Recently, one of our medical students asked me a question about health literacy, and the importance of that concept for surgical patients. This rather broad and innocent question led to an interesting discussion of the importance of education for surgical patients. According to Baker1, health literacy relates to a patient's ability to obtain, understand, and comprehend information regarding their health, medical conditions, treatments, and long-term care. This is obviously critical for patient engagement in shared decision making; as Nutbeam and Lloyd note2, health care literacy really should be considered a social determinant of health. How Literate Are Our Patients?

Vernon et al3 reported a surprisingly low rate of health literacy–36% of the adult population of the United States have basic or below basic health literacy levels. Surprisingly, health literacy does not necessarily correlate with educational level or communication skills. As a late mentor of mine quipped, “When a Nobel laureate is a patient, their IQ plummets.” Presumably this is a result of anxiety, a threat to sense of self, and loss of control. If this ubiquitous anxiety is present in the setting of insufficient health literacy, patients will be unable to navigate the health care system.4 Aside from medical considerations, health care literacy also directly impacts the cost of care. Most patients presenting to any office with spinal issues do not have a neurologic deficit, deformity, fracture, tumor, or instability–in short, they do not have “surgical pathology.” Clearly for patients to participate effectively in two of the most common initial nonoperative interventions, physical therapy, and use of non-steroidal anti-inflammatory drug (NSAID) therapy, a modicum of comprehension and engagement is required. In a study of patients with lumbar spondylosis, poor health literacy correlated with under-utilization of NSAIDs, further impacting treatment efficacy.5 Such gaps in treatment have been associated with poorer medical outcomes, specifically in spine patients. Lans et al found patient health care literacy correlated inversely with baseline patient reported outcome scores.4 How can health care literacy be assessed, and what steps can clinicians take to improve health care literacy? The first goal is to identify the patient with basic or below basic understanding. Some of the studies to assess patients are the Test of Functional Health Literacy in Adults (TOFHLA), Literacy in Musculoskeletal Problems, the Newest Vital Sign (NVS) and the Rapid Estimate of Adult Literacy in Medicine. Each test is somewhat unique. The TOFHLA, for example, along with the NVS, evaluate comprehension and quantitative skills. The Rapid Estimate of Adult Literacy in Medicine is currently the only test that evaluates communication. Additionally, the TOFHLA and NVS are also available in Spanish.7,8 Ideally, the synthesis of the strengths and weaknesses of various tools, not necessarily limited to these three, and formation of a so-called “short form” would be helpful. The practitioner must realize that unless the patient is specifically asked whether or not they have questions, regardless of any additional materials (eg, handouts, posters), no meaningful educational dialogue is likely to occur. In one study, only 29% of physicians asked patients whether or not they had questions about their treatment plan.9 Finally, asking the patient to explain the risks and benefits as well as the nature of the treatment plan has been shown to be beneficial not only in facilitating health literacy but in establishing trust and two-way communication. Patients given the opportunity to ask questions establish a dialogue, and those who received a structured end of visit or post-discharge instruction package were significantly more likely to increase their health literacy scores compared to those did not. While this will require extra time and engagement on the part of the practitioner, it will pay dividends in many domains. At this point, health literacy is something we cannot ignore. As we move into our second all-digital issue, I continue to remain excited about SpineLine. In this issue’s From the Desk of the President, Zo Ghogawala, recounting his participation in a recent symposium, addresses some interesting points on scope of practice. This is something that I considered in a SpineLine10, suggesting perhaps that although NASS is not a credentialing body, consideration should be given to appropriate training granting clinical privileges. Dr. Ghogawala takes this to the next level and makes a compelling case that this should be part of our mission, specifically discussing endoscopic minimally invasive spine surgery. Hopefully this will provoke a dialogue and stimulate correspondence. In the Invited Review, Patel et al provide an excellent survey of primary spine tumors. In the Literature Review, Rancu and Grauer summarize the current state of robotic assisted surgery and spine trauma, particularly timely in view of the message from the President. In the Section Spotlight, from the Section of Intraoperative Neuromonitoring (IONM), Vogel and Fader discuss a critically important Advisory Opinion from the Office of the Inspector General cautioning against “surgeon deals.” This raises significant ethical issues, and is a must read. In Coding, Kalia et al review appropriate coding for SI joint arthrodesis and in Ethics, the Committee on Ethics and Professionalism, who will, henceforth, be submitting a monthly poll, ask an interesting ethics question: What is the appropriate response to a patient who has left negative feedback about their practitioner? In the News Section, not only is there a recap of Spine Summit, but another notice of Spine Across the Sea as well as a preview the upcoming annual meeting for 2024 in Chicago. Again, in keeping with the minimally invasive spine surgery (MISS) theme, the Case of the Month is MISS transforaminal lumbar interbody fusion. Finally, the 20 Under 40 program continues to grow. Dozens of candidates applied for this year’s honor, and the quality just keeps increasing. Enjoy this first issue of spring.