Health literacy sits at the center of Choosing Wisely decisions
Equity in healthcare decision-making depends on more than access to appointments, tests, or treatments. It also depends on whether patients can interpret risk, compare options, and speak up when a recommendation does not fit their goals. The BMJ Quality & Safety piece on Choosing Wisely places health literacy squarely in that conversation, linking literacy to the ability to make informed decisions and to the methods clinicians can use to support those conversations more effectively.
The topic matters because “low-value care” is rarely low-value in a simple, universal sense. A test or procedure may be unnecessary for one patient and deeply reassuring to another, but those judgments only become meaningful when patients understand the tradeoffs in front of them. In real practice, health literacy influences whether people grasp the difference between benefit and harm, whether they understand what a recommendation actually means, and whether they feel comfortable asking for clarification when the language turns technical.
One sentence captures the problem plainly: patients cannot weigh choices they cannot decipher.
Choosing Wisely depends on understanding, not just information
The Choosing Wisely framework asks clinicians to avoid unnecessary interventions, but the success of that effort rests on communication. A recommendation to defer a scan, skip an antibiotic, or avoid a lab test can sound persuasive to clinicians and still feel opaque to patients. If the explanation is rushed, jargon-heavy, or framed as a directive rather than a conversation, people with lower health literacy are more likely to leave without a usable understanding of why the recommendation was made.
That dynamic has equity consequences. Health literacy is not distributed evenly across populations, and it often overlaps with social disadvantage, language barriers, age, education, disability, and prior experience with the health system. A decision-making model that assumes every patient processes information at the same speed, with the same vocabulary, and with the same confidence will inevitably advantage some groups over others. In that setting, “shared decision-making” can become shorthand for a conversation that is formally shared but functionally uneven.
Health literacy is not a side issue in stewardship; it is one of the mechanisms that determines who benefits from it.
Conversations fail when risk is abstract and options are framed poorly
The clinical challenge is not only whether patients understand a single fact. It is whether they can compare outcomes, absorb uncertainty, and connect the recommendation to their own values. Many medical discussions rely on abstract language: “low risk,” “watchful waiting,” “false positives,” or “limited benefit.” Those phrases can be efficient for clinicians but hard to process for patients who are already under stress or who do not routinely navigate medical terminology.
Clear communication changes the balance. Plain language, concrete examples, teach-back, visual aids, and deliberately paced explanations can reduce the gap between expert knowledge and patient understanding. Questions framed around goals — symptom relief, function, avoiding harm, preserving time, limiting cost — often make the tradeoffs more visible than a purely technical presentation of evidence. The point is not to oversimplify. It is to translate the evidence into a form that patients can actually use.
Support tools matter because literacy varies at the bedside
Tools that support conversation become especially important when time is short and the stakes are high. Decision aids, interpretation services, structured question prompts, and clinician training in communication all have a role in making medical decisions more equitable. Each tool addresses a different failure point. Decision aids can organize risk and benefit in a patient-facing format. Interpretation services can prevent language from being mistaken for comprehension. Question prompts can help patients enter the conversation with specific concerns instead of silent uncertainty.
The broader lesson is that communication quality should be treated as a clinical variable, not a courtesy. If a patient agrees to avoid a test without understanding why, the decision may appear aligned on paper while remaining fragile in practice. If a patient rejects a recommendation because the rationale was never explained in accessible terms, the health system loses both trust and the chance to align care with evidence. Better communication is therefore not an ornamental add-on to Choosing Wisely; it is part of whether the initiative can work fairly.
Equity requires more than a universal script
A one-size-fits-all conversation will miss the needs of many patients. Some people want detailed statistics; others need a short, direct explanation first and more detail later. Some patients need family members included. Others need extra time, translated materials, or repeated review before they can weigh an option confidently. Health systems that treat these differences as exceptions rather than expected variation are likely to reproduce the same inequities they want to reduce.
Equity in decision-making also requires clinicians to recognize how their own phrasing shapes choices. A recommendation delivered as a dismissal can feel like denial. A recommendation delivered as an explanation can feel like respect. The content may be the same, but the effect is not. That distinction is especially important in settings where patients are deciding whether to proceed with screening, testing, medication, or procedures that carry real burdens as well as possible benefit.
Choosing Wisely, in that sense, is not only about what care to avoid. It is about whether the conversation itself is understandable enough to support an informed decision.
The unresolved challenge is making communication routine
The remaining challenge is operational rather than conceptual: how to embed health literacy support into ordinary clinical workflow without turning every visit into a special project. Training, workflow redesign, and patient-facing tools can help, but they must be used consistently and adapted to different settings. A clinic with limited time, limited staffing, or a multilingual population faces different barriers than a high-resource academic practice.
This BMJ Quality & Safety piece keeps the focus where it belongs: on the practical relationship between health literacy, patient choice, and equity. The question is not whether communication matters. The harder question is whether healthcare systems will treat it as a core requirement of safe, value-based care rather than an optional skill left to individual clinicians.