An environment that encourages health

Physicians and other health professionals can help their patients to be healthy, but not by giving them health. Our job is to create an environment that allows individuals and societies to be as healthy as they can.

Correspondence to
George L Spaeth, MD
Director, Glaucoma Service
Wills Eye Hospital, Glaucoma Service
840 Walnut Street, Suite 1110
Philadelphia, PA 19107
Telephone : +1-215-8259020
Fax : +1-215-9283194
E-mail : gspaeth@willseye.org

HEALTH professionals do not provide health. No one can give anybody else health. Physicians and other health professionals can help their patients to be healthy, but not by giving them health. Our job is to create an environment that allows individuals and societies to be as healthy as they can. Self-care, both of individuals and societies, is essential for health. For example, putting a broken bone back into proper position, performing a trabeculectomy properly, or treating atrial fibrillation with a systemic beta blocker does not make patients healthy. Unless patients with broken bones keep the fracture immobilized and eat sufficient protein and calcium, the bone will not heal. Patients who do not take their postoperative medication following trabeculectomy are not likely to get optimal results. And patients with atrial fibrillation who continue to lead lifestyles that trigger atrial fibrillation are not likely to be healthy, especially if they do not take their systemic beta blocker. Physicians need to do their part of the job properly: they need to set the fracture correctly, perform the trabeculectomy well, and diagnose a cardiac arrhythmia accurately and give the appropriate medication. But that is only part of the physician’s responsibility. The primary obligation of the physician is to be an advocate for the patient, the particular patient being cared for at that moment. This requires helping the patient understand that self-care is essential, and then giving the patient, as much as possible, the tools to assist in self-care.
Much has been written about “compliance” as a problem in medical care. Unfortunately, the very use of the word “compliance” is an indication of one of the roots of the problem: paternalism. To comply means to do something tha t somebody el se ha s a sked. Physicians frequently use an even more paternalistic word in describing what it is they “ask.” They refer to their written recommendations as “orders.” Orders do not empower. Telling somebody to use a particular medication does not empower. The word compliance symbolizes an attitude that is itself one of the reasons patients do not take their medications properly. Clarity in communication is essential to be understood. Simplicity also enhances meaningful communication. Telling a patient, “You have glaucoma. Use the Xalatan once, the Cosopt twice, and the Alphagan three times and I will check you in two weeks,” is not likely to help many patients.
In the first place, most patients want to know the significance of their condition, and why they need treatment. Patients who do not know that they have glaucoma, what glaucoma is, and why treatment has been suggested are less likely to take their medications properly. Some patients need little explanation. Others need a more thorough and complete explanation. It is helpful to refer them to other sources of information such as the Internet or printed materials. Providing written instructions would help the patient use medications correctly. Written instructions on large sheets of paper giving the name of the medication, the character of the bottle, the eye in which the medication is to be used, and the specific time of day it is to be used should be provided to almost all patients. In the case given, this would state, “Xalatan, tiny bottle, left eye, bedtime” on the first line. On the second line, it would say, “Cosopt, large bottle, left eye, with breakfast and supper.” On the third line it would be written, “Alphagan, purple top, left eye, with breakfast, lunch, and supper.”
It is helpful to tie the use of medications with a particular event in the person’s daily activities. For example, in the case just given, the patient happens to be an elderly woman who lives by herself and cooks all her own meals. She believes it is important to have three meals a day. She keeps her medications in the bathroom of her apartment, and the bathroom is adjacent to the kitchen. Thus, it is convenient for her to have access to her drops when she is preparing her meals. Knowing this information conveys to the patient the message that the physician is truly interested in her and wants to assure that she gets the best care.

Ways to Help Encourage Self-Care
There are various ways to encourage self-care:
1. Frightening the patient
2. Admonishing
3. Providing cognitive knowledge
4. Engaging
5. Removing denial
6. Providing management aids
7. Giving positive reinforcement

Every patient is unique; therefore, different methods of encouraging self-care need to be employed. Rarely, however, does frightening or admonishing patients result in good self-care. Educating them in terms that they can understand their condition, its consequences, and the possibilities of influencing it can occasionally be helpful. There is a great deal of available “patient information” about almost every condition. Pharmaceutical companies, academic institutions, agencies, and individual practices provide such patient-education aids. Often, however, these materials are slanted to ref lec t the pos i t ion of the group prov iding the information. When obtained from the Internet, the information may be confusing and conflicting. Even at best, it is not likely to influence behavior. What people do is not largely based on what they know intellectually. Behavior is far more a consequence of habi t s , appet i tes , emot ions , and exper iences . Successful treatment recognizes that intellectual knowledge is important, but that habits and emotions are far more important. Frightening, admonishing, and educating intellectually are not at the core of enhancing self-care. In contrast, engaging the patient genuinely so that the person feels the physician’s affection and concern helps the patient feel worthy, and encourages him to care for himself.
Few of us are good at recognizing reality. Obese patients usually have convinced themselves that they really are not eating more than they need; hypertensive patients rarely admit that they are overweight and not exercising makes their illness worse; most of those who smoke cigarettes have rationalized their smoking, believing that it is okay for them. Telling obese people that they are eating too much, hypertensive patients that they need to change their lifestyle, and smokers that they are increasing their likelihood of getting a serious disease rarely works. Though denial can be removed in some cases by dramatic confrontation, a more effective method is that which combines a caring, nonjudgmental approach with the provision of highly specific, concrete management aids.
One of the simplest and most effective with regard to the use of eye drops is tying up the time of application with a recurring activity of the patient. It is helpful for the physician, then, to find out what the patient does every day that occurs at the same frequency as the use of the medications. Most patients, for example, have little difficulty using a drop once daily at bedtime. On the other hand, it is almost impossible to have patients use a drop five times a day because there is almost nothing that anybody does regularly five times a day. Finally, reinforcement works better than punishment. Congratulating a person for an accomplishment (such as using medications properly) and demonstrating the beneficial effects of that accomplishment empower. Helping patients improve their self-image and making clear to them that they affect their own lives help assure good self-care.
Many years ago Francis Peabody gave the best, most succinct summary: “The secret of the care of the patient is caring for the patient.” When we truly care for our patients, we will not ask them to do things that they cannot do because of economic, intellectual, or emotional reasons. When we truly care for our patients, we will not chastise them when they fail to use their medications appropriately, especially when we recognize that the fault is ours rather than theirs. When we truly care for our patients, we will recognize that every one of them is different from every other one. When we truly care for our patients they will truly care for us.