Updated: Oct 18, 2019
“Our group has come to understand that the challenge of evidence isn’t simply communicating what we know clearly to our patients—although that alone is a significant challenge. Instead, the real challenge is how to use evidence to discover what’s best for the particular patient in light of his or her circumstances and values.” (Hargraves et. al. 2016).
Ever felt incredibly lucky? I certainly have recently. In addition to my new role here at Thought Architects, I just started with the University of Alberta in the Faculty of Medicine and Dentistry in the Department of Lifelong Learning (or L3 as the “insiders” call it). The leaders there believe that a key piece of continuing education that physicians, dentists and their teams need is the ability to foster others’ thinking – and they want to bring Cognitive Coaching into their “pillars” of support. What I love about this new gig is that I am surrounded by passionate leaders, thinkers and doers who want to impact change. (As an aside, stay tuned for my next podcast on leadership – and how it can be truly great!)
As part of this new work I am taking on, I found myself at the Mayo Clinic in Rochester last week. Their conference on “Care That Fits” is the next iteration of the Minimally Disruptive Medicine (MDM) model. At the heart of the MDM model is the need to look at care and the burden of care differently. There is a subjective sense of capacity and capability that any patient has when balancing the demands of life and care, and how much capability the patient feels they might have. The premise is that in medicine we not only need to be attune to the medical condition, but also the real needs of the patient. For example, it is more about our need to “do our job” of providing medical advice when asking a patient to more frequently monitor blood sugars when they might have issues of food insecurity, or might be living in an abusive relationship. Instead, our jobs need to be about honouring what the patient values and needs, provide the “best medical advice”, and then help the patient make up their own mind on what makes sense for them. The challenge that providers have is that what we might want patients to do might not be what they want to do – and how to be OK with that.
How do we create the right conditions so that our goal of care evolves to fostering a greater the sense of self-directedness a patient has to manage his or her own condition, life circumstances and environment. In Cognitive Coaching, self directedness is defined as someone who is able to:
1. Self-Manage – I am in charge of me
2. Self-Monitor – I know how I am doing
3. Self-Modify – I know how to make changes in what I want to do
A nuanced shift in medical practice occurs when considering MDM. Building the resourcefulness of the patient to be self-directed is the ultimate outcome and goal of care – not necessarily adhering to best-practice guidelines. This requires providers to intervene not at the behaviour level, but instead at the “thinking level”. All behaviour is preceded by thoughts. Impact the thoughts, you can impact the behaviour.
At some level, a patient will have to decide to make change or not make change. A change in their lifestyle, how they live or the decisions they make. As providers, we hope that patients will make decisions that foster health and well-being (at least by our definition - a possible blind spot). Providing that definition is our role as a “consultant”. Fostering a patient’s sense of resourcefulness for change is our role as a coach.
One supportive approach to aiding providers is the use of shared decision making approaches (SDM). Changing workflows in practice to support SDM can be challenging at times. The brilliant Kasey Boehmer (@krboehmer) and her colleagues have developed the ICAN Discussion Aid through several iterations of user-centered design principles, interviews, and observations. It captures a patient’s subjective sense of burden and capacity, and helps shape a clinical encounter towards what is important to the patient in their care. It has been used not only to support patient-centred care practices, but also as a program planning and quality improvement tool. You can find the tool online:
Interested in learning more? Reach out on Twitter (@msmaerov) or at firstname.lastname@example.org and I can share what I learned, and see if the ICAN might be a fit in your clinic!