[The family doctor who taught the first U.S. self-care class describes that class and the subsequent rapid growth of the self-care movement.]
I always find myself explaining Keith Sehnert as the George Washington of self-care. Keith graduated from Western Reserve School of Medicine in 1953. After working as a General Practitioner and later as Medical Director of Dorsey Laboratories in Lincoln, Nebraska, he joined the Reston-Herndon Medical Center in Herndon, Virginia. There, in 1970, he taught—and largely invented—the first of the modern breed of self-care classes, classes in which laypeople learned basic medical skills formerly reserved for doctors only.
The class drew wide media attention. In 1972, Keith became a visiting professor at Georgetown University and in 1974 founded the Center for Continuing Health Education at Georgetown.
The Center for Continuing Health Education did self-care research, taught health professionals from all parts of the country to conduct self-care classes, and prepared course materials for these classes. In 1977, Keith became Vice President and Director of the Health Promotion Group at InterStudy, a health-policy and health-futures think tank in the Minneapolis area, and joined the University of Minnesota School of Public Health as clinical professor.
It is in large part because of Keith’s efforts that there are now self-care classes in forty states. He is the author of How to Be Your Own Doctor (Sometimes).
TF: You were saying that you were a student of Ben Spock’s at Western Reserve.
KS: Yes, back in the early fifties. Spock was just starting out as a teacher there, and his book, Baby and Child Care (reviewed on page 207) was just out. Of course, no one had any idea then it was going to become so popular.
Did he have a big influence on you?
He did. He was very concerned that most patients were getting a great deal of treatment but very little teaching. He felt that was a mistake.
I don’t think there’s any doubt but that his book planted a seed for me. I’ve always thought of my book as a kind of Dr. Spock for adults.
Were there any other experiences at Reserve that nudged you in the direction” of self-care?
Yes, the influence of another very important teacher, T. Hale Ham. In those days the whole business of a doctor’s empathy for the patient and communication skills were spoken of as one’s bedside manner. We were all very concerned about our bedside manner. Dr. Ham used to say, “Keith, you just talk to your patients in whatever way is most comfortable to you—but keep in mind that if you’re a good teacher, your patients will think you’re a good doctor.”
How did you happen to end up teaching that first self-care class?
Well, you know, serendipity plays such a big part in these things. I’d just joined a family practice group in the Reston area of Virginia. The guy who’d actually planned the class was leaving to join the Family Practice Department at the University of Wisconsin. One day he just casually asked me, ” Look, as long as you’re going to be here, would you mind picking this thing up for me?” And of course I said yes.
How many students were there?
I think there were forty, maybe forty-two. About 80 percent women. Almost all of them were patients at the Medical Center.
What was the first class meeting like?
It was an interesting experience. Many of the people in the first class were women whose husbands had been recently laid off by a reduction in the Johnson administration space program. Some of them were living on unemployment insurance for the first time in their lives.
As we got to know each other better, a lot of anger toward the health-care system started to come up. Frustrating experiences. Times when they’d been treated insensitively.
The old authoritarian doctor image was hanging over our heads, even though I wasn’t the typical authoritarian doctor. There was a lot of asking, is this something that’s okay to talk about? Is it all right for me to ask this question? And when I made it very clear that it was, they really began to share their experiences and concerns. They began to express feelings they may never have expressed to anyone before—certainly never to a physician.
It soon became clear that they had a lot of health needs that weren’t being met by the health-care system. They’d been put down and ripped off. The women’s movement was beginning to be active around that time, and the women especially were beginning to look at their lives in some new ways.
Pretty soon people started saying, “Why can’t I take my father’s blood pressure?” “Why can’t I give my kids allergy shots?” “Why can’t I use an otoscope to look in my little boy’s ear when he has an earache?”
And I found myself saying, “I don’t know why not. Let’s do it.” So the whole course evolved out of the things people were asking.
Had there been any other similar classes up to that time?
No, to my knowledge, it was the first class of its kind. There had been orientation tours for new patients in certain clinics and patient education for some specific diseases like diabetes, but nobody had ever really gotten into this area before.
How would you define this new area?
1 think of it as directed toward a new kind of medical consumer, what I call the activated patient. In my Herndon class, their questions went well beyond the boundaries of what had been thought of as patient education at that time. They wanted to know why they couldn’t have their own black bags of medical tools at home. No one had ever thought of teaching laypeople to use such tools before. There weren’t any models for that. So we just had to go along and figure out how to do it as best we could.
What motivates a person to take a self-care class?
We’ve looked at that, and there seem to be seven basic reasons people give, over and over, for their interest in self-care:
1. wanting to save money on health expenses;
2. wanting to be able to take better care of their family’s health, to be able to make effective family-health decisions;
3. wanting to take more responsibility for their own illness care—like hypertensives who want to be able to keep track of their own blood pressure;
4. wanting to learn how to hook into the medical system like a number of older people who outlived their doctors and weren’t able to find a new one they were satisfied with;
5. wanting to learn more about their bodies and how they work;
6. people with illness in the family, wanting to feel more confident in dealing with it;
7. people who’ve gotten turned on to healthier life styles, wanting to hear more about jogging, nutrition, yoga, meditation, and whatever else there might be to this whole healthy lifestyle business.
