PERSPECTIVES Patient Education through Teaching for Conceptual Change

MARIANA O. HEWSON, PhD

APPROPRIATE PATIENT EDUCATION is thought to improve pat ient compl iance and save on overall heal th care cos t s ) Effective pat ient educat ion has also been pro- posed as a way to reduce the level of l i t igation against clinicians. 2 However , a low percentage of pa t ien t visits to clinicians include pat ient educat ion, 3 and a high percentage of patients do not understand or r e m e m b e r what their clinicians do tell them. 4 The specifications for effective educat ion are unclear in general; they are part icularly so in the special case of pat ient educat ion. Patient educat ion has diverse aspects, inc luding ex- plaining about disease, its cause and prognosis, pro- posed tests, procedures , and prescript ions, and teach- ing patients h o w to take care of themselves (both heal th care maintenance and t reatment plans) .

In general, pat ients are educated direct ly by clini- cians. However , in the cases of very young, very old, or compromised pat ients (deaf, blind, in pain) , a care- giver such as a parent , an adul t child, or a family mem- ber must be educa ted on behal f of the patient. Patients f rom cul tures different f rom that of the cl inician may bring an in terpre ter to the interview, provid ing fur ther complex i ty to an already c o m p l e x situation. While ed- ucat ion for different patients should and does take dif- ferent forms, we need a general approach to pat ient educat ion that accommoda tes these different situa- tions.

A recent rev iew of journal articles on interviewing skills programs for medical students showed a p redomi- nant interest in the mechanics of the in terview (such as introductions, quest ion structure, and c losure) at the expense of the equal ly impor tant funct ion of pat ient education. 5 Con tempora ry studies of cl inician - pat ient interactions make recommenda t ions concern ing pa- t ient educat ion 1, 6-13 at various levels o f specificity. For example , in the three-funct ion model of the medica l interview,6, 7 the third funct ion is to influence pat ient behavior through educat ion, negotiation, and motiva- tion. This mode l provides useful categories of skills for p romot ing pat ient education, especial ly that o f negoti- ation. Kle inman et al. 8 suggest that the "negot ia t ion of

Received from the Departments of Medicine and Pediatrics, Univer- sity of Wisconsin, Madison, Wisconsin.

Supported by the USPHS/HRSA training grants D28-PE- 15218 and DE-PE-55024, and MCHB training grant MCJ-559-072.

Address correspondence and reprint requests to Dr Hewson: Clinical Sciences Center, 600 HighlandAvenue, Madison, WI 53792.

shared mode l s " might be the "s ingle most impor tant step . . . in p romot ing c o m p l i a n c e " (p. 257) . Nego- tiation here means a c o m p r o m i s e be tween the different explanatory mode l s that may exist be tween cl inician and patient. Similarly, Waitzkin t° describes the neces- sity for a c l inician to negotiate the diagnosis and treat- ment plan wi th the patient. Part of the negot ia t ion pro- cess involves establishing the pat ient ' s perspect ive . Maynard H observed and d o c u m e n t e d an effective pa- t ient educat ion strategy used by clinicians, "pe r spec - t ive-display s e q u e n c e . " Delbanco t2 describes the im- por tance of obta ining the pat ient ' s perspect ive , and Eraker et al.t descr ibe a f ramework for including pa- t ients ' pe rspec t ives wi th decision analysis and behav- ioral decis ion analysis. None of these approaches ap- pear to incorpora te con tempora ry learning theory into their specifications for improving pat ient educat ion.

In this article, I p ropose a six-step model of pat ient educat ion based on a model of learning as concep tua l change, t4"t6 This serves to ex tend the scope of the three-funct ion mode l 6 and add to our unders tanding of the impor tance of the pat ient ' s perspec t ive in pat ient education. This mode l suggests specific teaching moves that can be made by the clinician. While I pre- viously descr ibed a similar mode l for teaching residents and medical students, t~ here I app ly the mode l to pa- t ient educat ion wi th e laborat ion of the condi t ions nec- essary for concep tua l change. First I descr ibe the cur- rent state of pa t ient educa t ion and the tradit ional educat ional approach , fo l lowed by a descr ip t ion of the model of learning as concep tua l change. The implica- t ions of the learning mode l for teaching pat ients are descr ibed and summar ized in a table. Finally, the ap- p roach to teaching for concep tua l change is i l lustrated using a hypothe t ica l case.

