“I never refilled the medicine. Was I supposed to?”
“I didn’t start that diet. I don’t know why, I just didn’t.”
“Yes, I did start smoking again.”
“I know I was supposed to see that specialist/get that test/go to physical therapy, but it got away from me and I didn’t make the appointment.”
If you are a healing professional, someone has said one (or all) of these things to you.
If you are a human being who has ever gotten advice from a healing professional, you have either said at least one of these things to them, or you might actually be a cyborg.
“Well, how do you expect to get better?”
“This isn’t going to happen magically!”
“You need to take your illness more seriously.”
“I told you this would happen if you didn’t use the nicotine patches I prescribed you.”
If you are a human being who has ever gotten advice from a healing professional and not followed through on it, they have reproached you in one of these ways.
If you are a healing professional who has ever had someone you were caring for disregard your advice, you have either said at least one of these things, or you, too, might be a cyborg.
Let’s do some teshuvah (repentance, return to the way things ought to be) for those words.
Guilt is a natural reaction to falling short. In small doses, it is a powerful motivating force. It works best when it comes from an internal voice that says, “I am better than my last action would indicate. I need to up my game.” But when imposed externally, or when it becomes overwhelming, it can quickly turn into shame, and drive people away from the behavior they wish they had done better with. A study of organ transplant recipients in Israel found that guilt toward the donor of the organ was among a handful of factors correlated with worse adherence to taking their immunosuppressive medications.[1] A Canadian study of patients in cardiac rehabilitation regimen found that patient guilt over family obligations that they couldn’t keep up due to their condition predicted worse adherence to treatment.[2]
As the quotations above showed, though, health professionals themselves are often the source of guilt. At the risk of sounding typically arrogant, I don’t need a study to tell me what happens to adherence in those cases. I’ve seen it with my own eyes – people stop coming back. Afraid of, or more likely annoyed by, the expected tongue-lashing at their next visit when they don’t follow through, they would rather skip the visit, change practices, see an alternative practitioner, or just give up.
I want us to practice some different language. Throw out the second group of four phrases above. Instead, repeat after me: “And now…”
The Hebrew for “And now…” is ve’atah, and it appears a lot in the Torah to begin segment of a speech or a story where one chapter is closing and another beginning. One place where it appears is in the reading for this week, Parshat Va’Etchanan, at the beginning of Deuteronomy 4:1. The Vilna Gaon reads this word and explains, “For when a human being repents everything they did in the past is forgiven and God looks at them as they are right now. This is the meaning of ve’atah.”[3]
The first step of repentance is confessing – admitting that we did something wrong. When you, the person seeking care, come before me, the healing professional, and say, “Yeah, I never went on that website to explain the FODMAP diet, so my GI problems are the same as ever,” that’s a confession. And my job is to say, “And now…?”
I’m with the Vilna Gaon – once you tell me, honestly, that some part of the plan never happened, we’re clear. We’ve got a blank slate and we’re starting again. It’s not my job anymore to say, “Didn’t I tell you?” or “What were you thinking?” Instead, it’s my job to say, “Let’s figure out how this time can be different?” or “What do you think might make it hard for you to reach the goals we’re setting?”
An internist in my state recently gave a webinar on how she helps people achieve meaningful lifestyle change in 20-minute visits. Her technique is to ask for one change they think they can make and then how likely they are to complete that project by the next time they see her. If the answer is “5/10,” she asks what they could do to make it into an 8/10 or higher. Invariably, they have an answer for her. I’ve definitely got time for that in my visits.
What I don’t have time for is the round-and-round recriminations and figuring out what went wrong, rabbit holes that have no end (and often no rabbit). Both you and I leave those visits feeling awful, like we’re bad at our jobs and mad at each other. I only have time for now.
Or, if you prefer, for “And now…”
[1] Shemesh Y et al. Feelings of indebtedness and guilt toward donor and immunosuppressive medication adherence among heart transplant (HTx) patients, as assessed in a cross-sectional study with the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS). Clin Transplant. 2017 Oct;31(10). doi: 10.1111/ctr.13053. Epub 2017 Aug 19.
[2] Jackson L et al. Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors. Heart. 2005 Jan;91(1):10–14. doi: 10.1136/hrt.2004.045559
[3] Aderet Eliyahu on Deuteronomy 3:29-4:1, https://www.sefaria.org/Aderet_Eliyahu%2C_Deuteronomy.3.29.1?lang=bi English translation mine.
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