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Bridges, why and from where to where?
ELSEVIER
Patient Education and Counseling 26 (1995) II-15
Bridges, why and from where to where? Jean-Philippe Assal’ Division
of Education
jbr
Chronic
Diseases,
Department
of Medicine,
3HL
University
Hospital,
1211 GeneLa
14, Switzerland
Abstract
Therapeuticintervention for chronic diseases doesnot rely only on drugsbut is alsostrictly dependenton how the patient hasbeeninformed about his diseaseand how he is able to masterthe various skillsrequired by his treatment. Education therefore plays a fundamental role in the efficacy of control of those diseases.But what is education? Among the various possibledefinitions, one could be metaphorically illustrated by bridges.How to get the message acrossfrom the medicalworld to that of the patient, or, insidethe medicalprofessionsfrom one group of providers to another. Different bridgesmay have different functions or roles. One is for commutingin the current daily life. Another one is to ensurevital needs.Bridgeshelp alsoto discovernew territories, but any new visitor may not always be welcomed in these new regions. Bridges need to be solidly constructed with a structure which can be methodologicallydescribed.This may help repair in caseof problems.Patient educationis a kind of bridge submitted to all sortsof forcesand barriers which may interfere with the passageof knowledgeand skillsfrom the health care providers to the patient and his family. Keywords:
Bridges;Education; Chronic diseases; Global approachto treatment
1. Introduction
2. Bridges for commuting
Sharing knowledge and skills, comparing experiences and sharing difficulties, trying to develop new strategies for a more efficient follow-up of patients has much in common with building bridges. Where should they be built, which technique should be recommended, and who is going to use them?
The simplest use of a bridge is that for commuting daily from home to the place of work and vice versa. Trying to make an analogy in the field of communication, this role of bridges can be compared with our verbal exchanges in our daily routine activities. 3. Bridges for life support
’ Tel.: + 41223729702; Fax: + 41223729710.
However, bridges have other functions, which happen to play vital roles, like in certain remote
073%3991/95/$09.50 0 1995ElsevierScienceIrelandLtd. All rightsreserved SSDI 0738-3991(95)00764-Q
12
J.-Ph.
Assal / Patient
Education
regions where the life of local people strongly depends on the availability of food, energy, petrol, etc., coming from other valleys. In the scientific communities, whether one deals with basic or clinical research, the role of such a bridge can be compared with the vital need of exchanges, the need of ‘cross-fertilisation’ between scientists, clinicians and all those involved in patient care coming from different sub-specialties. It is with the pressure of quite different ideas, opinions, skills and approaches coming from various and far away places that research may find its vital creative and energetic sources. This holds true in research whether basic or clinical, whether in biomedicine or in psychology, education and social sciences, or in the field of medical economy. In patient care and education there are at least 20 different sectors, all important to master, if we really want to develop new skills and behaviour to treat long-term diseases more comprehensively. 4. Bridges for discovering
new territories
Bridges can also help to conquer new territories. One illustration of this would be the amphibious vehicles used to disembark troups from the ship to the shore. Although this example it is not really a bridge, these amphibious vehicles have the same role. Their use may be hazardous because the new territories are difficult to penetrate, may be hostile and often strongly protected. These are the sort of bridges we are using at the frontier of research or at time of implementation in our daily practice of new medical approaches, such as programmes for patient education, workshops for empowering patients, and round-table meetings allowing patients to express themselves. Because some do not really believe in the therapeutic role of patient education, communication between health care providers at this stage, may be a risky one, and often deals with more questions than certainties. This distrust is also present when health care providers have to work as an interdisciplinary, or even more as an intersectoral team. Research and innovation in the clinical field is a kind of state-of-war in the field of classical medical practice, where ignorance of the effect of education increases resistance.
