by Dave Gardner
As health care costs perpetually rise, an innovative series of physician processes are attempting to include patients within the nation’s caregiving teams and, in the process, inspire healthier behaviors.
In the past, a physician’s efforts to drive a patient toward healthier behaviors may have been referred to as patient compliance. However, in the modern age that term is not accurate, according to Jennifer Joyce, MD, professor of family medicine at the Geisinger Commonwealth School of Medicine.
Dr. Joyce and her peers now promote a partnership where the physician is equally responsible for both determining an appropriate approach for each patient and exploring the personal and environmental issues that will impact that person’s ability to “adhere” to the advice. This creates a patient-centered model that can help the patient define what their goals are within a proactive and motivating system.
“The physician doesn’t make the patient healthy,” said Dr. Joyce. “The patient does through shared decisions with the health care team.”
This proactive and personalized wellness movement within health care is decades old, but the real changes toward patient involvement gained steam during the past decade. The scenario has been fueled by the reality that as much as 60 percent of illness in America involves behaviors and environmental influences.
“Self-inflicted illness is the wrong terminology,” said Dr. Joyce. “Physicians cannot blame patient for failures. We must look at systemic issues.”
A central theme in the promotion of patient health now involves a physician technique known as motivational interviewing. This can be defined as an approach that attempts to move an individual away from a state of indecision or uncertainty and towards motivation to make positive decisions and accomplish established goals.
According to Dr. Joyce, a process within motivational interviewing is known as the five whys. This is an interrogative technique used to explore the cause-and-effect relationships underlying a particular problem and determine the root cause by repeating the question, “Why?”
Each answer given by the patient forms the basis of the next question. The “five” in the process name derives from an anecdotal observation on the number of steps needed to resolve the problem and produce a sense of being understood.
The clinicians must attend simultaneously to the biological, psychological and social dimensions of illness, and during the process the physician will probe what really matters to the patient, what they look forward to, and ask what they desire to change with behavior. Patient goals are then established to bring about necessary changes, starting in small steps.
“Collaboration that includes the patient, their family, and the entire health care team is vital if behavior changes are to be achieved,” said Dr. Joyce.
Multiple barriers often inhibit a patient from pursuing the recommendations of a health care team, according to Allyson Matthys, DO, family medicine physician with The Wright Center for Graduate Medical Education. Some patients do sincerely ask for a list of physician recommendations that involve habits, stress management and time pressures, but even in these cases a drive toward wellness may become scuttled.
The problem of medication not being taken as instructed is one area where caregivers often encounter problems, driving physicians to determine the root cause of this phenomenon. Increasingly, patients may not admit that they simply can’t afford their prescribed drugs.
“Fortunately, physicians are now learning how rising drug costs are an issue for so many people,” said Dr. Matthys.
She also reported that the old coal miner belief of total neglect for health and wellness finally has ebbed within NEPA, but many patients do cherry pick with the ideas accepted by their physician. Often family pressures will be stacked completely for or against wellness, with obesity a huge problem that shows no abatement.
“As a physician we must find a motivator for each patient as their facilitator,” said Dr. Matthys. “We keep the patient talking, and as their ideas begin to change, we usually start small with recommendations, such as just a cutback from smoking as opposed to a total cessation.”
Dr. Matthys emphasized that most patients do not respond to a mandatory list of physician demands. Instead, the motivational interviewing process should question what the patient desires in the future, such as seeing grandchildren and/or being physically active, and then gently move the patient in that direction with applicable behaviors.
“They can’t get this all from us,” said Dr. Matthys. “Instead, they must own the process. If the physician hits a stonewall they must back off but keep dialogue open and be sure the patient is understanding what we are telling them. If we just keep hammering away the patient may go find someone else to talk to.”
She added that stress has become the mortal enemy of wellness. Frustration, anxiety and insomnia are commonly revealed within medical visits, with financial and family issues at the heart of the problems.
“Time is the enemy of all things,” said Dr. Matthys.
The national insurance industry has also become involved in the wellness arena with increased efforts to encourage patient healthy behaviors. Margie Andrews, manager, case and disease management area with Highmark Blue Cross Blue Shield, noted that the medical community is now understanding that varying patient behaviors are actually the product of unique and multiple stressors within that person, such as divorce, behavior, depression, or a lack of access.
Therefore, each physician has a responsibility to identify barriers with the goal of helping the patient to understand it is their health which is at risk. The hardest step may be the first, such as encouraging a patient to read food labels as part of a basic drive toward wellness and then gain confidence that further change is possible.
“There is a lot bad ambivalence out there on all sides which, must be addressed,” said Andrews. “To accomplish this, we focus on positives with the understanding that we all experience success and failure.”
Tom Novinger, MD, Highmark’s senior medical director, added that the drive toward behaviorally-inspired wellness is more about patient adherence than a good versus bad issue. Caregivers must get away from what has often been a confrontational, judgmental and a paternalistic past, instead favoring coaching and collaboration.
“Physicians also must learn to better communicate,” said Dr. Novinger. “When people act differently they do so for a good reason and family history is a powerful factor, so it’s vital we address where patient is at and give them control.”
Relapse, where a patient reverts to unhealthy behaviors, is a common step in a permanent behavioral change, according to Dr. Novinger. In most cases a one-step “fix” to a lack of wellness does not exist, making small behavioral changes vital that lead to greater overall wellness vital.
Physicians must also not give up despite setbacks in patient behavior. Instead, they must utilize all of the assets available, including Blue’s team of nurses who are available to applicable patients via a phone call.
“You never know when you will say something that triggers a positive change,” said Dr. Novinger.