PROBLEMS OF PATIENT EDUCATION

Teaching pat ients effectively is a chal lenge for cli- nicians. While w e find it difficult to specify cri teria for effective teaching, we do k n o w some of the reasons w h y pat ient educa t ion is ineffective. Behaviors by clini- cians that are coun te rp roduc t ive in the c l i n i c i a n - pat ient in teract ion include: 1) in ter rupt ing the pat ient before he or she has finished descr ibing the reasons for the visittT; 2) assuming that the pat ient has no knowl- edge of, skills for cop ing with, or att i tudes toward par- t icular illnesses and treatmentslS"2t; 3) not expla ining

393

394 Hewson, PATIENT EDUCATION FOR CONCEPTUAL CHANGE

the diagnosis or t rea tment plans adequately2°; 4) pro- viding information that is in conflict wi th the pat ient ' s views by not relating to the pat ient wi thin the context o f his or her par t icular env i ronment (physical, cul- tural, spiritual, or soc ioeconomic ) , stage of life, s, 9, t8.21 or par t icular " n e e d to know"22; and 5) ignoring the affective c o m p o n e n t of informat ion (such as nei ther showing empa thy for nor acknowledging the pat ient ' s emot ional responses).S-7

One assumpt ion under ly ing traditional pat ient ed- ucat ion is that the teacher (cl inician) possesses medi- cal skills and knowledge, and that his or her responsi- bil i ty is e i ther to tell pat ients something (drug regimens, lifestyle changes) or to show them h o w to do someth ing (change a dressing). This assumpt ion is based on the " m u g and jug" approach, in wh ich the cl inician is seen as the " jug , " the owner of the desired knowledge, attitudes, and skills, and the pat ient is the " m u g , " the emp ty vessel, the rec ip ient o f the clini- c ian 's knowledge. The responsibi l i ty of the cl inician is s imply to pou r the knowledge, attitudes, and skills into the mind of the patient.

The p r o b l e m wi th this app roach is that it suggests a passive process of transmission of information f rom one person to another. While this approach may appear to be direct and effective to the clinician, it may also have devastating consequences for the patient, result ing in emot ional and cognit ive denial wi th a reject ion of the diagnosis and p roposed t rea tment plan. In many pat ient educat ion sessions involving the transmission ap- proach, reject ion of informat ion by the pat ient remains nonverbal , and the pat ient leaves the session wi th little or no intent ion of fo l lowing the cl inician 's advice. Noncompl iance is the result o f nonaccep tance and may involve ei ther lack of agreement or lack of understand- ing by the patient. In e i ther case, the cl inician falsely thinks that pat ient educa t ion has been accompl i shed when the pat ient is told. The transmission approach assumes that pat ient e~ucat ion is unidirect ional: the cl inician delivers informat ion and the pat ient accepts it. An unfortunate corol lary to this approach is that if the pat ient does not accep t the cl inician 's advice, the p r o b l e m lies wi th the patient , w h o is labeled "non- compl ian t . " When pat ient educat ion fails, it may be necessary to examine the case for educat ional negli- gence: the lack of effective pat ient educat ion by the clinician.

ently. The conceptua l change approach provides an alternative to the v iew of the learner as passive receiver of information. From this perspect ive , learning is a process in which pr ior knowledge is the basis for in- terpret ing or giving meaning to new information or situations. 23

The componen t s of the mode l are described and illustrated wi th a hypothet ical case: Mrs. Brown, a 50- year-old mothe r of five, who has been feeling fat igued for some months.

