Is there is a magic pill for chronic illness?
Why does the pill that arrives in a tiny, plastic dispensary cup at the patient's bedside in the hospital have such a good adherence rate? And yet, that very same pill loses its magic when the patient stands alone in front of the medicine cabinet?
Is there a way to send patients home from the hospital or the doctor's office better equipped to follow the doctor's instructions to fill a prescription, exercise or eat a healthier diet when they are on their own?
Some patients go home and take good care of themselves and that self-care is supported by caregivers. But, many patients, particularly chronically ill patients, go home and take really poor care of themselves. Sometimes, their caregivers unwittingly undermine the patient's care. As clinicians, we are trained to intervene with those who are an imminent danger to themselves, but do we? How imminent does the danger need to be?
Jeffrey Brenner, the Camden doctor featured in Atul Gawande's New Yorker article "The Hot Spotters" argues that the primary care doctor can serve a critical function in helping patients take better care of themselves. "My philosophy about primary care is that the only person who has changed anyone's life is their mother. The reason is that she cares about them, and she says the same simple thing over and over and over."
Several behavioral change strategies are gaining attention that focus on "saying simple things over and over": the nudge and BJ Fogg's model of behavioral change. The evidence of the effectiveness of these strategies is growing, but we have only just begun to incorporate them into medicine. And none of these strategies focuses as Brenner does on the unique mix of care, authority and influence that the primary care doctor can have. As we build tools that help patients take better care of themselves between visits, we must remember that the strength of the nudge depends greatly on its source. A phone call from the patient's insurance company or employer is never going to be as potent as a contact from the patient's primary care doctor's office.
In addition to the personal connection, primary care doctors are in an exceptional position to nudge because of the breadth of their reach. They have 560 million visits with patients per year.
And yet, many primary care doctors feel hopeless telling patients to lose weight, quit smoking and take their medicine. From the doctor's perspective, it doesn't look like anyone heeds your advice. This leads many to undervalue the immense potential they have to influence patients to take better care of themselves at home. Part of the problem is that a single nudge in the visit isn't enough. Doctors need tools that help them give patients personalized, specific, actionable advice and the resources to refer patients from the point of care. A doctor's personal recommendation in the visit can be supported by technology and other members of the medical team between visits.
Evidence is plentiful that behavioral intervention in primary care practice is effective (see tobacco use intervention research and Robert Wood Johnson Foundation primary care research). The doubt is whether intervention in primary care is feasible and sustainable, when doctors only have 9 to 15 minutes per patient.
Our tools need to make behavioral intervention in primary care feasible and sustainable. Technology can make nudging standard practice and can put resources at doctors' fingertips for behavioral referrals that are as easy as writing a prescription. But, what if our technology actually facilitated better face to face interactions, priming doctors to be more effective, consistent and caring nudgers? And made it easier for doctors and patients to have hard conversations about taking better care of themselves? What if our technology made us more human, rather than less? Even in 9 to 15 minute visits.
It's not magic. Saying the same simple things over and over is actually really hard work, but there is something magical about the care that occurs between two people. For those of us who committed our lives to working with patients, it is the best part of the job.
Hilary Hatch, Ph.D. is a psychologist and psychoanalyst in New York City and an Instructor of Medicine at the Johns Hopkins School of Medicine. Dr. Hatch is Founder and CEO of Vital Score, a new vital sign for primary care. Modeled after the APGAR score, Vital Score quadruples the rate of doctors and patients talking about unhealthy behavior and makes referrals -- whether for smoking cessation, care management or medication adherence -- as easy as writing a prescription.
Vital Score is one of the five Merck | Heritage Provider Network Innovation Challenge semi-finalists. The sponsors have called on entrepreneurs, data scientists, designers, health care providers, and big thinkers to create the products or services that will support patients with diabetes and/or heart disease in adhering to their care plans and ultimately improving health. Semi-finalists will be presenting their solutions at Demo Day on January 23rd in NYC. Check out their progress, watch their Demo Day presentations, and find additional open innovation challenges by visiting Health Data Challenges.
This blog series is produced in partnership with Health Data Challenges, creators of The Health Data Challenge Series, a formal initiative of the Health Data Consortium, powered by Luminary Labs. The platform seeks to foster the use of data to drive innovation that will ultimately transform health and healthcare through high-stakes innovation challenges. Learn more at www.healthdatachallenges.com.
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