I’m guilty. I’ve posted over 1300 posts on this blog, and I know I’m guilty of doing two out of three, and failed to do the third. The two I’ve done a lot? What and why. What the evidence suggests and what could help people with pain and the clinicians they see. I’ve written about why these ideas might help and why they’re important. But I have not spent nearly enough time on how. And here’s why.
What is about specifying approaches, ideas, facts. It’s most of the content we read in research articles – the ‘so what’ conclusions. I write often about the ‘so what’ because research doesn’t help a lot if there isn’t any consideration of ‘what does this mean in practice?’ Most health professionals are taught ‘what’ during their training – it’s the cornerstone of clinical practice. Consequently, if you ask someone ‘what do you do?’ you’ll hear a lot about the assumed purpose of a profession, and the angle that profession takes on health. For example, physiotherapists will say ‘we’re about restoring movement and function’ and draw on ‘in-depth knowledge of how the body works, combined with hands-on clinical skills, to assess, diagnose and treat your symptoms.'(
Why refers to the underlying rationale for what a clinician offers. The ‘why’ is the justification for treatment. This is based on the clinical model or theory a clinician (and profession) uses to conceptualise both health and disease, and the specific way a treatment is thought to work. The why is used when explaining the importance of doing as the therapists suggests. This is especially important when you as the treatment recipient need to do things yourself: take medication, do home exercises, do the regular mindfulness and so on.
The ‘paternalistic’ approach to healthcare didn’t pay as much attention to explaining why because it was often assumed that the clinician was the authority, based on the Hippocratic convention of the doctor to ‘us[ing their] judgement to try to benefit the patient and protect the patient from harm.’ (Veatch, 1989, p.47). This stance, however, could over-ride the person’s own right to self-determination or autonomy. People have their own values and priorities – and these might not align with a health professional.
In an era moving towards person-centred care, it would be wonderful to learn that young medical practitioners (house surgeons, resident doctors) understood and respected this right, but a study by Driever et al (2022) found paternalistic attitudes continue. These were influenced strongly by context (because nuance is always present, right?) but also by practitioners’ belief that they are responsible for arriving at the ‘correct diagnosis’ and ‘providing the best evidence-based care’. Mostly they would propose a single specific treatment based on evidence-based guidelines and then ask the patient to consent. They’d offer benefits and risks of possible options and let the patient decide only when no guideline recommendation was available (p. 6), and otherwise decided whether the patient ‘could’ make their own decisions based on ‘a feeling, you can always tell’ (p.6). We have a way to go, huh.
But neither of these ‘what’ and ‘why’ processes consider something I think is utterly critical, particularly for people with chronic illnesses like chronic or persisting pain: how.
How refers to implementing, integrating, personalising and making health practices habitual. How is the hard part for many people. It’s about the best time of day to do the mindfulness. It’s about what to do when the first option for movement practice isn’t available – when walking for health can’t happen because the weather is ugly, or the gym isn’t open, or there’s nobody willing to play tennis. How is about remembering when to take the medication – is it with food? before food? after food? best in the morning? the evening? How is about activity pacing in a retail setting where people arrive and need serving right then, or when there’s a family wedding and it’s impossible to say to guests ‘stop now because I need to pace’. How is about ways to adapt over a lifetime. During a flare-up. When we’re ill with something else. When we’re on holiday. When we’re super busy at work. How is all the minutiae of living daily life.
As I said, I’m guilty throughout my writing this blog of doing a lot of what and why, and rather less on how. The reason: how is hard. How means dialogue. It means taking time to understand context and values. It means knowing principles and applying them in unique places, times and alongside other important values. Like many health professionals, I’ve assumed that readers will understand the what and why and know how to apply these ideas in their world. I’ve expected that people know their own contexts and be able to work out how to modify principles to fit their practice.
Thinking about this now, I appreciate I’ve been wrong. Knowing what and why doesn’t mean people know how. It’s a lot like riding a bicycle: you can read about what to do, you can understand why, but you won’t learn how until you get on the bike and do it yourself.
Does this mean I should specify how clinicians should do the things I write about?
I don’t think so – at least, not exactly.
In the same way we learn to ride a bicycle with support – either training wheels or a person pushing us to keep us balanced – clinicians probably need some scaffolding. Scaffolding is intended to to provide support and stability during construction. Scaffolding is intended to be temporary – we wouldn’t want to have to use scaffolding to get to the top of a multi-floor building once its opened. It’s used for a purpose. It’s not intended to remain.
Clinical scaffolding can look like simplifying, providing step-by-step processes, and providing structure. It can mean collaborating with a mentor or a clinical supervisor who understands and supports you as you develop your own approach to practice. It’s about operationalising concepts as they can be introduced into your unique context. Perhaps having a recipe to follow until you can improvise.
I’ve been worried about the introductory ‘recipe’ becoming The Thing rather than a temporary aid. But with my What and Why approach, I’ve done what many clinicians do: given bare information and rationale without delving into contextual application. I’ve justified this by saying I don’t know everyone’s clinical context – and I don’t. I can’t know your particular setting.
BUT, and here’s my learning today, I can break these ideas down into bite-sized ‘experiments’ you can try out. Look for more of these in my upcoming posts.
Today, here’s one to consider. When you suggest someone tries something like, say, activity pacing or mindfulness, go beyond telling them what and why. Find out how they might do this thing.
What time of day works best for their daily routine?
Who might be around to help (or hinder)?
What might get in the way?
What might support it?
Can this thing be done in different ways to meet the same goal?
Can this be an experiment to see what the person notices when they do it?
Driever, E. M., Tolhuizen, I. M., Duvivier, R. J., Stiggelbout, A. M., & Brand, P. L. P. (2022). Why do medical residents prefer paternalistic decision making? An interview study. BMC Med Educ, 22(1), 155.
Veatch, R. M. (1989). Medical ethics: Its implications for the development of professional ethics. In Values in Teaching and Professional Ethics, ed. C. T. Mitchell, 37–52. Macon, GA: Mercer University Press.