and Counseling
26 (1995)
II-15
5. Resistance to new bridges
Even before starting the construction of a bridge, there may be many resistances to overcome. A recent example has been the channel tunnel connecting England and France with, for instance, the resultant anxiety about rabies, the possible collapse of the tunnel, the danger of terrorism. These metaphors illustrate the atmosphere in which we often live in our professional setting, which carries all sorts of false beliefs by colleagues, by the administration, by health insurers and also by health policy makers. They are expressed by resistance to change, distrust, skepticism, denial that patient education may improve the medical efficiency of treatment, increase the quality of life of patients and their family and even, at the same time, reduce the cost of treatment. In this perspective, the resulting procedings of this congress will bring a collection of scientific proofs of the therapeutic importance of patient education, as well as greater international recognition of this aspect of therapy. The fact that WHO headquarters and Dr. Nakajima, its Director General, have sponsored our meeting, highlights the importance of this issue. 6. Need for technical expertise
Except for few exceptions found in nature, e.g. the natural arch bridge in the US, bridges cannot be built spontaneously. They require the highest technical skill and expertise. There is a fundamental role of engineering which can be often seen in famous metallic bridges like the famous Golden Gate bridge in San Francisco. Good communication among health care providers in general is not as spontaneous and as easy as one would imagine. It is even more complex and difficult when we have to deal with patients. Communication, educational strategies and patients’ psychological support require methodologies, structure and skill and therefore a lot of training. Such a meeting as Patient Education 2000 plays a structuring role in order to help us to develop more pertinent skills with our patients and also with the management of our own medical teams.
J.-Ph. Assal 1 Patient Education and Counseling 26 (1995) I I - 15
Fig.
I
13
15th century which was totally destroyed by fire in 1993. But, thanks to very precise architectural plans which the city of Lucem still possessed, this bridge could be re-built within 6 months. The fact that man has the architectural plans, and masters the technique of its construction, such bridges may be rapidly rebuilt. This example helps us to understand that we need to master in detail the various facets of the implementation of a patient education curriculum. Only after knowing the methodologies necessary to develop interactive patient education programmes, mastering the various skills to develop efficient long-term follow-up of patients, and being able to recognise and to overcome the various difficulties involved in patient care with chronic disease, can we guarantee the survival of a patient education programme and have the ability to face unforeseen difficulties. 7.1. Team work
Fig. 2
7. The weakness of bridges Bridges can be damaged, they even may collapse. Teaching programmes have failed because physicians, nurses and other paramedics did not seriously master the educational and psychological dimensions of the approach to patients. This is because they did not see the necessity of learning those skills, relying too much on their medical knowledge and biomedical expertise. The reverse is also true. We have all witnessed physicians and nurses switching to patient education because they did not sufficiently master biomedicine. In both instances, the result will be quite limited for patients and not worth the effort. Strong, recognized programmes like world famous bridges may be destroyed rapidly by external unforeseen factors like a Swiss bridge of the
This crucial aspect in the treatment of chronic diseases is constantly put forward as a major element of care in the success of chronic care. We mention it so frequently that it is to be wondered if the interdisciplinary approach is not more often missing. Missing even in places which appear to work in an interdisciplinary way. It is our personal experience that in many countries, due maybe to cultural reasons, physicians and nurses do not work together as they should. By not doing so they lose much of their efficiency in the treatment and follow-up patients. Many of the papers presented addressed this important topic of interdisciplinary and intersectoral dimension of care. We would like to acknowledge the role that WHO &ays in promoting these dimensions which medical schools and schools of nursing should strengthen much more. 8. Bridges, back to man Bridges may also be internal to our organism and the examples coming from our nervous system is illustrated. Recent experiences of neuropsychologists shows how the left and right hemispheres of the brain may be independently and simultaneously stimulated.
14
J.-Ph.
Assal
/ Patient
Education
and
Counseling
26 (1995)
I I - 15
Fig. 3
Some experiences have shown that when a person was listening to various types of music, brain scans could demonstrate visually how the left and
right hemispheres of the brain responded to music. Atonal music, very discordant music, stimulated the left hemisphere. More harmonious
Fig. 4
Fig. 5
J.-Ph.
