Improving Your Practice: The Patient Education Trap

Shavaughn Carter is a 43 year old single parent who is obese and was diagnosed with diabetes approximately ten years earlier. She was recently contacted by Melissa Benson, a nurse health coach, with her health plan's Living Well with Diabetes program. After getting acquainted and collecting some initial information, Melissa asks Shavaughn if she knows what she needs to do to manage her diabetes. Shavaughn replies "Well, after ten years I guess I must be an expert by now." So Melissa asks Shavaughn to describe how she manages her diabetes every day. Shavaughn rolls her eyes and thinks to herself "Well, here we go again." At the end of the phone call, Shavaughn agrees to start checking her blood sugar daily again, and they schedule a follow-up call in two weeks to assess progress. Melissa is pleased with the progress that they have made and Shavaughn seems receptive. Following the call, Melissa sends Shavaughn the "Living Well with Diabetes" guide. Two weeks later, Melissa calls at the scheduled time, but Shavaughn is not available. Melissa leaves a message, and makes two more unsuccessful attempts to contact Shavaughn later that week. Melissa wonders to herself "Why is it that so many members respond well to the first call, but avoid the second call, or later drop out of the program?"

Does this scenario sound familiar? Most of the patients who are at-risk of, or affected by one or more chronic diseases, have been previously counseled about how to care for their disease(s), or have been given lifestyle advice by health care professionals, relatives or friends. Patient education or advice can lead patients to passively agree, ignore, protest, or, when we’re lucky, take the advice. Think about a recent time when someone in your life offered you advice. What was your response? When the advice was unsolicited, you probably felt a little resistance. When you sought out the advice, you probably were more receptive. And how you responded probably had something to do with your relationship with the person giving you the advice. Did you feel that the person offering the advice really understood you or your situation? Did you trust them to give good advice? Clearly, many factors influence how advice or information is received and what people do with the information. It’s a fact that poorly timed or poorly delivered information or advice can actually reduce the chances of patient engagement or decrease motivation for change.

It is very easy to fall into the patient education trap. In our professional education programs, many of us were taught that patient education was the key to engaging and supporting patient self-care. However, patient education approaches have their roots in the paternal (active professional-passive patient) model of medical care—which is definitely not the mode we want to be working in with people who are at-risk of, or affected by, chronic diseases. Patient education is grounded in the old academic model of passive learning that assumes more knowledge translates to behavior change. It also assumes that people are rational and will make the right decisions once they understand "what's good for them." And when patients don't follow the plan, they are labeled "noncompliant" or "resistant." However, research from the field of health psychology suggests that "patient resistance" is less a patient problem, and more a patient-provider relationship problem. And engaging and activating patients requires a new generation of evidence-based, patient-centered motivational enhancement and coaching approaches. Self-management support strategies such as motivational interviewing have consistently outperformed traditional advice-giving and patient education in numerous sudies.1 While patient education-driven approaches might have worked for acute health care problems, today we know that they are less effective for people with chronic conditions.2 While many people with chronic diseases such as diabetes do not have accurate information about their disease, the traditional patient education approach is simply not sufficient. It is just one component of self-management support and health coaching. So, what is self-management support and how does it differ from patient education?

Self-management or self-care support entails helping patients solve the care problems that are important to them, dealing with the impacts of their disease(s) on their daily lives and goals, and helping them improve their confidence in their ability to manage their health. Self-management support “puts the patient in patient-centered care.” Most patients are simply not interested in managing their "disease," and in fact may deny the diagnosis because they feel distressed by the stigma of having a serious health problem or fear the consequences of the disease(s). What patients first need help managing is not their disease, but the current or potential impacts of the disease on their daily lives and their hopes and dreams. By helping patients manage the impacts of their disease(s), we help them manage their disease(s). This is the heart of self-care or self-management support.

Patients make a health-related behavior change when it’s a priority for them, when it’s important to them, and when they feel confident in their ability to make the change. Many patients with poorly managed chronic diseases do not feel successful in their lives, feel hopeless about the prospect of changing after previous failed attempts, or struggle with longstanding feelings of demoralization or shame. A call from a health coach—or an offer of support from a primary care provider—can be a lifeline, or it can be just another reminder to the patient that they are failing in some important aspect of their lives. They may simply be afraid. Sometimes it's just easier for a patient not to have the conversation because it's too uncomfortable. We cannot fix these things, but we can help our patients succeed in achieving relevant and specific health-related goals.

Numerous studies have demonstrated that patient self-efficacy is a particularly powerful factor in determining patient health and disease self-management. Self-efficacy refers to a person's belief that they are capable of taking action or attaining important life goals. Self-efficacy is not simply another buzzword, but a critical factor in health-related behavior change. In fact, a recent study in the Journal of Health Psychology found that self-efficacy is an important marker of cardiac function and a strong predictor of hospitalization and mortality among heart failure patients.3 By incorporating self-efficacy-based approaches into our practice, we can minimize patient resistance, improve self-care, and reduce avoidable disease-related complications and costs. These approaches can also reduce the frustration and discouragement that committed and caring providers feel, when despite our excellent advice and best efforts, patients persist in making choices that jeopardize their health and well-being.

