Book Forewords

In Foreword 1 of this book, Dr. Ian McWhinney describes the importance of learning about the therapeutic value of dialogue in helping patients change. In Foreword 2, Dr. Kirsti Lonka (click here) describes the introspective process of "higher learning" with respect to the personal and professional context of motivating behavior change.

The information and advice we convey to our patients is often ineffective. A knowledge of risk factors alone seldom dissuades people from smoking, excessive alcohol consumption, overeating, high-risk sexual behavior or substance abuse. Knowledge itself does not change behavior. Type 2 diabetes, for example, is increasing in many Western countries, driven by epidemic obesity and physical inactivity. Yet in clinical trials, lifestyle changes (exercise, diet and weight reduction) in people with impaired glucose tolerance can reduce the incidence of type 2 diabetes by 50-66%.1

Why is it so difficult to apply our knowledge? The guidelines are available and quite straightforward. If results can be obtained in the tightly controlled world of the randomized trial, why can they not also be obtained in the world outside? It is tempting to blame primary care physicians, their patients or both. But let us at least consider that the way medicine is being practiced and taught is part of the problem. We practice a medicine based on the metaphor of the body as machine. Our logic is of linear, unidirectional causal chains, and our notion of therapy is a technology of control. The mechanistic approach to medicine extends not only to treatment but also to behavior modification based on control, reinforcement, conditioning and social engineering-an approach that overlooks human decision-making and autonomy. Not surprisingly, this approach has significant limitations when it comes to promoting healthy behavior and the self-care of chronic disease.

Most guidelines are the product of linear logic. Problems arise when linear logic meets complexity in the form of patients with their thoughts, beliefs, assumptions, expectations, emotions and relationships. This complexity is the reality of medical practice, and Rick Botelho's motivational approach is designed to deal with this reality. His groundbreaking book springs from advances in psychology and moves beyond the linear logic of control and behavior modification.

The sciences of complexity and organization provide a context for understanding the nonlinear process of change for both practitioners and patients. The work also challenges the simplistic notion of a unidirectional translation of research into practice, thus transcending the research-practice divide. This book liberates practitioners from the constraints of evidence-based guidelines without ignoring the guidelines' significant contributions.

We cannot continue to think only in terms of single causes, single-point interventions and predictable outcomes. When linear logic meets the nonlinear logic of complexity, meanings must also be considered. As Dr. Botelho says, giving advice (the "fix-it" role) is not enough. Patients have to be engaged where they live. It is not easy to change oneself: there have to be good reasons, and the motivation to change has to come from the heart as well as the head. We are all-practitioners and patients-very good at self-deception, at finding reasons (rationalizations) for avoiding change.

For practitioners educated in the fix-it role, adopting a motivational role requires a major shift from "doing" to "being" with patients. As Dr. Botelho so rightly says, going through behavior change ourselves can help us to empathize with patients facing similar changes. The self-knowledge that comes from reflection on experience can help us to sense the appropriate role for us to adopt for a particular patient at a particular time. In adopting the motivational role, we acknowledge that, for all of us, change has to come from within. We cannot enforce change in our patients, but we can, with their agreement, help them to work through the process, clarifying their thoughts and expectations, identifying sources of resistance, pointing out inconsistencies and correcting misconceptions.

We are fortunate in having a body of knowledge on motivation and behavioral change from other disciplines, and Dr. Botelho makes very good use of this knowledge. There are skills here that can be learned, and the format of the book helps by being that of a workbook. A step-by-step approach takes the reader through the process of motivational practice, using many case examples, strategies and exercises. This book lends itself to being studied alongside clinical practice. I visualize the reflective practitioner changing gradually as he or she goes from patient to book and back to patient, until mastery is achieved, the knowledge and skills internalized and a lasting transformation accomplished.

The book has great relevance for the patient-centered clinical method, recently conceived and developed as a successor to the method that has dominated modern medicine.2 The previous method laid its greatest emphasis on diagnosis, as exemplified by the clinical-pathological conference. A clinician is presented with a case report and develops a differential diagnosis, which is then confirmed or otherwise by the pathologist. The injunction given to clinicians is "Either make a physical diagnosis or exclude organic pathology." With its predictive and inferential power based on organic pathology, the method has great strength. On the other hand, it makes the tacit assumption that therapy follows naturally from diagnosis. Although such is often the case, the method has little to say about the complexities of management or about the many situations in which no conventional diagnosis is appropriate. For many people, their health status is the outcome of many interrelated, complex factors, including economic, social, cultural, educational and attitudinal issues that intersect with their biological condition.

