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A 76-year-old man has his first visit with a pharmacotherapy specialist for the management of his anticoagulation. The patient states that he started warfarin last week as instructed by his physician. He is able to explain the reason that he was started on anticoagulation therapy. During the interview, some of the specialist's questions go unanswered or are answered inappropriately. For example, when asked if he has had any bleeding, the patient states that his breathing is fine. Which will most likely be a barrier to the effective education of this patient?