It’s easier to change a tire in a blizzard..

…than it is to change a person’s behavior.

There is a fable about a man who steps in a pothole that he did not see as he walked down the road.   He hurt his ankle and blamed others for having not tended the road.

The second man is walking on the same road, but he is watching where he walking. He also steps into the pothole and hurts his ankle. He also blames others for the presence of the pothole.

The third man walking on the same road is also watching where he is walking. He also steps into the pothole and hurts his ankle, but he blames himself for being careless.

The fourth man walking on the same road is watching where he is walking, sees the pothole and steps around it.

The fifth man looks down the road, sees the pothole, and takes a different road.

Our nation’s healthcare bill would dramatically decrease if we had less of the first three “men” and more of the last two.


Why don’t patients just change their lifestyles
and improve their health outcomes?
Why don’t patients just:
Eat better!  Exercise!
Take meds as prescribed!
Stop smoking!


Most of us are just human, impulsive, with brains driven to make the most expedient energy conserving decision – which (unfortunately) is to do the same thing we did the last time.

Our brains are highly motivated by short-term benefits; whatever “tastes good” or “feels good.”

Our brains consistently reason based on prior experience; “the last time I ate bacon I did not have a heart attack.”

There is no short-term benefit to saying no to a cigarette, cholesterol, skipping exercise, or substance abuse.  Our brains don’t think, “Wow, think how much better I will feel in 15 years…”

So how do we as nurses get patients to make these leaps in behavioral change?   The traditional answer has been, “Teach them what they need to do!”   When that doesn’t work we might send them to a class to learn, get them a private counseling session to teach them, give them handouts, hang posters, or have them watch videos.  Over and over and over….

Why does this so often fail to make long term change?

Teaching patients unmotivated to change –is of limited value.

We cannot magically will patients to change their behaviors.
The motivation to change behaviors MUST come from them!

#1 – We can’t control our patient’s behavioral choices.

One thing we can do is keep them as safe as we can while they continue to make unhealthy choices!

  • Treat them where they are clinically, not where we hope they will be if they change.
  • Remind and teach them what they need to do to feel better and be healthier.
  • Support the patient’s effort to improve their health, even miniscule changes. (Positive reinforcement, not negative!)
  • Repeat check ups regularly as per guidelines.

 #2 – Have the patient define their own “life” goals.

Ask the patient:
“How long do you want to try to live?”
“What risks (of illness, dying, disability) are acceptable to you?”

If living to 45 years (or less)– 60 is okay for them– there is no reason for them to stop smoking, drinking and drug use.

If impotency by the age of 50 is okay; there is no imperative for them to control diabetes, stop smoking or drinking excessively.

If early loss of mobility going up and down steps by the age 60 is okay, there is no reason to exercise and stretch.

If shortness of breath walking across the room or up steps is okay, continue to smoke and gain weight.

If loss of a digit or foot is tolerable, then smoking is okay with uncontrolled diabetes.


IF a patient doesn’t want those unpleasant outcomes,
it is obvious that changes in self-care are required.  

But then THEY will be making that choice to change behavior, not us!

As the saying goes, if you see someone step in a pile of manure, that’s life.
If you see someone else step in the pile and you step in it too, that’s stupid.

There is a big difference between a patient ASKING you what they need to do to have a different outcome — and us TELLING them over and over, like an annoying parent, what they should do!

#3 – We need to be willing to let patient’s control their destiny.

Not all patients want or expect to live to be 100.  We need to be reasonable, flexible, and good listeners.   There is a balance between teaching and harassment!

          A 79 year old woman who avoided coming for routine checks, was in for a mild itchy leg rash that was easily treated. She said, “By the way, I have a little lump on my left breast.”  
          On exam, I palpated a massive, obviously cancerous lump consuming half of her breast. There was no discrete mass on the right.   I sent her for diagnostic confirmation.   It showed that the entire right breast was one massive cancer and that it was spread now to half of the left!   I saw her and her son in follow up.
          “I don’t want any treatment. I just want to live to be 80, that’s all I ever wanted.”
          Her birthday was only a few months away.   After much discussion, the decision was made to put her on hospice and enjoy the time remaining.   In context, this was a time when no one talked about palliative care and aggressive treatment with radiation, surgery and chemo was the norm.   Even my collaborative questioned the choice at the time.  She lived 3 more years, with hospice support the entire time!  In control of her own destiny.

Patients diagnosed with late stage lung cancer often continue to smoke till they die, choosing shortness of breath in lieu of withdrawal symptoms.  Their specialist’s ongoing nagging rarely changes their behavior, it only creates a wall between them that does not accomplish anything positive for the patient.

But these two examples are easy.

What about the healthy, younger, chronic smokers, who really dig their heels in?   We can perfunctorily tell them to quit and check off the EMR box and walk away, or consider trying another approach.

Validate to the patient that smoking (or other unhealthy behavior) is their choice.
It immediately changes the dynamic.
Without health care professionals pushing back against their unhealthy choices, they naturally gravitate towards healthy – all on their own!

Speaking aloud as I typed the note, “So you are going to smoke one pack a day and you are not interested in quitting. You are aware of the risks of smoking and accept those risks.”  
          Patient sat up and interrupted, “I didn’t say I’d never quit.”
          I stopped typing and made eye contact. “What do you want me to write here?”
          “Well, can I get the patch?”
          “You don’t have to do that if you’d rather just continue to smoke.”
          “I’ve have been thinking about quitting.”
           This time,  I argued for smoking, to help her really own the idea. “Seriously, don’t feel like you have to do this for me. You obviously enjoy smoking. What will you do without it?”
This patient began arguing all the reasons she should not smoke and what she could do instead.   I wrote the script for the patch.

But what about the diabetic who refuses to stop eating donuts because she doesn’t want wrinkles that would come if she lost weight?

After fifteen years of trying every clever trick in the book, you write a post about how patients don’t change what they don’t want to change.

Then — document, document, document…

And focus on what the patient is willing to change!

For more stories follow the link to  Nursing Chose Me:  Called to an Art of Compassion!