The patient-centered clinical method is designed to deal with complexity. Like the previous method, it gives clinicians a number of injunctions.3 "Ascertain the patient's expectations" recognizes the importance of knowing why the patient has come. "Understand and respond to the patient's feelings" acknowledges the crucial importance of the emotions. "Make or exclude a clinical diagnosis" recognizes the continuing power of correct classification. "Listen to the patient's story" recognizes the importance of narrative and context. "Seek common ground" enjoins the physician to mobilize the patient's own powers of healing. Seeking common ground is the key to therapeutic success: the method requires it but does not indicate the skills required to achieve it. With this book, Rick Botelho has fulfilled this purpose.

Pedro Lain Entralgo,4 one of the foremost scholars of the history of clinical method, has reminded us that a part of the Hippocratic tradition was a "therapy of the word," whereby the physician tried to influence the patient to take the measures necessary to recover from his or her illness. The therapy called for all the physician's skill in rhetoric. Far from being an exercise in coercion, this was based on the skill of helping the patient to see what was in his or her own interest. Rhetoric at one time was regarded as one of the foremost and most difficult arts, worthy of its place in a classical education and in the curriculum of the medieval university, before the term and its meaning became debased in our own time. Dr. Botelho is teaching us a new therapy of the word.

REFERENCES

1. Pinkney J. Prevention and cure of type 2 diabetes. British Medical Journal 2002;325: 232-233
2. Stewart M, Brown JB, Weston WW, et al. Patient-centered medicine: Transforming the clinical
    method. Thousand Oaks, CA: Sage Publications; 1995
3. McWhinney IR. Textbook of family medicine, 2nd ed. New York: Oxford University Press; 1997
4. Entralgo P. The therapy of the word in classical antiquity. New Haven, CT: Yale University
    Press. 1961

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2. How to Motivate Healthy Learning
by Kirsti Lonka, Ph.D.,
Professor of Medical Education
Karolinska Institute,
Stockholm, Sweden

Knowledge about the best evidence does not necessarily change our professional behavior.1;2 Even when we use evidence-based interventions (such as providing information and advice), our patients do not necessarily change their behaviors. Most of us are not well educated in how to motivate patients who resist these interventions.

The process of developing motivational skills involves higher learning about ourselves and our patients. It involves reflecting about assumptions, perceptions, mental maps (ways of thinking), and exploring our feelings and differences in values. To initiate this process of continuing professional development (CPD), you can use this book and the accompanying guidebook (described below) to address personal and professional changes that underpin the lifelong learning process of enhancing motivational skills.

This process of higher learning prepares you to address the challenges and complexities of change when collaborating with your patients to create shared learning opportunities. Let me clarify how these books use two strategies synergistically in groundbreaking ways that epitomize what higher learning is all about.

Strategy 1. Use introspective journaling as part of your learning portfolio
In this information overload age, continuing professional education predominantly focuses on keeping up-to-date with the latest scientific discoveries. The major focus is on providing content. The self or the inner experience of the individual learner is at risk of drowning in a sea of overwhelming content. The neglect of self dehumanizes learners and places them at high risk of professional burnout, thereby losing the heart and soul of caring. Increasing considerations are given to our professional and personal growth.3;4 We also need to develop process skills to help patients learn how to improve their health.5

This book integrates improvement cycles as part of the journaling process for creating your learning portfolio (a compilation of personal evidence about your ongoing professional development).6-8 Each chapter offers you the opportunity to write a brief summary about what learning was new for you and how this new learning will change what you do. These assignments encourage you to find your personal voice by writing in the first person (I) rather than in the third person (he, she or it).

Research shows that writing is a powerful tool for this kind of higher learning.9 However, introspective journaling goes against traditional education in health care, and students and practitioners are reluctant to engage in such a learning opportunity. And yet, it is one of the most potent ways of enhancing their continuing professional development.

Strategy 2. This book inverts the traditional hierarchy of learning
European researchers have developed a hierarchy of learning categories, ranging from superficial to deep.10-12 A reformulation of these categories, as they relate to behavior change, is as follows:

As lifelong learners, we can continually refine our mental maps to deepen our understanding about the complexities of our clinical work, including the change process. The transformation from a novice to an expert on behavior change involves a continuous improvement process13-15 as well as the development of emotional awareness when working with patients.3;5 Such a learning process can enhance our capacities to help our patients find their own motives to sustain constructive behavior change.

