Teaching vs. Preaching: A Critical Look at Patient Education

By Shelley Simon, RN, DC, MPH, EdD

In an attempt to increase compliance and retention, many chiropractors engage in what they believe to be patient education only to become frustrated by their results. On close examination, some doctors' educational activities actually turn out to be a subtle form of indoctrination to get patients to do as they are told.

Understanding the critical difference between teaching (educating) and preaching (indoctrinating) requires a fresh perspective and new strategies. Is it time to reassess your approach to patient education? How often do you find yourself thinking or even saying, any of the following?

• I'm just trying to get this patient to understand why the course of treatment I'm suggesting would be good for them. Why don't they get it?
• If only patients could understand what I understand, they would realize that what I'm recommending is what they need.
• Why is it so hard for some patients to grasp the importance of following through with the full course of adjustments as I've advised?
• Just because this patient won't acknowledge they have a problem, that doesn't mean the problem doesn't exist. I've got to find a way to get them to see the value of care.

If these statements sound familiar, you may be unconsciously preaching instead of teaching, or engaging in indoctrination instead of education. All of the examples above share a sweeping assumption: that you know what an individual patient needs better than they know what they need. Now, you may be thinking, "But I do know what they need, I'm the doctor!" Perhaps, but that stance will drive away the very patients you spend a great deal of time and effort to attract.

Indoctrination vs. Education

Research demonstrates that a practitioner's interpersonal style is as important as clinical skills when it comes to determining patient outcomes. Patient receptivity or resistance is substantially influenced by a practitioner's communication style. When you counsel or educate in a directive, confrontational manner (indoctrinating), patient resistance goes up. Conversely, reflective and supportive counseling (educating) results in less resistance, increased patient satisfaction and more positive outcomes.

Let's look briefly at the difference between indoctrination and education. To indoctrinate is to coerce, impose your values and try to convince or teach someone to think the way you think - often in an effort to achieve your own objectives. Indoctrination says, "Think like me, be like me and trust me because I know what's best for you." Indoctrination tends to be one-sided and employs the use of selective data, misleading statistics, metaphors and analogies stretched beyond reason. Perhaps worst of all, indoctrination may be used to elicit fear on the part of the individual being indoctrinated. For the parent attempting to get a 3-year-old to eat their vegetables, this kind of indoctrination (hopefully minus the fear tactic) may be necessary. Not so with adult patients who have their own views, attitudes and opinions about health care. Practitioners who lean toward indoctrination often are, perhaps unconsciously, putting their own goals ahead of the patient's needs or readiness to take action toward better health.

Education, on the other hand, involves presenting meaningful data in a balanced manner. Statements can be supported with facts and references when needed. Information and alternatives are presented from as many perspectives as necessary to support the patient. Education appeals both to a person's reasoning ability and their emotional readiness to learn. It speaks to the learner's individual needs and concerns, not the needs of the person doing the teaching. The language of education promotes dialogue, exploration and awareness. Explaining the complex nutritional qualities of green beans to a toddler probably won't result in an empty plate and a full stomach. But relevant facts presented in an unbiased manner - and combined with good questions and careful listening - are very effective when dealing with adult patients trying to make informed decisions about their health.

An important point to keep in mind when offering patient education is that it must be based on the desires, goals and readiness of the patient. Education can be perceived as manipulative when your underlying agenda is to convert the patient to a certain way of thinking or toward a particular action you want them to take despite their concerns about cost, need or outcome.

Adults learn only what they are interested and ready to learn. Educating instead of indoctrinating requires self-awareness and skill, particularly if you've been subjected to many years of indoctrination yourself.

Here are three examples to further illuminate the difference between education and indoctrination.

The New Patient: John is in your office on the advice of his co-worker (who has been a patient in your practice for a long time) for immediate treatment of sudden onset low back pain. This is a recurrent problem for John. Both chiropractors and other health practitioners have told him over the years that he could avoid repeatedly "throwing his back out," if he would commit to daily back exercises and/or get routine preventive adjustments.

He says he doesn't have time to do the exercises and, while he doesn't come right out and say it, you sense that John thinks the doctors who recommend regular adjustments just want to keep him coming to their offices again and again. He's skeptical that a wellness approach would do him any good and feels he can't afford it. Which of these two statements would be most helpful to John at this point in your relationship with him?

(a) Today's treatment will give you temporary relief, but unless you want to live like this for the rest of your life, I recommend that you commit to the yearlong health maintenance plan we offer. Stop at the front desk on your way out and Beth will sign you up.

(b) It sounds like you have some concerns about recommendations you've received from other health care practitioners. How will your previous experiences impact your relationship with our office? What kind of information do you like to have when you're making decisions about your health?

