It’s National Kidney Month: Do You Know Where Your Patient Reading Levels Are?

An estimated 51.8% of noninstitutionalized American civilians have at least one of ten selected chronic conditions, including kidney disease/failure, and 27.8% have two or more.1 Chronic diseases require self-management—which must be informed by education patients can understand. What reading level can we assume they may comprehend? Here’s one clue; a 2023 survey2 finds that:
17 states – 34% – have compulsory education laws through age 16; high school sophomore (AL, AZ, DE, FL, GA, HI, IA, ID, MO, MS, MT, NJ, NY, NC, ND, VT, WY)
10 states – 20% – have compulsory education laws through age 17; high school junior (AL, AR, CO, IL, ME, MN, NE, SC, TN, WV)
23 states – 46% – have compulsory education laws through age 18; high school graduation (CA, CT, IN, KS, KY, LA, MD, MI, NH, NM, NV, OH, OK, OR, PA, RI, SD, TX, UT, VA, WA, DC, WI)
So, we can safely assume that most U.S. patients can read at a 10th grade reading level, right? Wrong. First, education experts recommend dialing back 3-5 years from last year of schooling completed to a comfortable reading level. So, someone with a 10th grade education would be comfortable with materials written at a 5th-7th grade reading level. Health literacy is an issue for an estimated 88% of Americans.3 Both the American Medical Association and the National Institutes of Health recommend a 6th grade reading level for all patient education.4 Second, other factors—predominantly fear—interfere with patient ability to read at their normal level.
Medical Trauma and Reading Level

Imagine that you are in your doctor’s office getting a diagnosis that comes as a shock to you—whether or not you expected it. What do you hear? What do you recall? What do you do? Let’s take a brief field trip into the world of medical trauma and its impact on the human brain.
While we may conflate healthcare with healing, “Medical traumas are psychological traumas that result from medical diagnosis and/or medical intervention. Threat of serious injury or threat to life due to illness is now encompassed within the DSM definition of psychological trauma.”5 In severe cases, medical trauma can lead to post-traumatic stress disorder (PTSD), and the author notes that “the sensitivity of a professional’s communication plays a central role in how people experience traumatic medical events and how they cope with the decontextualization and disempowerment of being patients.”3
Trauma and PTSD were linked to dialysis in a 2007 study of 144 in-center HD patients that found HD-related PTSD in 10.4% of participants, and at least one traumatic event in 77.8%.6 Women exhibited more helplessness, fear, and horror than men, and strong associations were found between PTSD symptoms, mental health, and especially anxiety.

The stress response in humans leads to a two-pronged cascade of hormones and physiological changes.7 Briefly, here’s what happens:
The autonomic nervous system (ANS) activates within seconds of trauma. Catecholamines, like noradrenaline, are released to prepare for fight-or-flight.
The hypothalamus-pituitary-adrenal axis activates more slowly and releases corticosteroids, like cortisol.
These hormones interfere with attention, working (short-term) memory, and long-term memory (retrieval).7 In effect, when stress hormones circulate, we humans remember the trauma—and we can fight, flee, or freeze—but we can’t learn. And, the only way past fear is through HOPE.8, 9 THIS is what we need to always remember when we try to educate kidney patients.

A couple of weeks ago, a friend invited my husband and me to take a 4-hour welding class. The instructor spent a couple of hours on safety and a ton of complex welding facts that meant nothing to us beginners. Regardless of education level, I believe we each need a cognitive framework (like a mental file cabinet or a skeleton) to help store and retrieve what we learn about something new.
Patient Education Reading Levels in the Real World
In preparation to submit a journal article on a study, I found 75 papers on tested reading levels of patient education across kidney disease, trauma surgery, cancer, wound care, heart failure, and more. Virtually none found patient education materials written at the 6th grade reading level. When I analyze materials, I find the same thing. Typically there are wild variations from paragraph to paragraph.
Even government materials don’t manage to hit the 6th grade target. Here’s a clip from one I analyzed:
Page 22-¶1: Here are some important facts to remember about how other insurance works with Medicare-covered services: | Here are some key facts about how other health plans work with Medicare: |
---|---|
• The insurance that pays first (primary payer) pays up to the limits of its coverage. • The insurance that pays second (secondary payer) only pays if there are costs the primary payer didn’t cover. • The secondary payer (which may be Medicare) might not pay all of the uncovered costs. • If your group health plan or retiree health coverage is the secondary payer, you’ll likely need to sign up for Part B before your insurance will pay. (Reading level 13.21) |
• A primary health plan pays first. It pays up to its own cost limits. • A secondary health plan pays next. It pays only if a primary payer did not pay all the costs. • Medicare can be a secondary payer. • A secondary payer may not pay ALL of the costs left by a primary payer. • Is your group health or retiree health plan secondary? If so, you may need to sign up for Part B before your health plan will pay. (Reading level 6.04) |
MEI Offer During March, 2025 for National Kidney Month
We are honoring Kidney Month this year by offering to assess your patient education materials—if you are in the first 20 respondents. Email one piece to kmappes@mei.org, and we will review it for use of medical terms, assumed knowledge, content sequencing, and emotional awareness. If the reading level is not 6th grade, we’ll rewrite 1-2 pages so you can see the difference. We can also teach your team how to write at a 6th grade level. Our aim is to offer patients HOPE and help them to improve their own health outcomes.
CDC – Boersma P, Black LI, Ward BW. Prevalence of multiple chronic conditions among US adults, 2018. CDC Research Brief, Sept. 17, 2020, volume 17.↩︎
Justia Education Law Center. Compulsory education laws: 50-state survey. Retrieved on 3/3/2025 from https://www.justia.com/education/compulsory-education-laws-50-state-survey↩︎
National Assessment of Adult Literacy. Health Literacy. Retrieved on 3/4/2025 from https://nces.ed.gov/naal/health.asp↩︎
Eltorai AEM, Ghanian S, Adams, Jr CA, Born CT, Daniels AH. Readability of patient education materials on the American Association for Surgery of Trauma website. Arch Trauma Res. 2014 June;3(2):e18161↩︎
Janssen JS. Medical Trauma. Soc Work Today. Retrieved on 3/3/2025 from https://www.socialworktoday.com/news/enews_0416_1.shtml↩︎
Tagay S, Kribben A, Hohenstein A, Mewes R, Senf W. Posttraumatic stress disorder in hemodialysis patients. Am J Kidney Dis. 2007;50:594-601↩︎
Vogel S, Schwabe L. Learning and memory under stress: implications for the classroom. NPJ Sci Learn. 2016;1:16011↩︎
Schatell D. The importance of hope in kidney disease and dialysis. KidneyViews blog post, 12/22/22. Retrieved on 3/4/2024 from https://homedialysis.org/news-and-research/blog/522-the-importance-of-hope-in-kidney-disease-and-dialysis↩︎
Ravert J. The lifesaving value of hope. KidneyViews blog post, 2/9/23. Retrieved on 3/4/2024 from https://homedialysis.org/news-and-research/blog/528-lifesaving-value-of-hope↩︎
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