Transcript of Dr Andy Flett, ‘The Floss Exercise: Personal Experience to Aid Understanding’:
One of the key things I’m interested in as both a researcher and a teacher in the medical school, is patient behaviour, and why patients behave in the ways in which they do; so I’m interested in the decisions they make about seeking medical help for symptoms that they’re experiencing, how they act in the medical consultation, how they respond to how a doctor talks to them or asks questions or describes what’s going to be in a surgical procedure.
I’m also interested in issues to do with treatment and adherence, and that’s pretty much why people might choose not to take their medicine, why they might choose not to follow the advice given to them by their doctors and this is actually a huge problem because the NHS spends millions and millions and millions of pounds on setting up services for patients who quite often don’t follow the advice of their doctor and end up becoming ill as a result. So obviously we’ve got a vested interest in trying to persuade, or have doctors skilled enough to be able to communicate with their patients in such a way that it encourages them to follow their advice.
So one of the things I use to describe this process is called the Health Belief Model, and it’s a very simple model which describes the key factors that a patient takes into consideration when deciding to follow a treatment or not. And those are things to do with how severely they perceive their likelihood of succumbing to an illness in the first place, their beliefs about how severe the illness is likely to be, and also a weighing up of the pros and cons of taking a medication – you know, does the medicine cost money, are there side effects, will they have to take time off to go to a clinic, all sorts of things which mitigate against the perceived benefits of taking a medication.
And also there’s things like their general attitude toward health and their motivation to stay healthy and also their perception of what other people do, their peers around them, the social support they have, the advice they get from relatives and friends and colleagues. So these are all things that are kind of jumbled together in this model that’s used to predict whether or not a patient might follow treatment advice.
And again one of the things I find, or I found originally was that if I was just describing this model to a group of medical students they’d be like “yeah, great” … they’re often thinking about one thing only, and that is, “Is this going to be in the exam?”, and they want to be able to boil down what you’re teaching them into discrete facts that they can memorise and churn out again and get the marks for – this very reductivist model, conception of education. And the danger of a lecture in that sense is that it’s simply going to be that transmission of a few facts that they’re trying to memorise, it doesn’t really engage them in much meaningful learning or critical understanding of the nature of this model and how it might work.
So … I set about ways of thinking about more of a practical task for the students and decided to get them to change an aspect of their health behaviour, or at least focus on it for a couple of weeks, to give them a first-hand impression of what it’s like trying to do that and that’s one of the real difficulties that people face when trying to adopt a treatment regimen, so – I wrote to some dental manufacturing companies and one of them was very kind enough to give me quite a large supply of dental floss. This is a very basic model.
And what I do is, I do my talk about health belief models at the start of our three-week module, talk about the various models that exist and all the factors that go into these things, and then I give all the students a free complimentary dental floss – which obviously they love, all medical students love being given stuff, lifelong career freebies – and I give them an instruction to floss their teeth every day for a couple of weeks. And then two weeks later, I do another talk, which is more about the specifics of treatment adherence and the economic models, about why it’s important and going into greater detail about the various factors from research and why people do or do not adhere to treatment regimens.
And by this time obviously, I find out from them, did you manage to floss your teeth every day; and a tiny number do – it’s about four or five per cent manage to floss their teeth every day, which – it surprises them, it’s a surprising statistic. It’s a simple instruction, it’s an easy thing to do, I’ve given them a free floss, there’s no cost to them, you would imagine that most of them would do it, but actually most of them fail doing it so by having that first-hand experience of failing to floss your teeth every day they’re sort of getting a feel for why patients might not take their heart medication or attend clinics for appointments – you know, they’re seeing how real life gets in the way of medical treatment, no matter how important that medical treatment might be.