Tag Archives: modifying health behavior

The Fastest Way To Disempower, De-Activate, and Disengage Any Patient

I may not know how to tell the difference between an empowered patient, an engaged patient, or an activated patient.  But I do know that fastest way to disempower, disengage, and de-activate any patient is a trip to the doctor’s office or the hospital.  A visit to an average primary care physician (or specialist) is to an empowered/activated/engaged patient what Kryptonite is to Superman.  It will stop all but the strongest willed patients dead in their tracks.

We patients have been socialized that way.   Think about your earliest memories of “going to the doctor.”  For me, I remember my Mom taking me to the Pediatrician.  Early on I learned by watching the interaction between my Mom and the doctor that they each had a role.  The doctor’s role was that of expert – he spoke and my Mom listened.  I was there just to have one or more extremities twisted and prodded.  And oh the medicinal smell…

Things haven’t changed much in the 40 years since I was a kid sitting in Dr. Adam’s office.  Well maybe the smell isn’t as medicinal.  But the roles played by doctors and patients haven’t changed much.   Studies over the last 30 years consistently demonstrate this unfortunate reality.  If you were to believe the admonitions of the NIH, AHRQ, hospitals, pharma and every WebMD-look alike, you would think that patients these days would be more involved in their visit…asking questions, sharing information and making decisions.  But as most physicians will attest…most patients don’t have much to say in the exam room anyway.   And the longer they have to wait before being seen, the less patients are likely to bring up the few questions they wanted to ask.

This is a huge problem.  It belies conventional wisdom that the key to fixing health care begins and ends with changing patient behavior.  If only we could get patients to be more compliant, if only patients would do what I tell them, blah, blah, blah.

Physician behavior, specifically, the way they think about, relate to and talk to patients needs to change (no e-mail, text messages and social media will not solve this problem)…before long term, sustainable change in patient behavior is possible.

If you look at most theoretical models underpinning patient empowerment, patient activation, etc., you will see that none of them factor in the impact of the care delivery context, e.g., doctor’s office, hospital room, surgery suite, or pharmacy, on patient behavior.   A patient considered Stage IV (Activated) on the Patient Activation Model (PAM) or the “Action Phase” using Stages of Change would “crash and burn” if their doctor is among the majority who employ a traditional physician-dominated, biomedical communication style or “bedside manner.”

How empowered, activated, or engaged can a patient be if they don’t know when to open their mouth, are ignored , or fear taking up too much of the doctor’s time?

Yes you can and should probably change physicians…but since so many physicians “practice” the same way…even supposedly Patient Centered Medical Homes…what’s the point?

Until health plans and providers take a serious look at incentivizing physicians to become more patient or relationship centered, behavior change efforts directed at patients can only accomplish just so much.

That’s my opinion.  What’s yours?

Sources:

Cegala, D. An Exploration of Factors Promoting Patient Participation in Primary Care Medical Interviews.  Health Communication, March 2011.  1–10, 2011.

Related Posts:

6 Seconds To More Effective Physician-Patient Communications

Lack Of Time And Reimbursement  – Is That Why Physicians Don’t Do a Better Job Communicating With Patients? 

The Critical Role of Patient Trust In Their Doctor – Infographic

[tweetmeme source=”Healthmessaging” only_single=false]Often the simplest solutions to problems are the best.   So it would seem when it comes to the impact that increasing patient trust in physicians could have on  many of the  intractable challenges that face the health care industry everyday like non-adherence, lack of involvement, poor health status, dissatisfaction and so on.

I explore the link between patient trust and outcomes in the following infographic I curated and designed.   What surprised me is how a patient’s level of  trust in their doctor, like so much of what I talk about in this blog,  boils downs to the patient’s perception of the physician’s ability to communicate.

Patient Trust in Their Doctor

Looking For A Way To Engage Patients In Behavior Change? Try “Storytelling”

[tweetmeme source=”Healthmessaging” only_single=false] My wife had just finished meeting with her medical oncologist for her bi-annual check-up at MD Anderson’s Thoracic Clinic.   We were sitting in an area called “the Park” rehashing what her doctor had said when a mother and her daughter sat down at our table.   There were lots of empty seats in area but for some reason they decided to sit with us.  Call it serendipity.   It turned out that both my wife and Megan (the daughter) had just gotten “good news” from their respective oncologists.

We ended up talking with our new friends for one and a half hours – my wife and the daughter about the travails of cancer (hair loss, uncertainty, and so on) – the mother and I about care giver stuff (insurance authorization, navigating the health system, etc.).  My wife and I always feel so energized after “talking story” with other dealing with the same issues.   You see these “chance meeting” always happen to us….and a lot of other patients as well I suspect.

Talking Story Hawaiian Style

I have always supposed that there was some “therapeutic benefit” to these chance meetings with other cancer patients.    Turns out I was right according to a recent study of hypertensive patients in the Annals of Internal Medicine.

The study explored the use of culturally-appropriate “storytelling” among a population of inner-city African-Americans (71% women) diagnosed with hypertension.   In the study, an experimental group of patients received a DVD showing “people just like them” talking about their experiences living with high blood pressure.  For example, lessons learned about how to best interact with their physicians, and strategies to increase medication adherence.   A control group received a general introductory DVD on hypertension without the “storytelling.”