1. K n o w l e d g e h a s s t r u c t u r e . Knowledge is thought to be stored in the mind in the form of struc- tures consisting of concept ions . 24-26 Concept ions are defined here as coherent , identifiable ideas incorporat- ing knowledge (knowing " t ha t " and knowing " h o w to" ) , attitudes (a state of mind concern ing some mat- ter), values, and beliefs. People a t tempt to unders tand the reasons for illness by construct ing their own mean- ings of facts and events.

Mrs. Brown has a conception of illness that involves some knowledge of physiologic dysfunction and methods of coping, the attitude that dysfunction is abnormal, and the belief that illness is causal.

2. Existing knowledge affects what people l e a r n . People make sense of n e w ideas, physical sensa- tions, and emot ional arousal in terms of their exist ing concept ions (such as rel igious beliefs, cultural myths, language usage, and popu la r medical science), 26-2s wi th result ing gaps (missing information) , errors (misconcept ions) , and confusions (undifferentiated or conflated ideas).14

Mrs. Brown has a conception that her body is like a ma- chine and that illness means some part of the machine is not working properly. She sometimes attributes physical "wear and tear" as the cause of illness in the body or the mind (such as depression as a mental weakness).

Mrs. Brown has been thinking: "Why am I so tired? Is there something wrong? Have I become physically worn out from mothering all these kids?" (error). She visits her clinician, who orders a blood test. After receiving the results of one test, which indicated an elevated sedimen- tation rate, she worries. She recently read in a magazine article that sedimentation rates are high in cancer pa- tients. She concludes that elevated sedimentation rates indicate serious illness (confusion), and her high sedi- mentation rate might mean that she has cancer (error).

LEARNING AS CONCEPTUAL CHANGE

Learning is a c o m p l e x process about wh ich sur- pr is ingly little is known. Most p e o p l e w h o have learned effectively k n o w that learning is se ldom a passive trans- mission of information; rather, it involves effort in making sense of new information, deve lop ing new atti- tudes, and learning n e w skills. Learning involves change, such as in knowing more , or knowing differ-

3. L e a r n i n g o c c u r s w h e n e x i s t i n g concep- tions change. Concept ions change by integrating (adding) new concep t ions to fill the gaps, by differen- tiating (clarifying) concep t ions that are confused, and by exchanging misconcept ions for be t ter ones. t4, 29

The clinician explains that Mrs. Brown's raised sedimen- tation rate simply indicates that she has a condition that may necessitate attention. He suggests further tests as a

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 8 (July), 1993 39S

precautionary checkup. Mrs. Brown thought increased sedimentation rate meant serious illness but is relieved to hear that it may not mean much. She differentiated her original limited understanding of sedimentation rates as an indicator of cancer into a slightly more extended un- derstanding of sedimentation rate as a general, nonspe- cific sickness indicator.

4. Conceptions change under certain condi- tions. People learn (change their concept ions) when they judge new concept ions to be more compel l ing than old ones; the new concept ions have more status or more value for the person. The criteria for finding con- ceptions compel l ing are: intelligibility (it must make sense); plausibili ty (it must be realistic); and fruitful- ness (it must be seen as useful for explaining a situation or problem). 15, 16 In the face of new facts, events, or ideas, people may discover that their existing concep- tions have become inadequate or incorrect (with gaps, errors, and/or confusions); they are seen as less fruitful, or less plausible, with consequent lower status than before. In other words, the status of the concept ion changes. This results in dissatisfaction with existing conceptions, which is the precursor for conceptual change.

rejected the idea, telling him that she was coping with life and there was nothing wrong with her mind. The diagnosis was intelligible, but neither plausible or fruit- ful (due to her conception of depression as a sign of mental weakness).

