Toward the end of August I begin to dream about fall, how this place will empty of people, the air will get cold and leaves begin to turn. Everything will quiet down, everything will become a skeleton of its summer self. Toward
the end of August I get nostalgic for what’s to come, for that quiet time, time alone, peace and stillness, calm, all those things the summer doesn’t have. The woodshed is already full, the kindling’s in, the last of the garden soon
will be harvested, and then there will be nothing left to do but watch fall play itself out, the earth freeze, winter come. ~David Budbill “Toward the End of August”
As the calendar page flips to September this morning, I feel nostalgic for what is coming.
Summer is filled with so much overwhelming activity due to ~18 hours of daylight accompanying weeks of unending sunny weather resulting in never-enough-sleep. Waking on a summer morning feels so brim full with possibilities: there are places to go, people to see, new things to explore and of course, a garden and orchard always bearing and fruiting out of control.
As early September days usher us toward autumn, we long for the more predictable routine of school days, so ripe with new learning opportunities. This week my teacher friend Bonnie orchestrated an innovative introduction to fifth grade by asking her students, with some parental assistance, to make (from scratch) their own personalized school desks that will go home with them at the end of the year. These students have created their own learning center with their brains and hands, with wood-burned and painted designs, pictures and quotes for daily encouragement.
For those students, their desks will always represent a solid reminder of what has been and what is to come.
So too, I welcome September’s quieting times ushering in a new cool freshness in the air as breezes pluck and toss a few drying leaves from the trees. I will watch the days play themselves out rather than feeling I must direct each moment. I can be a sponge.
“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.