Assal / Patient
Education
Fig. 6
melodies liked by the subject stimulated the right hemisphere which is associated with pleasurable emotions. While listening to an opera, the same person stimulated right and left hemispheres; the left verbal skills allowed access to the right’s emotional insights. The verbal content of the music, left hemisphere, was therefore complementary to the right emotional hemisphere. These experiences could also open concepts in the field of conditions of learning. The setting in which we learn, as well as the content we have to learn, may determine neurological reactions which in turn may facilitate or interfere with the learning ability. 9. Conclusions It is probable that many of us participated in this meeting because we realized, through our professional experiences, that the therapeutic
and Counseling
26 (1995)
I I - 15
15
chain is only as strong as its weakest link. The picture presented remarkably illustrates medical care. On one hand there are 2 very strong hooks which give the impression that this chain is a very strong one. The same is true in medicine. At one end of the therapeutic chain, there is evidence of the efficiency of basic pharmacological research and production of very powerful drugs (one hook); at the other end of the therapeutic chain there is also evidence of the outstanding effects of many drugs, some of them life-saving. Medicine is remarkably powerful. But what happens when patients do not take their treatment correctly? How frequently do we discover in our daily practice just how fragile our therapeutic efficiency is? Today there is not even 2% of the medical investment which deals with this crucial sector of adherence to treatment and empowerment of patients. There is an urgent, mandatory need to address our attention to these weakest links in the therapeutic chain. Treatment of chronic diseases that cannot be cured implies new approaches for both partners, whether health care providers or patients. This meeting tried to offer ways to answer Konrad Lorenz’s observations: (a) Said but not heard, (b) heard but not understood, (c) understood but not accepted, (d) accepted but not put into practice, (e) put into practice, but for how long? References [I] Assal J-Ph. A Global Integrated Approach to Diabetes: A challenge for more efficient therapy. In: Davidson JK ed. Clinical Diabetes Mellitus. A Problem-Oriented Approach. 2nd edn. New York: Thieme, 1991. [2] Assal J-Ph. Educating the diabetic patient: which programme is specific to IDDM and to NIDDM? In: Concepts for the Ideal Diabetes Clinic. Berlin: de Gruyter, 1992. [3] Assal J-Ph. Educating the diabetic patient: difficulties encountered by patients and health care providers who have to teach NIDDM and IDDM patients. In: Concepts for the Ideal diabetes Clinic. Berlin: de Gruyter, 1992. [4] Lacroix A, Assal J-Ph. Peut-on ameliorer les prestations pedagogiques des medecins qui enseignent aux malades? Diabete Metab (Paris) 1992; 18: 387-394. [5] Peraya D, Lacroix A, Assal J-Ph. Former les medecins qui apprennent aux malades a se soigner. La Revue d’Education Medicale, Tome XII, No. 2, janvier 1994.
Patient Education and Counseling 26 (1995) II-15
Bridges, why and from where to where? Jean-Philippe Assal’ Division
of Education
jbr
Chronic
Diseases,
Department
of Medicine,
3HL
University
Hospital,
1211 GeneLa
14, Switzerland
Abstract
Therapeuticintervention for chronic diseases doesnot rely only on drugsbut is alsostrictly dependenton how the patient hasbeeninformed about his diseaseand how he is able to masterthe various skillsrequired by his treatment. Education therefore plays a fundamental role in the efficacy of control of those diseases.But what is education? Among the various possibledefinitions, one could be metaphorically illustrated by bridges.How to get the message acrossfrom the medicalworld to that of the patient, or, insidethe medicalprofessionsfrom one group of providers to another. Different bridgesmay have different functions or roles. One is for commutingin the current daily life. Another one is to ensurevital needs.Bridgeshelp alsoto discovernew territories, but any new visitor may not always be welcomed in these new regions. Bridges need to be solidly constructed with a structure which can be methodologicallydescribed.This may help repair in caseof problems.Patient educationis a kind of bridge submitted to all sortsof forcesand barriers which may interfere with the passageof knowledgeand skillsfrom the health care providers to the patient and his family. Keywords:
Bridges;Education; Chronic diseases; Global approachto treatment
1. Introduction
2. Bridges for commuting
Sharing knowledge and skills, comparing experiences and sharing difficulties, trying to develop new strategies for a more efficient follow-up of patients has much in common with building bridges. Where should they be built, which technique should be recommended, and who is going to use them?
The simplest use of a bridge is that for commuting daily from home to the place of work and vice versa. Trying to make an analogy in the field of communication, this role of bridges can be compared with our verbal exchanges in our daily routine activities. 3. Bridges for life support
’ Tel.: + 41223729702; Fax: + 41223729710.
However, bridges have other functions, which happen to play vital roles, like in certain remote
073%3991/95/$09.50 0 1995ElsevierScienceIrelandLtd. All rightsreserved SSDI 0738-3991(95)00764-Q
12
J.-Ph.
