Sometimes both physicians and patients learn the hard way

“There are three kinds of men. The ones that learn by reading. The few who learn by observation.  The rest of them have to pee on the electric fence for themselves.”
- Will Rogers

Learning is a universal human experience from the moment we take our first breath.  It is never finished until the last breath is given up.  With a lifetime of learning, eventually we should get it right.

But we don’t.  We tend to learn the hard way when it comes to our health.

As physicians we “see one, do one, teach one.”   That kind of approach doesn’t always go so well for the patient.   As patients, we like to eat, drink, and live how we wish,  which also doesn’t always go so well for the patient.  You’d think we’d know better, but as fallible human beings, we sometimes impulsively make decisions about our health without using our heads (is it evidence-based?) or even listening to our hearts (is this what I really must have right at this moment?).

Cows and horses need to touch an electric fence only once when reaching for greener grass on the other side.  That moment provides a sufficient learning curve for them to make an important decision.  They won’t try testing it again no matter how alluring the world appears on the other side.   Human beings should learn as quickly as animals but don’t always.  I know all too well what a shock feels like and I want to avoid repeating that experience.  Even so, in unguarded careless moments of feeling invulnerable (it can’t happen to me!), and yearning to have what I don’t necessarily need,  I may find myself touching a hot fence even though I know better.   I suspect I’m not alone in my surprise when I’m jolted back to reality.

Many great minds have worked out various theories of effective learning, but, great mind or not,  Will Rogers confirms a common sense suspicion: a painful or scary experience can be a powerful teacher and,  as health care providers, we need to know when to use the momentum of this kind of bolt out of the blue.  As clinicians, we call it “a teachable moment.”  It could be a DUI, an abused spouse finally walking out, an unexpected unwanted positive pregnancy test,  or a diagnosis of a sexually transmitted infection in a “monogamous” relationship.  Such moments make up any primary care physician’s clinic day, creating many opportunities for us to teach while the patient is open to absorb what we say.

Patient health education is about how decisions made today affect health and well being now and into the future.  Physicians know how futile many of our prevention education efforts are.  We hand out reams of health ed pamphlets, show endless loops of video messages in our waiting rooms, have attractive web sites and interactivity on social media, send out innumerable invitations to on-site wellness classes.  Yet until that patient is hit over the head and impacted directly– the elevated lab value, the abnormality on an imaging study, the rising blood pressure, the BMI topping 30, a family member facing a life threatening illness– that patient’s “head”  knowledge may not translate to actual motivation to change and do things differently.

Tobacco use is an example of how little impact well documented and unquestioned scientific facts have on behavioral change.   The change is more likely to happen when the patient finds it too uncomfortable to continue to do what they are doing–cigarettes get priced out of reach, no smoking is allowed at work or public places, becoming socially isolated because of being avoided by others due to ashtray breath and smelling like a chimney (i.e. “Grandma stinks so I don’t want her to kiss me any more”).  That’s when the motivation to change potentially overcomes continuation of the behavior.

Health care providers and the systems they work within need to find ways to create incentives to make it “easy” to choose healthier behaviors–increasing insurance premium rebates for maintaining healthy weight or non-smoking status, encouraging free preventive screening that significantly impacts quality and length of life, emphasizing positive change with a flood of encouraging words.

When there is discomfort inflicted by unhealthy lifestyle choices, that misery should not be glossed over by the physician– not avoided, dismissed or forgotten.  It needs emphasis that is gently emphatic yet compassionate– using words that say “I know you can do better and now you know too.  How can I help you turn this around?”

Sometimes both physicians and patients learn the hard way.  We need to come along beside one another to help absorb the shock.

Emily Gibson is a family physician who blogs at Barnstorming.

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  • MMA Acupuncture

    Thanks for the thought provoking article. I think all individuals working in healthcare understand the frustration of trying to promote life changing healthy habits just to see our efforts have minimal effect. Sometimes the best way to promote change is to be the change that you want to see – Gandhi

  • MMA Acupuncture

    Thanks for the thought provoking article. I think all individuals working in healthcare understand the frustration of trying to promote life changing healthy habits just to see our efforts have minimal effect. Sometimes the best way to promote change is to be the change that you want to see – Gandhi

  • portia chalifoux

    You’ve overgeneralized this to include everyone. You also framed this in terms of blame and failure. You’ve placed yourself in the role of judge and jury. And the way I’m framing this probably doesn’t make you feel all warm, fuzzy and ready to change, does it? So let me use a different approach and see what you think:

    You also included the seeds for motivating people to make healthful changes. You wrote about patients’ discomfort and their desires for change. By using those two assumptions and aligning yourself as the patient’s coach and ally, you now have a formidable team by which to set mutually agreeable goals, strategies to achieve them that are within the patient’s culture, mores and accessible resources. Identify the patient’s strengths, and capitalize on those. The patient’s successes are now your successes.

    Instead of difficult conversations, it should now be easier to ask the patient how s/he’s doing, what isn’t working so well or feeling comfortable, and take it from there.

    • Emily Gibson

      Portia, your point is well taken. Clearly you understand motivational interviewing using a strength-based focus to identify areas of positive change. No electric shocks needed in that approach.

      Sometimes patients are holding on to the hot fence and won’t let go, no matter how much it is hurting them to do so (or may be hurting others who try to grab hold to pull the patient away.) One approach is to stand at the side and suggest that continuing to hold on to the fence hurts and how capable they are of letting go on their own and wondering if they are ready yet. If they aren’t ready, then we’ll come back another day and ask again.

      However, there are times when the health care provider must point out the obvious when a patient is in crisis and speak the truth to them, at risk of being considered judgmental. Does that lack compassion? Not if it comes from a caring heart. Most of us in this business care very much.

      With over twenty years working in addiction treatment, I’ve had much opportunity to try the different approaches. What seemed to be the most effective teachable moment for some (by no means all) addicts? When their choices resulted in their lives, their health, their support system falling completely apart. There are no strengths left. They need to be hauled off the fence by a team of helpers and provided a new foundation to rebuild from. The work of rebuilding is theirs to do, but it is not done in isolation. It is admitting one’s own helplessness to do it alone that can be the turning point.

      I guess that is what I liked about the Will Rogers quote. He astutely understands the variability in human nature and behavior.

      • Steven Reznick

        Great article and great response.

  • Mitchell

    Another area of influence to consider is how to leverage large populations where healthcare financing is a shared burden. The work place community is quickly adopting an outcomes-based incentive approach where the achievement of reasonable lifestyle-controlled health factors has a direct economic correlation to the employees’ out of pocket expense. If you demonstrate improvement in certain modifiable risk factors or outright achieve pre-determined goals, your portion of healthcare funding will be less than the obese smoker with high blood pressure and troubling cholesterol levels who knows his risks and shows no improvement year over year. To some degree, we are all “coin operated”. A personal event could be a dire prognosis, a friend’s unexpected heart attack or the prospect of paying thousands of dollars more a year in premium contributions because you are unable to walk twenty minutes a day and keep your mouth shout more often. Motivational Interviewing, Active Listening and other proven behavioral health strategies are important learning tools for those that want to help themselves. For the balance of the recalcitrants, the teachable moment occurs when they understand that lack of personal accountability has a high personal cost.

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