A deeper level of learning has been added to the categories described above: personal and professional change.16 Ideally, we should undergo deep change as the consequence of engaging in any significant learning process. The self-awareness process that is encouraged in this book series involves reflecting about ourselves and our patients in ways that can enable us to work with them most effectively.4;5

This orientation and approach are what I find particularly appealing about Dr. Botelho's work. These books incorporate the principles of modern learning theories. The CPD process used in these books begins with self-focused change, both in your personal and your professional life. Then you learn a method to expand your range of skills as a motivational coach. To work in patient-centered ways, you can use your expanded range of skills to understand better your patients' thoughts, feelings, perceptions and values and to develop an individualized process of engaging patients in the change process over time.

This "process" textbook is an invaluable resource. After reading this book, you can refer back to appropriate sections when you get stuck while working with a patient. Section IV provides key content and specific suggestions for initiating dialogues with patients about tobacco cessation, alcohol risk and harm reduction and self-care of chronic diseases, as illustrative examples, but this process can be expanded to any unhealthy behavior. You will probably find that it works best to use this book as part of an ongoing learning process, using improvement cycles (see Introduction) repeatedly over time by incorporating specific suggestions into your practice. The book can also help you initiate a learning portfolio, so that you can gather evidence about the impact of this learning process on your CPD and your work with patients.

I had the pleasure of participating in one of Dr. Botelho's workshops. I have seldom observed how the application of educational principles and methods fits so well with modern learning theories. (View the videotape used in this workshop at www.MotivateHealthyHabits.com.) He is also developing online courses based on his books, so that professional bodies and educational institutions can develop formal curricula to address this major deficiency in professional education. Ideally, students and practitioners need longitudinal curricula and continuing professional development opportunities to become better motivational coaches. This increases the chances for us to develop a learning organization, where professionals create a shared vision about patient care.17

This book on motivational practice captures what higher learning is all about: the cognitive, emotional, perceptual and ethical aspects of personal change. Health care professionals of the 21st century can use this book and the guidebook to assist themselves and their patients in the change process. Dr. Botelho's work gives us all hope that it is truly possible to make modern learning theories work in action, for both practitioners and patients.

REFERENCES

1. Davis DA, Thomson MA, Oxman AD, et al. Changing physician performance. A systematic
    review of the effect of continuing medical education strategies. Journal of the American Medical
    Association 1995;274: 700-705
2. Davis D, Evans M, Jadad A, et al. The case for knowledge translation: Shortening the journey
    from evidence to effect. British Medical Journal 2003;327: 33-35
3. Hager P, Gonczi A. What is competence? Medical Teacher 1996;18: 15-18
4. Schon DA. Educating the reflective practitioner. Toward a new design for teaching and learning in
    the professions. San Francisco: Jossey-Bass Publishers; 1987
5. Makoul G. The interplay between education and research about patient-provider communication.
    Patient Education and Counseling 2003;50: 79-84
6. Lonka K, Slotte V, Halttunen M, et al. Portfolios as a learning tool in obstetrics and gynaecology
    undergraduate training. Medical Education 2001;35: 1125-1130
7. Parbooshingh J. Learning portfolios: Potential to assist health professionals with self-directed
    learning. The Journal of Continuing Education 1996;16: 75-81
8. Snadden D, Thomas M. The use of portfolio learning in medical education. Medical Teacher
    1998;20: 192-199
9. Tynjala P, Mason L, Lonka K. Writing as a learning tool: Integrating theory and practice. Studies in
    Writing, Vol. 7. Dordreth, The Netherlands: Kluwer Academic Publishers; 2001
10. Entwistle N, Ramsey P. Understanding student learning. London: Croom Helm; 1983
11. Lonka K, Joram E, Bryson M. Conceptions of learning and knowledge: Does training make a
    difference? Contemporary Educational Psychology 1996;21: 240-260
12. Lonka K, Ahola K. Activating instructions. How to foster study and thinking skills in higher
    education. European Journal of Psychology of Education 1995;10: 351-368
13. Chi MTH, Glaser R, Farr MJ. The nature of expertise. Hillsdale, NJ: Erlbaum; 1988
14. Glaser R, Bassok M. Learning-theory and the study of instruction. Annual Review of Psychology
    1989;40: 631-666
15. Schmidt HG, Boshuizen HPA. On acquiring expertise in medicine. Educational Psychology
    Review 1995;5: 205-221
16. Marton F, Dall'Alba G, Beaty E. Conceptions of learning. International Journal of Educational
    Research 1993;19: 277-300
17. Senge PM. The fifth discipline: The art and practice of the learning organization. New York:
    Doubleday; 1990