An anxious face appears at the door and lets me in. She takes me through a small kitchen, hazy with cigarette smoke, where a number of other concerned faces look at me expectantly. I nod briefly before I'm led upstairs to a small sparse bedroom where a lady in her late fifties has finally given in to lung cancer. Her lifeless body looks cruelly destroyed by the illness. Before I leave I stop in the kitchen and try to find some suitable words of comfort to offer the gathered relatives. As I am talking I notice a cigarette packet lying eerily on its own on the table. It shouts a grisly warning — SMOKING KILLS. I wonder what these grieving smokers think. If seeing a loved one prematurely ravaged by an illness, doesn't make them want to throw away their cigarettes, what is an impersonal warning on a cigarette packet going to do?
In his book, Redirect: the Surprising New Science of Psychological Change, the psychologist Timothy D Wilson takes an evidence-based look at approaches that have been used to try and change problematic behaviour. He points out that well-meant common sense often doesn't work. In fact, it often has the opposite effect. Most attempts to modify behaviour are not adequately tested, many do not work, and some even do harm. He mentions numerous attempts to deal with problems such as teenage pregnancy, drug and alcohol problems, where the problems actually got worse as a result of well-intentioned interventions. Scaring people with shock tactics often just reinforces people's fatalistic beliefs about their own self image which leads to habits becoming more ingrained.
This chimes with my experience. Over the years I've seen so many enthusiastic initiatives fall by the wayside. For the New Year I decided to declutter my room. As I cleared mounds of old papers I found many forgotten glossy pamphlets, proudly announcing various projects that promised to deal with all sorts of health problems. Many had been launched with a fanfare of brightly coloured balloons and t-shirts with snappy slogans. Most of these have long fallen by the wayside. A few years down the line the pamphlets look as out of place as Christmas decorations in January
The New Year also brought me news that I should nag patients more. The NHS Future Forum1 wants health staff to routinely talk to patients about their lifestyles, even when they are suffering an unrelated illness. Is there any evidence that this will make any significant difference? Or will it, like many of the projects described by Wilson, cause more harm? The Forum thinks that this approach will transform the relationship between medical staff and patient. I suspect that it will transform relationships from one of trust to a suspicious parent–teenager one. Patients will feel that whatever problems they bring we will only be interested in nagging them about keeping their lives tidy.
Yet over time I do see people changing and make better choices for their health. I believe that it comes first of all from dealing with a patient's own primary concerns and worries, then gradually planting seeds about other things they can change when the time is right, and allowing them to nurture these in their own way. If simply being aware of problems and using willpower worked then the landscape at this time of year wouldn't be strewn with already broken New Year's resolutions.
Clumsily trying to shoehorn your own agenda into consultations at every possible opportunity will just alienate patients and ingrain unhelpful behaviours even deeper, and another well-meant idea will go up in smoke.
- © British Journal of General Practice 2012