So you include more than just traditional Western medicine in your classes?
Oh, yes. Of the really alternative approaches to health, yoga is the main one we’ve used—mainly because a neighbor of mine happened to be a fine yoga teacher. If I’d lived next door to a Thai chi teacher, we might have included that. The introduction to yoga has certainly been well-accepted by our students.
I think giving these kinds of alternatives is awfully important, particularly because through them people can learn to get the same kinds of things they might now be getting from alcohol and various other chemicals. And those are not ways I like to see people relieve their stress.
How long did the Course for Activated Patients go on?
We ran two classes a year for almost three years. Then, in February of 1973, Howard Eisenberg did a story on the class for Parade magazine, and I got over two thousand letters as a result. That made me realize that what we were up to might be something with a much wider appeal than I’d thought.
About that time I began getting inquiries from the federal Department of Health, Education and Welfare, from a number of foundations, and from several of the faculty and deans who were interested in doing something more in the way of self-care at Georgetown University.
Several publishers started wining and dining me and convinced me that there was a need for a book on what we were doing. So I took a six-month sabbatical and collaborated with Howard Eisenberg on How to Be Your Own Doctor (Sometimes). Shortly after that, the Center for Continuing Health Education was formed at Georgetown, and I became its director.
So you were there until 1977?
Yes. Then our grant ran out, and the functions of the Center were divided between the Health Activated Person Program at the Georgetown School of Nursing, where they’re continuing to give an ongoing self-care course for the Washington community, and the Health Activation Network (see page 268), who put out a newsletter, “The Health Activation News,” to train self-care teachers and help people establish new courses.
You know, Keith, I have a feeling that if it had been some other doctor teaching that class, it might have ended up as just a lot of boring lectures. Have you had special training in communication, or are you just good at it?
Well, as you know, one of my daughters, Cindy, is deaf, and that’s made me very aware of the importance of getting and giving feedback. It got me very interested in good communications, and when I was talking to a patient I would always give and ask for feedback to be sure we were understanding each other.
And then the other thing was how much I loved doing it. I discovered that I liked being a facilitator better than being an authority. There was a feeling of real partnership. It was wonderful to relax out of my professional role and, if somebody asked me a question, to say, “1 don’t know. How do you suppose we’d go about finding out?”
It was a very rare thing in my medical education to hear a doctor say, “I don’t know.”
Incredibly rare. We were taught we were supposed to know all the answers.
How have health professionals reacted to self-care classes?
I like to say, scratch a doctor and you’ll find a teacher underneath. Most doctors have been too busy with day-to-day practice to develop as teachers, but once they do it, they find that it’s fun.
I’ve brought a lot of health professionals into selfcare classes, and while at times I’ve had to more or less drag them kicking and screaming into the pit, once they take off the white coat, loosen the tie, and get their shoes off, they find they’re having a fine time. It’s a real relief to be able to show your human side, and the people in the classes are always so appreciative.
There’s a real sense of working together for a common goal. Most of us went into medicine for pretty altruistic reasons. We’re not all dollar-sign guys. And when you start relating to people as active partners instead of passive pawns, they really appreciate it, and they let the doctor know.
In my medical school training, except for a little bit in psychiatry, I didn’t receive any formal training in communicating with patients. Many people would say that medical education makes doctors less capable of communicating on a meaningful level. Are there any signs that this is changing?
Well, coincidentally, I just finished reading a report on self-care from the Association of American Medical Colleges. They’re getting together a major project in which they will begin teaching self-care communication skills in a number of medical schools. Dr. James Hudson is going to be the Project director.
The American Medical Students Association also has modest self-care programs going at a number of medical schools. And of course there are all kinds of new and fairly informal projects at individual schools—there’s something here at the University of Minnesota Medical School, the University of Arizona has one, as does Georgetown University. There’s a big interest at UC Berkeley, and you were just telling me about the self-care class you visited at Wright State School of Medicine in Dayton. There’s actually quite a lot going on in the medical schools already.
Any signs of health insurance companies being willing to reimburse policy holders for self-care education expenses?
Blue Cross of Montana has started doing this on a very small scale, and some of the other Blue Cross plans have been saying they’re going to get into this area— they’re putting on some prevention education programs now. Several other insurance companies are looking into self-care education. International Group Health in Washington has started several projects. IGP’s head guy, Jim Gibbons, is a real self-care advocate.
Could you comment on the kinds of people who are—and should be—teaching self-care classes?
I’ve always felt that the ideal teacher was the nurse. Certainly the greatest enthusiasm for self-care has come from nurses, nurse practitioners, and physicians’ assistants. Many of these allied health professionals feel much more strongly about prevention and self-care than about diagnosis and treatment—which continues to be the main concern of most physicians.
Do you think it’s important for the people teaching these classes to have clinical experience?
