Saturday, April 16, 2011

A Stark Reminder of My Own Privilege: "Many Americans have poor health literacy"

From the Washington Post:
An elderly woman sent home from the hospital develops a life-threatening infection because she doesn't understand the warning signs listed in the discharge instructions. A man flummoxed by an intake form in a doctor's office reflexively writes "no" to every question because he doesn't understand what is being asked. A young mother pours a drug that is supposed to be taken by mouth into her baby's ear, perforating the eardrum. And a man in his 70s preparing for his first colonoscopy uses a suppository as directed, but without first removing it from the foil packet. 
Each of these examples provided by health-care workers or patient advocates illustrates one of the most pervasive and under-recognized problems in medicine: Americans' alarmingly low levels of health literacy - the ability to obtain, understand and use health information. 
A 2006 study by the U.S. Department of Education found that 36 percent of adults have only basic or below-basic skills for dealing with health material. This means that 90 million Americans can understand discharge instructions written only at a fifth-grade level or lower. About 52 percent had intermediate skills: They could figure out what time a medication should be taken if the label says "take two hours after eating," while the remaining 12 percent were deemed proficient because they could search a complex document and find the information necessary to define a medical term.
For some reason, this rather depressing article reminded me how amazingly privileged I am - that I have been able to go to a great college, to live abroad for several years doing work I loved, to get a graduate degree at Harvard, and to have my current job.

Though I am always aware of the extent to which I have been blessed, I often subconsciously assume (though my conscious self knows better) that everyone more or less knows what I know and can understand what I understand - the cognitive bias behind this is known as the Dunning-Kruger effect:
The Dunning–Kruger effect is a cognitive bias in which unskilled people make poor decisions and reach erroneous conclusions, but their incompetence denies them the metacognitive ability to appreciate their mistakes.[1] The unskilled therefore suffer from illusory superiority, rating their ability as above average, much higher than it actually is, while the highly skilled underrate their own abilities, suffering from illusory inferiority. This leads to the situation in which less competent people rate their own ability higher than more competent people. It also explains why actual competence may weaken self-confidence. Competent individuals falsely assume that others have an equivalent understanding. "Thus, the miscalibration of the incompetent stems from an error about the self, whereas the miscalibration of the highly competent stems from an error about others."[2]
Most people who know me probably wouldn't say that I suffer from a sense of "illusory inferiority," but I do often subconsciously assume that others understand everything that I understand. Sometimes, it's shocking to be reminded that this isn't so - and this WaPo article did that for me.

As a government employee who deals with huge amounts of money and dabbles daily in the lives of millions of people, I mostly avoid the Dunning-Kruger effect by letting data drive my decision-making.

Largely because of the Dunning-Kruger effect (coupled with the status quo bias), I am a huge proponent of what Thaler and Sunstein call "paternalistic libertarianism" in their excellent book Nudge: Improving Decisions About Health, Wealth, and Happiness (a must read for anyone who ever has to make any decisions that affect the lives of others).

They point out that a lot of people A) make bad decisions and B) will stick with whatever the default is, no matter what the default is. Therefore, wise public policy should 1) always set a default and 2) should always set the default that leads to the best long-term outcome for most people (these are the "paternalistic" aspects of their approach), while 3) leaving plenty of room for people to change the default to what they think is best, if they want to change it - even if this leads to a worse outcome for them than the default would (this is the "libertarian" part of their approach).

Given how bad people's choices about diet, health, and other matters are, public policy, especially in the area of health, could definitely use more nudging.

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