Tim Senior is a GP at Tharawal Aboriginal Corporation, Airds, Australia.
Recently I saw Ted and Rachel (obviously not their real names). They were living temporarily in a share house as they had recently been made homeless. Ted is a happy man despite his current circumstances, but has diabetes that is not well controlled. He takes his medication, but the kitchen is shared, frequently messy, and with little fridge access. Ted has got me thinking about the tools we have to encourage behaviour change.
The tool we most frequently fall back on is ‘patient education’, and it’s often just used to mean ‘telling the patient a bunch of facts about their condition’, and sometimes simply means ‘telling the patient what to do’. This, of course, might be really useful where there is a knowledge gap that is preventing the patient from acting, but it can seem that we assume every gap we see is an educational gap.
Maybe this stems from our own training. Our own behaviour was changed through many years of education, having a series of bullet-pointed facts delivered to us by experts in dark lecture theatres and journals and textbooks. What alternatives have we experienced? We were even taught motivational interviewing via bullet points. We’ve never been motivational-interviewed into changing our own professional behaviour as a learning exercise.
“… providing a webinar or handing over a patient information leaflet is easily measured and looks like some work has been done. Changing a system, on the other hand, can be bruising …”
This dedication to seeing every need as an educational gap has all sorts of assumptions behind it. If we think that Ted needs education about the role of healthy eating in diabetes, then we are assuming he has access to the fridge, that the stove works, that food and power are affordable. We may be right about an education gap, but identified the wrong gap, and what he may need is education about how to cook, not what food to eat. We would also be assuming he wants to make these changes.
In other examples, the gap might not be tied up in a lack of knowledge, but in identity and belonging. How responsive someone is to our patient education depends on whether they feel we have understood them and their context. No amount of education will change the mind of someone who has anti-vaccine beliefs, because this is not a problem of knowing things, but a problem of gaining a sense of identity and belonging with a group who share similar beliefs.
Seeing any gap as an educational gap may be contagious too. It’s become a health system response to decide that GPs are ideally placed to do whatever activity the recommender is enthusiastic about, and decide that GPs just lack the special bit of knowledge and skills that would unlock this potential. All that’s required is a series of webinars. Never mind that there may be funding constraints, a lack of capacity, other priorities for the patients we are seeing, or even that the activity doesn’t really need doing at all.
Of course, providing a webinar or handing over a patient information leaflet is easily measured and looks like some work has been done. Changing a system, on the other hand, can be bruising, but I suspect there’s a more common reason than a lack of knowledge for things not being done.
For our patients like Ted and Rachael, as well as for improving our own practice, we need to work out where we have educational gaps and where the system is failing people to try to fill these gaps. Changing a system is difficult, though, so I’m sure there is no shortage of webinars that will teach us how to do it.