The Process of Learning

A four-stage learning process is inferred from this model of learning: 1) the person 's concept ions con- cerning a particular situation are initially in equilib- rium, and the existing concept ions have high status; 2) disequil ibrium is created when these concept ions no longer seem to be adequate to explain or predict the situation (awareness of discrepancies such as gaps, errors, or confusions), the status of existing concep- tions is lowered, and dissatisfaction is experienced; 3) the person responds to his or her dissatisfaction and disequilibrium, accommodat ing to the new situation by integrating new concept ions to fill the gaps, differ- entiating confused conceptions, and exchanging mis- concept ions for more appropriate ideas; and 4) equi- l ibrium is reestablished when concept ions are once again adequate for the demands of the situation, and the new concept ions are attributed high status.

Mrs. Brown's previous idea that an increased sedimenta- tion rate indicated serious disease had high status (it was intelligible, plausible, and fruitful), but after her doc- tor's comments, the status of that conception was re- duced (no longer fruitful, but still intelligible, and possi- bly plausible), and she was prepared to accept that there may be another reason for her fatigue. At the same time, the status of depression as a cause of her fatigue had low status for Mrs. Brown due to her view that depression involved mental weakness.

5. The s t a tus o f c o n c e p t i o n s a f fec t s satisfac- tion. When a person finds an idea intelligible, plausi- ble, and fruitful in making sense of experiences and the idea has high status for that person, he or she becomes commit ted to it. People strive to make sense of facts and events that impinge on their lives, and the ability to make sense is an important source of emotional satisfaction. 3°

Mrs. Brown: "This is confusing, but I 'm glad to get a better understanding of the implications of an increased sedimentation rate. I 'd still like to know why I'm so tired all the time."

6. Rejection o f ideas is due t o l ack o f s t a tu s o f those ideas. If a person does not find a new concept ion intelligible, plausible, and fruitful, the new concep- tion has low status for that person. Existing concept ions may have higher status than the new concept ion. In this case, the new concept ion is rejected, and no concep- tual change takes place. 14

When Mrs. Brown's doctor first suggested depression as a possible cause for her fatigue, she became upset and

Implications of a Learning Model for Teaching

The model of learning as conceptual change has implications for teaching, wh ich can be interpreted as negotiation of shared meanings. The teaching process can be viewed in six steps: 1) orientation, in wh ich the teacher establishes an appropriate learning environ- ment and focuses on the topic; 2) elicitation, in which the teacher finds out the student 's existing concept ions and the status of the concept ions; 3) diagnosis, in which the teacher (often in collaborat ion with the stu- dent) determines whether the student 's concept ions have gaps, errors, or confusions and decides what needs to change; 4) intervention, in wh ich the teacher facili- tates student learning by stimulating student dissatis- faction with existing conceptions, and in collaboration with the student facilitates integration, differentiation, and /o r exchange, using appropriate teaching methods such as mini-lectures, brochures, diagrams, models, demonstrations, experiments, discussions, and de- bates; 5) application, in wh ich the teacher helps the student apply the new concept ions to the situation or problem; and 6) review, in wh ich the teacher or stu- dent reviews the current concept ions and progress made by the student.

PATIENT EDUCATION AND TEACHING FOR CONCEPTUAL CHANGE

Personal views of illness arise from personal expe- riences of illness, from efforts to make sense of these experiences, and from socially constructed concep- tions that exist in society in the form of c o m m o n knowl-

396 Hewson. PATIENT EDUCATION FOR CONCEPTUAL CHANGE

edge, folklore, and language such as idioms or meta- phors.~lo, la-2x Personal concept ions of illness often differ f rom or thodox medical concept ions of dis- ease, ~a-21 reflecting the person's culture, religion, oc- cupation, gender, class, social or geographic environ- ment, or education. The importance of personal explanations cannot be overestimated. These concep- tions usually have high status for individuals and, more- over, are re inforced by society.

If the cl inician fails to facilitate new understanding by the patient, three things can happen: the clinician can accept that the patient may be right and can use the oppor tun i ty to review his or her own conceptions~°; the cl inician can negotiate a clinically safe, ethically sound, exper imental situation in which the patient can safely try out his or her ideas, with preestablished con- t ingency plans in case the medical condi t ion worsens; or the cl inician can at tempt a pragmatic compromise be tween diverse views by first articulating the patient 's concept ions and then incorporat ing the concept ions of the patient and clinician into one hybrid but fruitful approach to caring for the patient. ~°, 28 The word "hy- br id" is chosen to mean the blending of two diverse viewpoints, which benefits from the vigor associated wi th hybridism. In each of these situations it is prefera- ble that the clinician know the patient 's concept ions in order to plan treatment that takes them into account.

