Patient education important for patient health

Wanting to learn is one of the most important aspects of self-care.

Issue: September 10, 2011

ByGeorge L. Spaeth, MD

George L. Spaeth

People are healthiest when: 1) they want to care for themselves, 2) they have the facilities to care for themselves, including well-trained, effective health personnel, 3) they can afford the facilities, 4) they know how to care for themselves, and 5) they care for themselves. There are some things that patients cannot do for themselves, such as remove a cataract or excise a tumor from their tongue. However, even such things as cataracts and tumors result at least partially from how people care for themselves. Patients knowing how to care for themselves well is at the heart of good health, for the individual patients and for the society.

Granted, we all need help. Infants survive only with assistance. But from early life on, the major reasons why some people are successful, happy or healthy are that they have good fortune and take good care of themselves. Good fortune is in some ways a type of good self-care. As Thomas Jefferson said, “I am a great believer in luck, and I find the harder I work, the more of it I have.”

Importance of learning

One of the most important aspects of self-care is wanting to learn. Is it not fascinating and frustrating that no person can make any other person learn? All learning results from us being open to the opportunities around us. The word “doctor” means teacher. A doctor then is first and foremost an educator. While there are thousands of volumes written on patient education, very few of them have any impact on patient behavior. But having said that, it is also worth remembering that we all, patients and doctors, need assistance in some form or other. For us to grow, we need coaches and critics to help us learn as much as we can.

Good doctors are good educators. Education literally means to lead forth, to lead out. It does not mean to fill up with information, rather to try to fill up with information. The first prerequisite for learning is wanting to learn. Every living creature of every kind has a built-in drive to want to learn. Good parents, good teachers, good doctors know how to nourish that drive. One of the most important ways to do that is to help the person develop methods of learning: critical thinking, bias analysis, appropriate skepticism, and trusting the importance of thinking clearly. How do physicians, already pressed for time, go about doing that? The answer is that they do it by being role models themselves. The first tip regarding effective patient education, then, is to acknowledge that most of what is done in the name of patient education is a waste of everybody’s time and money. Elaborate brochures and videos, for example, only have a beneficial educational effect on those who already wish to learn. And by and large, those individuals will find ways to learn on their own. However, when doctors, by the way they act, demonstrate that they do not think clearly, are not skeptical and are unaware of their own biases, they miseducate patients.

Things patients need to learn

One of the most important things patients need to learn is how to be good patients. Few patients seem to understand that their job is to be observant, skeptical and precise in reporting their observations about how they feel in accurate, full detail. That is their primary job. It is not to suggest diagnoses or treatments — although the doctor may welcome some suggestions but indicate respectfully that what he or she really needs to know from the patient is what the patient is thinking and feeling. Patients will not provide accurate comprehensive information unless the physician welcomes that type of behavior. The way to teach patients to be good patients in that regard, then, is to encourage them to act in that way:

Ask them to bring in notes summarizing what has happened since the last visit.

Insist that they report their symptoms in detail, great detail, and then really listen to what they are saying.

Insist that they be specific and quantitative, giving specific dates, and discourage use of words such as “little,” “much” or “recently,” which are so nonspecific and nonquantitative that they are of no help.

Ask probing questions.

Welcome being challenged about what you do or suggest.

Encourage patients to get information elsewhere, such as from the Internet, especially if it feels as though their reaction to what you have said is skeptical. Pick up on comments that give you an opportunity to move further. For example, if, in response to the question “How are you?” they answer, “Pretty good,” ask, “Why only pretty good?” And then be prepared for them to answer that.

Speak so that the patient can understand: Do not use abbreviations, jargon or words that are meaningless to the patient. When speaking with colleagues or students in front of patients, do not say OD, OS or NVG or use words that are meaningless to the patient. In actuality, it is best to use abbreviations and jargon only rarely, even when not speaking in front of patients. Always speak in the language the patient can understand, using words the patient can understand.

Do not ask patients if they understand, but rather ask what they understand.

Avoiding false certainty

Patients believe that what you think is important is important. When you make a big fuss about their intraocular pressure, they believe it is important. If you say, “Everything looks fine, and your intraocular pressure is 14,” they will think that they really have a pressure of 14 and that you can measure it that precisely. They will also think they are fine because their pressure is actually 14. Of course, the truth is that the person measuring the pressure does not really know that the pressure is actually 14 and that it is a rare situation (if it ever occurs) in which just knowing the pressure is enough to lead to the comment that “everything is fine.”

If, on the other hand, the physician says something like, “Your pressure today is somewhere around 14 and that is a significant improvement since the last visit, when it was 24,” the patient will learn that there are subjective components to every measurement, even something as apparently simple as intraocular pressure, and that determining whether somebody is “fine” or not cannot be made just on the basis of an approximation of the pressure.

Doctors like to feel in control. Doctors do not like uncertainty. Patients want to believe their doctor is in control and certain as to what to do. But, as Voltaire said, “Doubt is uncomfortable, but certainty is ridiculous.” Patients deserve to know definitively that their doctors do not pretend to know with certainty what they do not know with certainty. Patients are reassured, not worried, when in response to a question such as “Do I have glaucoma?” doctors say, “I don’t know the answer to that question, but I do know what we need to do next.” Patients must be confident that their doctor knows what needs to be done.

Effective education of patients has to be directed toward a particular patient who has particular characteristics at a particular time, so that particular individual can be led forth and can be helped to learn how to learn and how to take care of himself or herself better. Some, like the proverbial mule, need to be hit with a two-by-four in order to get their attention. Some need to be nudged ever so gently. All need to experience the most critical aspect of good education, specifically, a sense of being profoundly respected. They will experience that if indeed they are profoundly respected.

George L. Spaeth, MD, FACS, can be reached at Wills Eye Hospital, 840 Walnut St., Philadelphia, PA, 19107; 215-928-3197; fax: 215-928-0166; email: gspaeth@willseye.org.
Disclosure: No products or companies are mentioned that would require financial disclosure.