The study found that that patients diagnosed with uncontrolled hypertension benefited the most from receiving culturally sensitive “storytelling” messages promoting hypertension control.  People in the experimental group (at 3 months post baseline) had an 11mm Hg greater reduction in systolic blood pressure than the control group.  Smaller reductions (6mm) were also found for diastolic blood pressure among the experimental group.  No change in systolic or diastolic blood pressure was found among patients in the experimental group diagnosed with controlled hypertension.   Blood pressure reduction in these patients from baseline to 6 to 9 months also favored the intervention group for systolic and diastolic blood pressures.

Researchers theorized that narratives or “storytelling” can break down cognitive resistance people may have to behavior change by helping listeners:

  • make meaning of their lives
  • actively engage them in their care
  • influence  their health behavior
  • get them to imagine picture themselves taking part in the same behavior/action

So What Does This Mean For You?

Storytelling may well turn out to be an effective, inexpensive, and highly appealing strategy for engaging patients with all kinds of conditions in behavior change.  Primary Care Medical Groups, Accountable Care Organizations, Health Plans, Population Health Management and Disease Management Vendors should explore ways of “pairing up” culturally-like patients…say with uncontrolled hypertensive patients with culturally similar patients who have successfully gotten their condition under control. Same thing diabetes, asthma and other conditions. Social media, e-mail and the telephone are ways that patients can begin sharing their stories…and improving health outcomes.

If you would like more information on “storytelling” and how it might work for your organization, feel free to contact me by leaving a comment below.

Sources:

Houston, T. et. al.  Culturally Appropriate Storytelling to Improve Blood Pressure A Randomized Trial.  Annals of Internal Medicine. 2011;154:77-84.

Health Behavior vs. Doctor-Patient Communications – Are We Focused On Modifying The Wrong Thing?

[tweetmeme source=”Healthmessaging” only_single=false] It seem like everyone these days is focused on changing some aspect of patient health behavior. You know, getting patients to get a mammogram or PSA test, exercise more, take medications as prescribed, or simply becoming more engaged in their health care. If only we could change unhealthy patient health behaviors….the world would be a better place.
 
I agree with the sentiment, but I think that patients and their health behavior often get a “bad rap” from health care professionals. I would even go so far as to say that much (not all) of what we attribute to poor patient behavior is more correctly attributable to ineffective doctor communications with patients.
 

In my last post I talked about the link between strong physician advocacy, e.g., I recommend, and desirable health outcomes, i.e., patients getting more preventive screening.
 
Here’s what I mean. Mammography studies have consistently shown that screening mammograms rates would be much high if more physicians “strongly recommended” that women get screened, e.g., “I recommend” you get a mammogram. In studies where physicians advocated for screening, mammography screening rates were always higher compared to physicians that did not advocate for them.
 
The same phenomenon can be found in studies dealing with exercise, weight loss, colorectal cancer screening, HVP immunization, and patient participation in clinical trials. In cases where physicians unequivocally recommended to patients that they do XYZ, patients were much more likely to do it…or at least they were much more likely to try. I am not naive enough to believe that an unequivocal recommendation from a physician is a “cure all” for the most recalcitrant patients. Factors such as level of patient trust in the physician and patient’s agreement with the physician’s diagnosis are mediating factors. Depression and fatigue from dealing with chronic conditions also play a role. But the evidence clearly suggests that a good many patients probably would respond positively to a strong recommendation from their physician.
 
Here’s an anecdotal experience describe by a physician comment on my last blog post:
 

“I agree that doctor-patient communication is critically important. My 50 year-old best friend shuns doctors, but told me he is getting a colonoscopy because his doctor strongly recommended it. “

Here’s the basis for my thinking. Many patients operate on the principle that if my doctor thinks something is important they will tell me. On this point patients can be quite literal. I have seen studies in which obese patients do not see themselves as “obese.” Their self perception is validated every time their doctor fails to tell the patient that they have a serious weight problem and that they need to lose 20 pounds in no uncertain terms. If I have such a big weight problems why hasn’t my doctor said anything?
 

Think back to your recent trips to the doctor. If you are like me, you may be hard pressed to think of a single instance in which your physicians ever said the words “I recommend” to you.

 
The only such instance I can recall was when my wife’s oncologist (Stage 4 Lung Cancer) said “I recommend that you start the chemo treatment immediately….tomorrow wouldn’t be too soon.” My wife did what her doctor recommended and she is alive today some 6 years later.

Sources:

Carroll, J., et al. Clinician-Patient Communication About Physical Activity in an Underserved Population. Journal of the American Board of Family Medicine. 2008;21:118–127.

Taylor, V., et al. Colorectal Cancer Screening Among African Americans: The Importance of Physician Recommendation. Journal National Medical Association. 2003;95:806-812.

Brown, T., et al. Predictors of Cardiac Rehabilitation Referral in Coronary Artery Disease Patients. Journal of the American College of Cardiology. Vo. 54, 2009.

Albrecht, T., et al. Influence of Clinical Communication on Patients’ Decision. Clinical Oncology 26:2666-2673. 2008.