New York Upstate Medical School, Syracuse, New York.

Martin Zielinski, M.D.

Meanwhile, Dr. Zielinski and the team are continuing this research. They revised all templates for discharge instructions in the Division of Trauma, Critical Care and General Surgery to reach a less than 8th grade reading level.

“Our current trauma research fellow, Dr. Joy Hughes, is leading a study on the effects that learning disabilities have on understanding discharge instructions,” says Dr. Zielinski. “We are developing methods to enhance patient understanding such as 3-D models on the patient’s specific wound and how best to care for it at home, as well as videos teaching these methods.”

The team is pleased with results so far, he says. “We can indeed enhance patient understanding, and this leads to positive outcomes for both the patients and the providers.”


This research is in collaboration with the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

“The Kern Center provides outstanding resources with knowledgeable people who are on the cutting edge of the science of health care delivery,” says Dr. Zielinski. “Dr. Habermann and her team are invaluable contributors without whom we could not have been successful on ensuring our patients receive the best care possible.”

Elizabeth Habermann, Ph.D. (@EBHabermann), is the Robert D. and Patricia E. Kern Scientific Director for Surgical Outcomes. Surgical Outcomes is one of several focus areas in the Kern Center for the Science of Health Care Delivery.  Center members collaborate to discover new ways to improve health; translate those discoveries into evidence-based, actionable treatments, processes and procedures; and apply this new knowledge to improve care for patients everywhere.

Editor's Note: This post has a Flesch-Kincaid grade level of 10.5, as measured in Microsoft Word.

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Tags: Asad Choudhry, care transitions, Center for the Science of Health Care Delivery, Findings, Martin Zielinski, News, surgical outcomes

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