Research has demonstrated that unless existing naive or socially constructed concept ions are identi- fied and expl ic i t ly negotiated, they may block further related learning in this area. 29 For this reason, it is of paramount importance to elicit a patient 's ideas about his or her illness and its etiology, prognosis, expec ted course, severity, and acceptable methods of treatment. Instead of assuming that the patient is an " emp t y ves- sel" that the clinician must fill with his or her own ideas, the clinician must learn a new set of behaviors.

The six steps of the model of teaching for concep- tual change are appl ied to patient educat ion in Table 1, with strategies and suggested clinician behaviors. In real life, the steps b lend into one another, and the clini- cian may cycle through them a few times. However, awareness of these steps can help prevent a clinician from falling into the trap of using the transmission ap- proach in pat ient education.

Application of Teaching Approach

Using the earlier example of Mrs. Brown, the six steps could occur as follows. 1) The cl inician orients his patient wi th greetings and acknowledgment of the agenda for her visit ( fol low-up on fatigue). 2) The cli- nician elicits her current thoughts and feelings about her health through open-ended questions. He identifies the stress she is experiencing, primarily due to her youngest chi ld 's leaving home for college, and hears her say that she thinks her body is like a worn-out ma-

chine. He acknowledges this comment . The cIinician makes a medical diagnosis that Mrs. Brown's fatigue is caused by depression, with which she does not agree. 3) The clinician makes an educational diagnosis that she is operating with an error (misconcept ion of body parts wearing out) , which is inadequate to explain her situation or to p romote healing, a confusion concern- ing the importance of sedimentat ion rates, a confusion of the medical meaning of depression, and a gap con- cerning the effects of depression. 4) The clinician in- tervenes by first helping Mrs. Brown clarify the confu- sion about sedimentat ion rates. He then helps Mrs. Brown exchange her misconcept ion of worn-out body parts for an understanding of depression, its symptoms, and possible causes ( " e m p t y nest" syndrome, midlife crisis). To do this he first attempts to raise her dissatis- fact ion with her existing explanation of her illness by suggesting to her the logical consequences of her con- cept ion of " b o d y as machine ." He then attempts to help her raise the status of depression as a cause of her fatigue by elicit ing from her the fact that her mother suffered from depression at a similar age. Her mother got bet ter with medications and resumed an active life. This helps her see the diagnosis as intelligible, plausi- ble, and fruitful. Her old concept ion of worn-out body parts now has lower status for her, and she is able to reject it. The clinician makes it possible for her to inte- grate new knowledge about depression into her exist- ing concept ions by giving her a mini-lecture on the causes and symptoms of depression and offering her a brochure on the topic. He prescribes an antidepressant and counseling. 5) The clinician checks the applicabil- ity of the plan by asking Mrs. Brown how she will inte- grate the medical regimen into her daily routine. 6) The clinician concludes the session by reviewing Mrs. Brown's problem and his medical diagnosis and check- ing her understanding of the situation, the status of her diagnosis, and her willingness to fol low through wi th the treatment plan.

Role of the Clinician in Patient Education

If we accept that peop le learn through conceptual change, then the role of the teacher is no longer that of a transmitter of information. In addition to being a skilled diagnostician, the clinician becomes a facilita- tor of patient learning about the diagnosis of the dis- ease, its etiology, prognosis, and management. The cli- nician works collegially with the patient in handling the illness and helps the patient to construct and nego- tiate the meaning of illness. The clinician seeks to em- power the patient through understanding and manag- ing the illness in the best way possible. The clinician encourages pat ient collaboration in managing medical problems, encouraging open conversation, and accept- ing that patient disagreement is possible. When view- points be tween the patient and clinician differ signifi-

JOURNAL OF GENERAL INTERNAL MEDICINE. Volume 8 (July), 1993 397

cantly, the clinician serves as a diplomat seeking ways to reconcile the conceptions.

