This week’s topic for discussion on the Patient Engagement Design MOOC began with a presentation by a patient that discussed that from a patient perspective, that level of engagement varies. I really liked how Dana Lewis (the patient) used Maslov’s hierarchy of needs as a way to present patient needs. When an issue is life threatening, the patient needs to be much more engaged – they are motivated to be much more engaged. I think this first presentation was a good started point at trying to develop an appreciative understanding of the patient experience. It helps to understand what the true ‘need’ is in the patient engagement problem.
Where I got lost was the presentation by Nir Eyal regarding the HOOK model (used in economics) and the entire focus on ‘habits’. I failed to see the link. When Nir Eyal confirmed that the HOOK model was based upon Skinner’s bevaviourist theory, I realized why I was having trouble. You see, behaviourist learning works great for temporary change (how many ‘habits’ have you developed only to stop them later?) – but not for life-long change. What wasn’t mentioned in the stimulus-response model was that when you remove the reward the behaviour stops. So, yes, the use of random (variable) rewards encourages the behaviour, what isn’t said is that when you stop the rewards the behavior also stops. This makes for a change that is not sustainable. Works well for short-term goals, but not for life-long goals.
In the field of education, when we consider deeper learning, and particularly when we are looking at learning that we want people to truly internalize, we look to the constructivist and social-constructivist theorists. This is a completely different view on how people learn (and therefore, how people change their behaviour). It is philosophically different.
In patient engagement, we use terms like ‘collaborate’ and ‘engage’ – and the assumption here is that we are looking for patients not just to ‘mimic a new behaviour’ but to truly believe in the change that is expected. So, if we want true engagement, we need to start from a theory that is based upon engagement. We should be talking about Vygotsky. We should be talking about how people learn through social negotiation with one another – and by actually engaging in conversation between patient and one’s care team, and through that engagement we can then co-develop (together) a treatment plan that works. Without the co-creation, we are going back to ‘dictating’ model that puts the physician as ‘expert’ and ignores the uniqueness of the individual patient. This is not engagement.
So now I challenge the course creators to find a better model or way of teaching this topic – one that is based upon the psychology theories of Vygostky and not Skinner!