It certainly helps. One of the real dilemmas these days is that people hear this from Reader’s Digest, that from the National Inquirer, and something else from Prevention. They need to be able to ask someone who has done more than just read the books.
How about in the schools? Do you think it would be an advantage to include people with clinical experience as a part of health-education classes?
Yes. Not only are clinical workers more likely to have experience with these matters, but it’d be very valuable for kids to be able to talk to a health worker at some time other than when they’re sick or need shots.
Do you see a connection between the widespread popularity of running and the developing self-care movement?
Absolutely. Because as people start feeling better from jogging, and begin to sleep better and eat better, they’re going to discover they have more energy than they ever did before. Then they begin to realize that health is a resource to be conserved, not something you can waste and then discard like a cigarette butt or a wrecked car.
Yes. Your body is a temple. Why treat it like a motel?
Yes, that’s a good one. So when people increase their nutritional awareness, or start jogging, or get into stress reduction, they feel better. And taken they say, “Well, gee, maybe I can kick smoking and kick alcohol and practice a healthier lifestyle. And it’ll pay off.” And it does!
What other cultural changes are we likely to see?
One we’re already seeing is a change in men’s thinking and behavior. For so long we’ve had this macho male image about everything that’s harmful or illegal.
If I smoke and it’s bad for me, I must really enjoy it. It’s a sort of bad-boy mentality. To have fun, you’ve got to be destructive—driving too fast, abusing your body or those of people around you.
That tough-guy mentality is softening. As I go into groups of my peers—men in their late forties or early fifties—I find I seldom hear the sort of thing which was the rule not very many years ago. You know, ” Boy, did we have a good time last night. I bet old Fred and I drank a fifth of booze . . .” and so on. That kind of bragging.
Now I’ll more likely hear a guy say, “You know, I’m so proud of myself. I finally quit smoking after twenty-two years.” And everyone is very interested in how he did it. They’re talking about jogging and cutting down on their drinking.
I had some unpleasant experiences—before going to medical school—when I tried to find certain health information in a medical library. It would have been much easier to look for comparable information in just about any other field—engineering, physics, biology. But technical medical information—for someone who is not a medical professional—is almost impossible to come by.
I recently called the National Arthritis Foundation to ask how our readers could order copies of a book they put out. It covers arthritic diseases in depth, it’s comprehensive, and it’s cheap—one of the best available sources of information on arthritis. I was told that it wasn’t available to laypeople, ”because they might misunderstand it. ” A medical librarian at Yale told me that she had been taught to discourage laypeople who came into the medical library in search of information, “because it was probably somebody looking for evidence for a malpractice suit. ” Why is medical information kept so secret?
Until recently, the medical mystique was much like the religious mystique in the days of Martin Luther and the Protestant Reformation—the language of the laity was one world and the language of the clergy was another. They didn’t even say their prayers in the same language. It was a priesthood. There were things that the layperson wasn’t supposed to know about.
I think that what we’re seeing now, with the demystification of medical language, is comparable to the change Luther made in bringing Christianity into the language of the people.
That’s the most important thing that happens in these self-care classes. First, you let people know that it’s okay for them to step into this formerly forbidden area, and second, you guide them in their first steps. So the main thing is not the class itself, but the fact that it can get people started. It’s a perceptual door opener.
It should be the goal of every health professional to transfer useful and accurate tools, skills, and knowledge to his or her clients. To hide these “professional secrets” and keep them for one’s own aggrandizement is a malfunction of one’s professional role.
One last question, Keith. Would you look into your crystal ball and share your thoughts about the kinds of changes we’re going to see in the next ten years as a result of the growing enthusiasm for self-care?
When I first moved to Minnesota last year, I picked up a paper and saw that a man was considering running for governor on a health-promotion platform. I think we’re going to see mayors and governors and other political leaders picking this up—and probably in your state of California, too. I think self-care will be one of the big political issues of the next decade—in the way that education and agricultural reform and honesty in government have been hot political issues.
A second thing is that the business community is going to get increasingly involved in health promotion, self-care, and helping their employees become wiser buyers and wiser users of health-care services. The big corporations especially are feeling the pain of rising health-benefits costs. In fact, the guys bathe executive suites are hitting the ceiling. These decision-makers are suddenly realizing that health insurance premiums, disability insurance, early retirement, days lost from work due to illness, are all things they can do something about. Several companies last year paid more for health benefits than they did for any other product or service. So I think we’re going to see a lot of self-care promotion on the part of industry.
Third, I think a lot of leadership in this area is going to come from senior citizens. I think that women will continue to be especially active in self-care, and I think we’ll begin to see unions taking a major role.
Fourth, we’re going to see school systems putting in really high-quality self-care programs running all the way from kindergarten to high school. There are some exciting things happening along such lines in Maine, Montana, and Minnesota schools already.
And finally, I think we’re going to see a growing number of fitness/self-care/health-promotion groups, health-information centers, health clubs, self-care classes and study groups, alternative health centers, stop-smoking clinics, and exercise facilities, more widely available black-bag tools, and so on.