The discharge instructions were clear, at least to the team who wrote them. Take the new medication with food, watch for swelling, call the office if symptoms worsen, follow up in two weeks. The patient nodded through the explanation and left. Three days later, he was back in the emergency department with the same symptoms he was discharged with.
When Dr. Arun Veera reviewed the case, the clinical care had been appropriate. The medications were correct. The follow-up plan was reasonable. What hadn’t been confirmed was whether the patient could read the discharge summary, understood the word “swelling” in the context of a medication side effect, or knew what counted as “worsening.”
We give patients a plan and assume they can execute it. Execution depends on literacy. Literacy is rarely assessed.
Veera, a board-certified family medicine physician with 14 years of clinical experience, points to the National Assessment of Adult Literacy, the most recent federal study of its kind, which estimated that roughly 36% of U.S. adults have basic or below-basic health literacy. That threshold means they struggle with tasks like reading a medication label, interpreting a screening result, or following a dosing schedule. Among older adults and those with limited formal education, the figure is higher.
“That’s more than a third of the adult population,” Veera says. “It’s not a niche issue. It’s a central clinical variable we haven’t built into how we deliver care.”
The Invisible Mismatch
Health literacy is hard to see in a clinical encounter because patients rarely disclose it. Adults who struggle with medical information often hide it well, using strategies developed over years: nodding, repeating back the last phrase they heard, deferring detailed questions, taking the paperwork home.
“Most patients don’t say they didn’t understand,” Veera notes. “They say they understand, take the paperwork, and figure it out later. Or they don’t figure it out, and we only find out when something goes wrong.”
This creates a systematic blind spot. The physician leaves the encounter believing the plan was communicated. The patient leaves believing they’ve been given instructions they’ll find a way to follow. Both are operating on incomplete information.
The clinical impact is measurable. Patients with limited health literacy have worse outcomes across nearly every condition studied, including diabetes, heart failure, and asthma. They’re more likely to be readmitted, more likely to visit the emergency department, and less likely to use preventive services. The gap persists after controlling for income, insurance, and severity of illness.
Beyond Reading Level
Veera emphasizes that health literacy isn’t just about reading. It’s about the whole set of skills required to navigate the healthcare system: finding a specialist, understanding an insurance statement, filling out an intake form, interpreting a lab result on a patient portal, making sense of conflicting information from different sources.
We ask patients to be system navigators. We give them a complex system, minimal orientation, and then grade their outcomes as if the navigation was easy.
This broader framing matters because it changes what the solution looks like. Rewriting a discharge summary in plain language helps, but it doesn’t help a patient who can’t get to the pharmacy, can’t afford the copay, or can’t reach the office when the symptoms worsen on a Saturday.
“Literacy interventions often focus on the information,” Veera says. “The harder work is making the system navigable for people who don’t already know how it works.”
Teach-Back and Its Limits
The standard clinical response to health literacy concerns is the teach-back method: the physician asks the patient to explain the plan in their own words. Studies have shown it improves recall and adherence, and Veera uses it routinely.
“Teach-back is a good tool,” he says. “It’s also the minimum. It catches whether the message landed. It doesn’t address the structural barriers that make the plan hard to execute even when the message was clear.”
He describes patients who can teach back the plan perfectly but still can’t follow it: the medication costs too much, the pharmacy hours don’t align with the work schedule, the follow-up appointment is six weeks out because the clinic is short-staffed. Literacy was intact. The plan still failed.
Literacy is necessary. It isn’t sufficient. The environment around the patient has to match the literacy we’re assuming.
Measuring Before Assuming
Veera argues for treating health literacy as a vital sign: something measured, documented, and used to tailor care. Validated brief screeners exist, and some health systems have started embedding them in intake workflows. Few have made the results meaningfully change what the clinician does.
“The measurement has to change the care plan,” he says. “Otherwise it’s just another data point in the chart.”
In practice, that means shorter word lists, visual schedules instead of text lists for medication timing, consolidated appointment scheduling so the patient doesn’t have to coordinate three offices, and follow-up phone calls instead of patient portal messages for those who don’t use portals.
These aren’t exotic interventions. They’re routine care delivered differently for patients whose literacy and system-navigation capacity the clinic has bothered to assess.
A System Responsibility
For Veera, health literacy isn’t a patient attribute. It’s a system responsibility.
“Every plan we build assumes a level of literacy that more than a third of our patients don’t have,” he says. “That’s not their failure. It’s ours, and we can fix it if we stop assuming and start measuring.”