Education versus Motivation

Preventative medicine and holistic medicine certainly are nothing new for traditional family doctors. Every clinical medical course I took between 1958 and 1962 emphasized that disease and illness must always be looked at within the context of the whole person and the individual patient. On graduating in 1962 I was a firm believer in promoting healthy life styles. We told patients not to smoke, that alcohol could cause cirrhosis, and obesity and lack of exercise could lead to heart disease. By the early 1970’s we were aware of good cholesterol, bad cholesterol and its relationship to heart disease.
In the last ten years of my practice my patients would have scored 100% on a questionnaire regarding healthy life styles. Unfortunately, they would have scored 20% to 30% in terms of compliance pertaining to healthy life styles. So what makes us think that public health education will save our public health care system? And is the issue really lack of education or lack of motivation?
At least 25 years ago, studies with alcoholism showed that the initial investment in providing education was extremely cost effective. Ten percent would change their drinking habits. Unfortunately, more investment in educating the remaining 90% was not cost effective because there was a lack of readiness on the part of the patient. In fact, as practitioners, we failed miserably at treating alcoholism, and a peer group called Alcoholics Anonymous seemed to have more success and more cost effectiveness. Education was involved but more importantly, there was incentive and support and it was community based. Look at the tremendous number of weight control groups that have been in existence for the last thirty years. Most of them have an education component, an incentive component, and a support component. Still, obesity continues to be on the rise and as a consequence, type II diabetes. So how will educating the public re “healthy life styles” save our health care system? How do we motivate people to change?
About ten years ago an asthma treatment program was shown to have considerable success. The community was quite remote and the program consisted of a variety of health care professionals that registered all the asthmatics of all age groups in the area. They were involved in intensive education, regular visits, reinforcement of goals, reminders of appointments, and regular reporting protocols.. In other words, a type of ongoing parenting program was in place. Hospital emergency department visits and admissions definitely decreased. Caregivers had intensive control over the patients; almost like a hospital without walls. Caregivers were motivated, but were the patients?
I believe it was Dr. Rachlis who coined that wonderful saying: “It is better to build a fence at the edge of a cliff than a hospital at the bottom of it”. From a “disease prevention perspective”, this certainly is true in the case of the asthma program mentioned, but do we want, from a freedom perspective, government or any-other designated group having that much control of our lives? When will that “fence at the edge of the cliff” become a “corral” that completely surrounds us? In a “one payer system we should remind ourselves of the old saying: “He who pays the piper, calls the tune”. In Canada, people who have liver failure from alcohol intake, may be rejected in our transplant program but accepted in private clinics in the U.S.
It should be noted that there has been some success with smoking cessation in Canada. I saw the first good move in that direction with the dramatic increase in the cost of cigarettes 10 to 15 years ago. Along with this there was the trend to label smoking “uncool,” and now to where it is thought to be disgusting. More societal regulation has caused the smoker to be uncomfortable both physically and mentally while smoking and we know most creatures move to comfort and away from discomfort. Education, in my view, only played a small roll in the decrease. Labeling of cigarette packages seemed to have little impact. In fact, teen age females still seem to be a prevalent smoking group. The panacea of prevention in my view will not save our “Universal” healthcare system and the “We will look after you no matter what” attitude is both counterproductive and demeaning. Positive and negative incentives must be and will be necessary to motivate and change people’s high risk life-style behaviors. The issue is our choice as to who imposes the incentives, and what they will be. In a “one payer taxation supported provider system” it will be the government and may be unilateral. In a multi/provider/payer system it will be between you and your provider/insurer system. You choose: Government control and dependence---- or self determination for those that can, and a hand UP for those that can’t.