Conceptual changes involving integration, differ- entiation, and exchange occur within the mind of the patient. The role of the clinician is to facilitate the changes by first identifying the gaps, confusions, and/ or errors in patients' conceptions, and then using ap- propriate strategies to negotiate the status of the pa- tients' conceptions relative to those of medicine. The clinician does not correct the patient, but helps the

patient to correct him- or herself through appropriate teaching based on negotiation of meaning.

SUMMARY

It is not enough for clinicians to gather good pa- tient information and then dictate management plans. If patient education is to be successful, attention must be paid to tailoring educational input to the patient's particular needs. If the conceptual change approach is

TABLE 1 Six-step Model of Patient Education

Step Strategies Behaviors

1. Orientation Establishes appropriate learning environment

and focuses on topic

2. Elicita~'on Determines patient's conceptions of illness

3. Diagnosis of conceptions Decides whether patient's conceptions are

appropriate

Decides what needs to change

Involves patient

4. Intervention Uses strategies to facilitate patient learning by

creating dissatisfaction with existing conceptions, and raising status of new conceptions

5. Application Invites patient to apply new conceptions

6. Review Reviews current understanding, progress made

Is courteous, friendly, and respectful, using appropriate verbal and nonverba[ behavior

Introduces topic for discussion (illness. diagnosis, prognosis, etiology, or treatment)

Elicits patient's conceptions concerning topic (illness)

identifies status of conceptions (intelligibility, plausibility, and fruitfulness)

Listens carefully

Is empathetic, supportive

Decides whether patient has gaps, errors, or confusions

Decides whether patient's conceptions need integration, differentiation, or exchange

Negotiates patient's "need to know"

Raises dissatisfaction with existing conceptions (helps lower their status)

Helps raise status of new conceptions

Helps patient integrate new conceptions, differentiate confused conceptions, and exchange misconceptions

Checks patient's ability to apply new idea to problem or life situation

Clinician and patient review their mutual understanding of situation, and status of new conceptions

Clinician checks patient commitment to proposed plan

Greets, introduces, smiles, is relaxed, warm, and friendly, looks at patient

Says: We need to talk about X

Asks open-ended questions

Asks: What does the idea mean? How plausible is your idea? How useful is it to you in explaining your illness?

Lets patient speak without interrupting

Acknowledges and legitimates ideas and associated feelings

Wonders: What does patient need to know? Is patient confused? Are there misconceptions?

Wonders: What strategy could I use? What methods are appropriate?

Asks: What do you think you need to know?

Explicitly compares patient's and clinician's conceptions of problem, suggests logical consequences of ideas

Names. describes, explains, clarifies

Uses appropriate teaching methods, such as mini-lectures, models, brochures, diagrams, discussion, experiments, and demonstrations

Asks: How can you use this idea? Can you explain things? Can you predict things?

Asks: Is this intelligible? Does it seem plausible? Do you believe this will help you?

Asks: Do you agree? Will you comply with treatment plan?

398 Hewson, PATIENT EDUCATION FOR CONCEPTUAL CHANGE

followed, patient differences due to factors such as age and culture will be taken into account. Likewise, the different types of patient education described earlier can be accommodated, since the patient and his or her particular needs are always the focus of all medical conversations. The conceptual change approach for pa- tient education potentially can help clinicians avoid the temptation to ignore patients' perspectives and provide instruction tailored to patient needs, thereby reducing the possibility of educational negligence.

The author thanks her colleagues Richard Day, MD, Sharon Foster, PhD, Mary Baroni, PhD, RN, Peter Hewson, DPhil, Phillips Kindy, MSSW, and Judith Van Kirk, MS, for their useful comments and edito- rial help in the preparation of the manuscript.

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