“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 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?).
The cows and horses on our farm 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 the rewards of continuing 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 aside one another to help absorb the shock.