Assal / Patient
Education
regions where the life of local people strongly depends on the availability of food, energy, petrol, etc., coming from other valleys. In the scientific communities, whether one deals with basic or clinical research, the role of such a bridge can be compared with the vital need of exchanges, the need of ‘cross-fertilisation’ between scientists, clinicians and all those involved in patient care coming from different sub-specialties. It is with the pressure of quite different ideas, opinions, skills and approaches coming from various and far away places that research may find its vital creative and energetic sources. This holds true in research whether basic or clinical, whether in biomedicine or in psychology, education and social sciences, or in the field of medical economy. In patient care and education there are at least 20 different sectors, all important to master, if we really want to develop new skills and behaviour to treat long-term diseases more comprehensively. 4. Bridges for discovering
new territories
Bridges can also help to conquer new territories. One illustration of this would be the amphibious vehicles used to disembark troups from the ship to the shore. Although this example it is not really a bridge, these amphibious vehicles have the same role. Their use may be hazardous because the new territories are difficult to penetrate, may be hostile and often strongly protected. These are the sort of bridges we are using at the frontier of research or at time of implementation in our daily practice of new medical approaches, such as programmes for patient education, workshops for empowering patients, and round-table meetings allowing patients to express themselves. Because some do not really believe in the therapeutic role of patient education, communication between health care providers at this stage, may be a risky one, and often deals with more questions than certainties. This distrust is also present when health care providers have to work as an interdisciplinary, or even more as an intersectoral team. Research and innovation in the clinical field is a kind of state-of-war in the field of classical medical practice, where ignorance of the effect of education increases resistance.
and Counseling
26 (1995)
II-15
5. Resistance to new bridges
Even before starting the construction of a bridge, there may be many resistances to overcome. A recent example has been the channel tunnel connecting England and France with, for instance, the resultant anxiety about rabies, the possible collapse of the tunnel, the danger of terrorism. These metaphors illustrate the atmosphere in which we often live in our professional setting, which carries all sorts of false beliefs by colleagues, by the administration, by health insurers and also by health policy makers. They are expressed by resistance to change, distrust, skepticism, denial that patient education may improve the medical efficiency of treatment, increase the quality of life of patients and their family and even, at the same time, reduce the cost of treatment. In this perspective, the resulting procedings of this congress will bring a collection of scientific proofs of the therapeutic importance of patient education, as well as greater international recognition of this aspect of therapy. The fact that WHO headquarters and Dr. Nakajima, its Director General, have sponsored our meeting, highlights the importance of this issue. 6. Need for technical expertise
Except for few exceptions found in nature, e.g. the natural arch bridge in the US, bridges cannot be built spontaneously. They require the highest technical skill and expertise. There is a fundamental role of engineering which can be often seen in famous metallic bridges like the famous Golden Gate bridge in San Francisco. Good communication among health care providers in general is not as spontaneous and as easy as one would imagine. It is even more complex and difficult when we have to deal with patients. Communication, educational strategies and patients’ psychological support require methodologies, structure and skill and therefore a lot of training. Such a meeting as Patient Education 2000 plays a structuring role in order to help us to develop more pertinent skills with our patients and also with the management of our own medical teams.
J.-Ph. Assal 1 Patient Education and Counseling 26 (1995) I I - 15
Fig.
