In the “olden” days, doctors gave orders (“Take these medications, start exercising and go on a diet.”), and if patients failed to follow through, they were labelled as “noncompliant”.
That term literally meant that the patient did not bend to the will of the doctor, and since M.D.s are neither gods nor psychic surgeons, that should not be our goal at all.
The term, noncompliant has now been replaced by the somewhat better term nonadherent, which means that the patient did not stick to the plan.
We now recognize that the majority of an individual’s medical care is his or her own responsibility – what is done in the huge expanse of time between medical visits: habits, physical activity, diet and the taking of medication. We use the term, self-management to describe the many ways that a patient provides self-care for general health or chronic conditions such as diabetes, atherosclerosis, heart failure or high blood pressure.
At the heart of this new approach is a renewed respect for patient autonomy or independence. The patient always has a choice to do those activities that best help achieve their goals. But to make informed choices, health care providers, including physicians, have to act in collaboration with individuals, providing relevant information about their medical conditions and support to make positive changes in their lives.
Though doctors may be up to date about the evidence-based management of medical conditions, patients know their lives better and every individual has unique personal goals and their own ways of finding meaning in their lives.
Through B.C.’s Practice Support Program, family physicians have been learning new approaches to support patients in the self-management of their own health – what I call facilitating positive change.
One key is that the choice of goal should be the individual’s. The doctor may ask, “Is there anything you would like to change in your life in the next two weeks – a specific goal you would like to achieve?”
If the patient cannot come up with one out of the blue, the doctor may offer some suggestions based on their personal health status. What may be offered is a menu of choices, perhaps involving eating, physical activity, stress management, smoking cessation, sleep or medication.
One useful tool is the acronym SMART. It reminds the physician of the essential elements of goal setting: specific, measurable, achievable, relevant and timed.
By specific, we mean what exactly does the patient want to do? If the big goal is to become more physically active, what specific activity will the individual begin? When would it be done? How often? Where? With whom? An example could be walking for 15 minutes during lunch breaks with a coworker on Mondays and Fridays around the park close to the office.
In addition to the specifics and measurables, the goal must be achievable or doable for the individual. To jump from doing no exercise to training for the Sun Run may be too great a leap. We will often ask the patient after setting a preliminary goal how confident they are that they can achieve that goal. With a confidence level less than 6 on a scale of 10, we should adjust the goal to something more realistic and achievable. Better to start a little lower and go a little slower than to risk early injury, failure and discouragement.
The goal that an individual agrees to must be relevant – not only to the improvement of their health but to their lives. It must be important to the patient. Every change requires personal motivation.
A patient with early osteoarthritis of the knees may be motivated to exercise to lose weight so that he can continue to work and support his family. Another may want to quit smoking to create a healthier environment for her children.
After helping a patient choose a personal goal, the effective physician coach will discuss the timing of follow-up. When should we check up on how you’re doing with your goal? If a patient has not been successful, we can discuss the obstacles we may not have anticipated, problem-solve and modify the goal. If patients have made positive changes, with growing confidence they can create new goals – walk or run a little longer or more often or make changes in other areas of their life.