The New Staff Member: You're delighted to have Suzanne working in your front office. She has years of experience dealing with patients and insurance companies, all of it in MDs' offices and hospitals. She understands that your office is different, but she's not completely sure how. Suzanne worries that patient recall is intrusive to patients and she is a bit skeptical about the kind of care you provide. Which of these two statements would most likely help Suzanne begin to understand the benefits of your service and become a valuable employee?

(a) We do things differently here and I really need for you to be on board. It's part of all our jobs to keep patients on track. If we neglect recall, they won't come in because they don't always understand what is in their best interest.

(b) I've found that a good way to familiarize new employees with the benefits of our services is to have them experience care firsthand. By receiving care, you can get a sense of why our office procedures are important in supporting patients' goals. Is this something you'd be interested in?

Your Mother-in-Law: Rose has always had a bias toward allopathic medicine. Indeed, both her second and third husbands were surgeons. While you're not trying to win Rose over as a patient, you'd like it if she'd stop making snide remarks about your profession to friends and family members, and most especially to you. Which of the following two statements would be more effective with Rose?

(a) You are obviously biased and don't understand what I do. Are you aware that one of the leading causes of death in the U.S. is related to medical error?

(b) I notice that you have strong opinions about health care, and I'm not going to try to change your way of thinking. But I bet you'd be surprised to know that

I have collaborative relationships with a number of MDs, many of whom had their own biases before we began sharing patients.

Making the Shift

Can you learn to more effectively encourage patients to pursue better health? Is it possible to communicate in a way that supports patients in following through with the treatment and/or lifestyle changes you recommend? Yes and yes. Having read this far, you understand the difference between indoctrination and patient-focused education. If you want to shift your attention to the latter, here are eight attitudes and behaviors you can begin practicing this week to increase your self-awareness and improve your outcomes.

1. Remember that all patients have one primary question: What's in it for me? Stay focused on their needs and desires and the outcomes that are most important to them. In doing so, you will find yourself naturally spending more time educating patients and less time trying to convince them you know best. Review your printed marketing and educational materials and your Web site to make sure the information goes beyond justifying the profession and methodology of chiropractic. All of your materials should speak directly to the outcomes and benefits patients receive as a result of seeing you for care.
2. When someone expresses interest in the kind of care you provide, engage them from a place of curiosity about their needs. Resist talking about what you do, your process or your philosophy until you have a genuine sense of what the other person is struggling with. Often, asking just one extra question about what's going on with someone can help you better formulate how to move them from being simply interested to becoming a patient.
3. Find out what patients already know or believe. Patients arrive in your office with opinions - about you, about their health and about the health care system. Yet we rarely ask about what they already believe, understand or expect. If we want to encourage patients to become more actively engaged in their care and more accountable for their outcomes, we must adopt an approach of sincere, patient-focused education. In doing so, we invite them to be involved, encourage them to think and support them in making good choices.
4. Slow down. Pause long enough to allow the patient to take in what you are sharing and formulate their own questions. Avoid slipping into monologue mode. It's the rare patient who comes to your office for a lecture.
5. Educate based on what the patient needs at this moment in time. Offer the right information at the right time. Avoid overwhelming a patient with too much too soon, but once someone understands the fundamentals of their health issue and the benefits of the care you are providing, go a little deeper to help them understand the situation beyond just the basics you've already shared.
6. Use simple language without being condescending. Avoid jargon, but tailor information to each patient's level of understanding. When it becomes obvious that a patient wants to communicate at a more sophisticated level, go there. Show respect for patients who have done research and gained knowledge about their condition and treatment options.
7. Acknowledge that there is a place for a wide range of healing modalities. You probably have patients who see you for the majority of their health care, relying on you as their primary care provider. Others may visit your office very selectively and see allopathic medical professionals most of the time. Honor both approaches.
8. Resist the urge to "win over" everyone to your way of thinking about health care. When we face resistance to our ideas, the tendency is to respond with a patterned, ineffective approach in an effort to bring someone around to seeing our point of view. Some of these patterned behaviors include using power, the force of reason, giving more information or evoking fear tactics. If you find yourself in a defensive or argumentative mode about your profession, consider the possibility that your ego has gotten the best of you. Whether you are speaking or writing about your profession, remember that you don't need to defend or justify your right to do what you do.

Focus on Genuine Education

Engaging in thinly veiled indoctrination undoes all the good that our best patient-care efforts seek to achieve. When we try to shift patient beliefs about their health without first finding out what they are and what purpose they serve for that individual, we risk being perceived as inauthentic, self-promotional or disrespectful. By focusing our energy and skill on genuine, patient-centered education and learning opportunities, we build trust with patients and become a partner in helping them achieve long-term health. In doing so, we authentically acknowledge our patients and maximize their potential for transformational learning and healthier lives. By taking another look at your approach to patient education and experimenting with some of the concepts and behaviors outlined in this article, you may improve your outcomes and discover an enhanced sense of ease and satisfaction in your practice.

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