I
13
15th century which was totally destroyed by fire in 1993. But, thanks to very precise architectural plans which the city of Lucem still possessed, this bridge could be re-built within 6 months. The fact that man has the architectural plans, and masters the technique of its construction, such bridges may be rapidly rebuilt. This example helps us to understand that we need to master in detail the various facets of the implementation of a patient education curriculum. Only after knowing the methodologies necessary to develop interactive patient education programmes, mastering the various skills to develop efficient long-term follow-up of patients, and being able to recognise and to overcome the various difficulties involved in patient care with chronic disease, can we guarantee the survival of a patient education programme and have the ability to face unforeseen difficulties. 7.1. Team work
Fig. 2
7. The weakness of bridges Bridges can be damaged, they even may collapse. Teaching programmes have failed because physicians, nurses and other paramedics did not seriously master the educational and psychological dimensions of the approach to patients. This is because they did not see the necessity of learning those skills, relying too much on their medical knowledge and biomedical expertise. The reverse is also true. We have all witnessed physicians and nurses switching to patient education because they did not sufficiently master biomedicine. In both instances, the result will be quite limited for patients and not worth the effort. Strong, recognized programmes like world famous bridges may be destroyed rapidly by external unforeseen factors like a Swiss bridge of the
This crucial aspect in the treatment of chronic diseases is constantly put forward as a major element of care in the success of chronic care. We mention it so frequently that it is to be wondered if the interdisciplinary approach is not more often missing. Missing even in places which appear to work in an interdisciplinary way. It is our personal experience that in many countries, due maybe to cultural reasons, physicians and nurses do not work together as they should. By not doing so they lose much of their efficiency in the treatment and follow-up patients. Many of the papers presented addressed this important topic of interdisciplinary and intersectoral dimension of care. We would like to acknowledge the role that WHO &ays in promoting these dimensions which medical schools and schools of nursing should strengthen much more. 8. Bridges, back to man Bridges may also be internal to our organism and the examples coming from our nervous system is illustrated. Recent experiences of neuropsychologists shows how the left and right hemispheres of the brain may be independently and simultaneously stimulated.
14
J.-Ph.
Assal
/ Patient
Education
and
Counseling
26 (1995)
I I - 15
Fig. 3
Some experiences have shown that when a person was listening to various types of music, brain scans could demonstrate visually how the left and
right hemispheres of the brain responded to music. Atonal music, very discordant music, stimulated the left hemisphere. More harmonious
Fig. 4
Fig. 5
J.-Ph.
Assal / Patient
Education
Fig. 6
melodies liked by the subject stimulated the right hemisphere which is associated with pleasurable emotions. While listening to an opera, the same person stimulated right and left hemispheres; the left verbal skills allowed access to the right’s emotional insights. The verbal content of the music, left hemisphere, was therefore complementary to the right emotional hemisphere. These experiences could also open concepts in the field of conditions of learning. The setting in which we learn, as well as the content we have to learn, may determine neurological reactions which in turn may facilitate or interfere with the learning ability. 9. Conclusions It is probable that many of us participated in this meeting because we realized, through our professional experiences, that the therapeutic
and Counseling
26 (1995)
I I - 15
15
chain is only as strong as its weakest link. The picture presented remarkably illustrates medical care. On one hand there are 2 very strong hooks which give the impression that this chain is a very strong one. The same is true in medicine. At one end of the therapeutic chain, there is evidence of the efficiency of basic pharmacological research and production of very powerful drugs (one hook); at the other end of the therapeutic chain there is also evidence of the outstanding effects of many drugs, some of them life-saving. Medicine is remarkably powerful. But what happens when patients do not take their treatment correctly? How frequently do we discover in our daily practice just how fragile our therapeutic efficiency is? Today there is not even 2% of the medical investment which deals with this crucial sector of adherence to treatment and empowerment of patients. There is an urgent, mandatory need to address our attention to these weakest links in the therapeutic chain. Treatment of chronic diseases that cannot be cured implies new approaches for both partners, whether health care providers or patients. This meeting tried to offer ways to answer Konrad Lorenz’s observations: (a) Said but not heard, (b) heard but not understood, (c) understood but not accepted, (d) accepted but not put into practice, (e) put into practice, but for how long? References [I] Assal J-Ph. A Global Integrated Approach to Diabetes: A challenge for more efficient therapy. In: Davidson JK ed. Clinical Diabetes Mellitus. A Problem-Oriented Approach. 2nd edn. New York: Thieme, 1991. [2] Assal J-Ph. Educating the diabetic patient: which programme is specific to IDDM and to NIDDM? In: Concepts for the Ideal Diabetes Clinic. Berlin: de Gruyter, 1992. [3] Assal J-Ph. Educating the diabetic patient: difficulties encountered by patients and health care providers who have to teach NIDDM and IDDM patients. In: Concepts for the Ideal diabetes Clinic. Berlin: de Gruyter, 1992. [4] Lacroix A, Assal J-Ph. Peut-on ameliorer les prestations pedagogiques des medecins qui enseignent aux malades? Diabete Metab (Paris) 1992; 18: 387-394. [5] Peraya D, Lacroix A, Assal J-Ph. Former les medecins qui apprennent aux malades a se soigner. La Revue d’Education Medicale, Tome XII, No. 2, janvier 1994.