For the last 20 years, I have been providing patient education and care and for the last 15 years, I have been a Certified Diabetes Educator. But, the most learning and advancement in my career has happened over the last 8 years—when I started using the Conversation Map® tools.

The single greatest impact on my effectiveness as an educator is that I have learned to listen and not to teach. In order to make this transformation, I had to unlearn old habits that took me over 10 years to build. The benefits have been great; the skill of active listening allows me to be more empathetic to my patients, better understand their needs, and help them help themselves.

Besides learning from using the Map, I also have gained several insights from Healthy Interactions Senior Map Developer, Chris Hohenberger, who has been developing Map tools for the past 25 years. Working with Chris has been rich and enjoyable and I’d like to share some of his experiences and perspectives with you.

Q1. Chris, how did you get involved in Conversation Map development? Does being an attorney help you in the Map development process?

A long time ago, I went to work for a strategic planning company. At that time, we were working on ways to help our customers better implement their strategies. One of the biggest roadblocks to strategy implementation was the learning speed of the organization; how quickly could an organization of hundreds of thousands learn about the market forces, financial directives, customer value drivers, and the operating processes of their business in order to be successful? The result of this quest was the Map process and methodology. The skills learned as an attorney fit the development of the Map methodology like a glove. As a trial attorney, I was trained to ask questions and present tangible and sometimes intangible evidence to elicit a story to help 12 people reach a conclusion. In the Map methodology, we take data and information that tells a story and create Socratic dialogue questions to allow a small group of people to have a conversation that leads to inevitable conclusions. 

Q2. A few weeks ago at a session, your feedback to me was, “do not jump in and answer a question.” A patient had a question and my reaction was to respond immediately with an answer, as it was a “teachable moment” for the group. Another time, I reviewed all of the medication categories during a session and you asked, “Why are we teaching them about mediations that they are not even taking?” I responded, “Because they need to know, otherwise I am not providing DSME for them.” Why is it so bad to teach a little at the Map session? 

Our focus is not on taking away opportunities for “teaching moments,” but rather, to create “learning moments.” There is widespread support for the premise that in order for learning to take place, some or all of the following elements must be present for the learner (regardless of the type of learner – ie, visual or auditory). These include:

1. Meaningful content – the information received by the learner must be relevant to them.¹
2. Safe & supportive environment – If trust and support are established with the learner, learning is increased between 15% and 22%. If the fear of failing is present, learners forget as soon as the need to know is over. ¹
3. Assessment – The brain has an ability to demonstrate understanding in a variety of ways. Are learners provided different methods for demonstrating understanding? Is program assessment provided?²
4. Feedback – The brain thrives on feedback. It is a critical ingredient for building intrinsic motivation, accurate mental models, personal and professional growth, increasing the quality of work, and boosting self-esteem.²
5. Time (soak time) – Time is needed for the brain to find patterns between new information and prior experiences. The brain continues to search for meaning long after the initial question is asked.¹
6. Choices – Choices alter the chemistry of the brain and increase the likelihood that the learner will be able to detect relationships between new information and situations with existing patterns in the brain. ¹
7. Collaboration – It has been said that none of us are as smart as all of us.  Learning is born out of linking new information to prior experiences and exposing ourselves to more inputs, creating greater opportunities for new connections!

In the Conversation Map process, we ask that the facilitator not provide immediate answers. Instead, we want learners to make new connections and to have adequate soak time to connect the dots. If we simply respond with an immediate answer to a question, the learner’s search shuts down.  Perhaps added input throughout the rest of the Map session will allow for the necessary time and/or input to arrive. If after the session is complete, the facilitator feels that erroneous conclusions are present or a question is left wanting, then feel free to step in. Better yet, find a new question to help facilitate the connections!

Q3. What is the purpose of the Conversation Map session?

The primary reason/cause for building the Conversation Map arose out of our core belief that people will tolerate the conclusions of others (ie, leaders, doctors etc.), but they will only act based on their own conclusions. So the principle function of any Map session is to present information and data to people in such a way that they will come to their own conclusions. With these conclusions, they are better equipped to take responsibility for their welfare and make the desired behavior change. As a wise man once said: “An individual without information cannot take responsibility; an individual who is given information cannot help but take responsibility,” Jan Carlson, Former Chairman of SAS Airlines.

Q4. The concept of the Conversation Map tools has been around for 25 years, but only 10 years in the field of direct patient education. What can we, as providers of self-management education, learn from the corporate use of the Map tools?

From my perspective, healthcare has done a much better job of educating their “customers or patients” than business has ever done. However, businesses that have used the Map methodology have come to learn that their greatest sustainable and competitive advantage is to trust the collective wisdom of their employees. By sharing the business intelligence that is typically locked behind the doors of executive boardrooms, they are enhancing the overall capability and capacity of their organizations. Likewise, if healthcare professionals could trust the collective wisdom of their patients and allow them to wrestle with the pertinent information they need to effectively self-manage their condition, they will come to the right conclusions, and with those conclusions, change behaviors.

Q5. What is the question that I should be asking you but I am not?

Answer: Perhaps a meaningful question is: what is the connection between learning and behavior change? How does one create the conditions for real and sustained change? We submit that if you are going to speak to change you must speak to learning—they cannot be separated. According to behaviorists, learning and change are interconnected. Specifically, learning can be defined as the relatively permanent change in behavior brought about as a result of experience or practice.³ In Learning in Adulthood: A Comprehensive Guide, learning is defined as “a process that brings together cognitive, emotional and environmental influences and experiences for acquiring, enhancing and making changes in one’s knowledge, skills, values and worldviews”⁴ (48, emphasis added).

Q6. What have you learned from working with clinicians like me?

Like most educators, the principle motivator for clinicians is the care and welfare of their student-patient. Their medical expertise is amazing and their desire to transfer that knowledge is equally amazing. The more time we spend with clinicians like you, the more we believe the Map methodology offers them an opportunity to elevate the conversations and the transfer of knowledge necessary to make meaningful behavior change.

1. Chapman C. If the Shoe Fits…How to Develop Multiple Intelligences in the Classroom. Northbrook, IL: IRI/Skylight Publishing; 1993.
2. Black P., William D. Inside the Black Box Raising Standards Through Classroom Assessment. London, England: GL Assessment; 1998.
3. Cunia E. Behavioral Learning Theory. Principles of Instruction and Learning: A Web Quest. 2005.
4. Merriam S, Caffarella R, Baumgartner L. Learning In Adulthood: A Comprehensive Guide. 3^rd edition. San Francisco, CA: Jossey-Bass; 2006.