Here are five effective strategies that health care professionals can use to support patient engagement, disease self-care and healthy behaviors?

1. Demonstrate your value early in the relationship. Whether you're a nurse, physician, pharmacist or behavioral health professional, you should look for an opportunity to provide some advice or education early in the relationship. This will help you establish your credibility, which is obviously a key first step in building a professional relationship. However, any advice or patient education attempt must be patient-centered, properly timed, and effectively delivered. Most patients appreciate advice—when it is relevant to their needs and when it is invited. Be careful of moving too quickly into the patient education mode. Listen to the patient, find advice that is relevant, and ask for permission before delivering, For example "I have heard you complaining about the side effects of your ACE inhibitor medication. Would you like some information about other medications you can ask your doctor about that may be less likely to cause coughing?" This approach keeps the focus on the person first and the disease second. Asking permission before giving advice may seem like a formality, but it helps inoculate against patient resistance and it keeps the focus of care on the patient.

2. Listen more and talk less. Effective health coaches do more listening and less talking—particularly early in the relationship. They ask open ended questions, and affirm what the patient is experiencing, thinking or feeling, and also summarize periodically to check understanding and empathy. Effective health coaches are very strategic in their questions and responses, and know how to speed up the conversation or slow it down to keep things on track. Effective asking and listening are much more complicated skills than educating or informing. Listen to your colleagues when they're working with patients; you'll find that the best health coaches aren't the ones doing all the talking, or the ones asking aimless questions and passively listening. Instead they're very strategic in their questions and responses. Fortunately, these communication and coaching skills can be developed.

3. Find the "hook." What's important to the patient? What gets them out of bed in the morning? Do they live for their job? Is being a good parent their priority? Do they enjoy travel? Spending time with friends? Find the "hook" and use it to focus your work. Health coaching is all about helping the patient achieve what's important to them. Often in health care we take the opposite approach, encouraging the patient to take better care of their health and selling them on all the benefits they will experience in their life if they do. However, by first finding the hook, we can increase engagement and build an effective health coaching relationship. Our goal is to help patients be successful in their own lives by taking control on their health. Good health may be our goal, but it may simply be a means to another important life goal for the patients we work with.

4. Stop selling change. All of us want to help patients when they're not managing their health. For example, we know how important it is for a patient with diabetes to manage their blood sugar, eat right or engage in regular physical activity. It can be painful or frustrating to see someone making decisions that you know will have negative future consequences. And if the patient does not accept our advice about health-related behaviors, our first inclination may be to give them more reasons for change. When we sense resistance to change, it's often tempting to start telling patients how much better they will feel when they take their medications, or walk regularly. However, this can easily lead into a cycle of resistance. Resistance can be either active (easy to spot) or passive (tough to spot). Researchers in social psychology have found that people are more likely to follow-through when they voice their own reasons for taking some action. Giving patients reasons for change is not as effective as patients coming up with their own reasons for change. Avoid selling change and instead help your patients make the own arguments for change.

5. Focus on "quick wins." If you've been asking some good open-ended questions, affirming and summarizing, and demonstrating empathy, sooner or later you will hear some "change talk." For weight loss, it may be a simple statement such as "I know I should get some of this weight off," or "I know my eating habits send the wrong message to my kids," or "I'm not happy with the way I look." This is a critical time in your work with a patient. When you hear change talk, ask for permission to make that problem or goal a focus. For example, "Do you think that's something you want to work on?" If the patient agrees, ask them to suggest some small action that they can take to help them reach their goal. Is it walking for 15 minutes three times a week? Taking some vegetables to snack on at work rather than buying snacks from the vending machine? Help the patient identify some positive action, no matter how small. Setting and achieving small goals builds self-efficacy and sets the stage for more change. Many people who try to change try to do too much, too soon, which can reinforce poor self-efficacy. You can help break this cycle by keeping the focus on small, specific and achievable goals. For a person who wants to lose weight, eliminating one soda a day can result in a 15 to 20 pound weight loss in one year!

Incorporating these simple steps into your health coaching encounters can help you be a better change facilitator and make your work more enjoyable and fulfilling. While patient education is a critical component of health coaching, it must be delivered in the context of evidence-based communications and motivational enhancement strategies. When you feel that you're trying too hard, or that you're doing all the work, you may be evoking patient resistance. Pushing too hard for change can be frustrating and it rarely works. When you encounter resistance, the best strategy is usually to slow down or stop what you're doing. Bring the focus back to the patient and their goals using open-ended questions that help confirm that you are targeting the goals that are most important to the patient.

Rubak, S, et al. Motivational interviewing: a systematic review and meta-analysis. Br J Med. 2005;55: 305-312.

2Bodenheimer, T., et al. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469-2475.

3 Saker, U, et al. Self-Efficacy as a marker of cardiac function and predictor of heart failure hospitalization and mortality in patients with stable coronary artery disease: findings from the heart and soul study, Health Psychology. 2009;28:166-173.

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