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Patient Engagement: Expert David Sobel Talks about Challenges

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 This interview is the fourth in a series of brief chats between CFAH president and founder, Jessie Gruman and experts - our CFAH William Ziff Fellows - who have devoted their careers to understanding and encouraging people's engagement in their health and health care.

David S. Sobel believes that there is good evidence that 'small success (in behavior change) may lead to lasting health improvement.

Gruman: Are there specific insights you have come across recently that you think would be useful for those working to support people's increased engagement in their health and health care?

Sobel: There is an accumulation of evidence that behavior change may not be very difficult if you apply what is known about behavior change.  In the book Switch there is an example if you set as your goal a clean room, you have an early experience of failure.  But if you put a 5-minute timer on, i.e., you clean your room for 5 minutes, you are more likely to have a success experience. In his book, 59 Seconds: Think a Little, Change a Lot, Richard Wiseman is challenged to provide the evidence on what people can do to leverage evidence-based behavioral techniques to change rapidly (a worthwhile read!).

Small success may lead to lasting change.  But the experience of success/efficacy appears to have direct health promoting effects independent of the benefits of any particular behavior that is changed.  Success change boosts mood, confidence, optimism and these are associated with better health outcomes, as well as a happier, more satisfying life!

Gruman: Can you be more specific about what this might mean

Sobel: My young son used to think life was about continuous improvement in all domains. As human beings we thrive on sensing improvement and mastery. However, whether as a result of age, accidents, or illness we begin to experience a decline in one or more domains of life.

One of the things people learn in the Chronic Disease Self-Management program is how to identify one small area where something can change, for the better.  In addition, there is mounting evidence that adhering to medications (even if it is a placebo!) improves health outcomes. In other words, our beliefs or daily affirmation of doing something to improve our health (whether taking a medication, a vitamin or even a placebo) increases our sense of control over future health'and in fact, seems to shape our future health independent of the pharmacological effect of the medication.

Gruman: How do we help people have those confidence-building success experiences?

Sobel: One way is to shrink the change or help them identify some small baby steps that set people up for success. The other is to clear the path and make the change easier, often through changing the environment or providing 'hot triggers' to cue the behavior.

We too often set up others and ourselves for failure experiences with unattainable goals, resolutions, and expectations. Someone recently conducted a survey of diabetes educators what are all the things diabetic patients need to do?  The survey found that it would take a person two hours a day to accomplish them all. Clinically we have to help patients prioritize what is likely to have the biggest impact on their health, engage them in prioritizing how this fits with all the other complexities and demands in their lives, and finally, teach them the skills to set small goals and have success experiences. This is one of the fundamental self-management strategies used in the Chronic Disease Self-Management Program at Stanford.

Gruman: What are the implications of this line of thinking for clinicians?

Sobel: I lead a training program on collaborative communication on medication adherence for clinicians that included strategies like motivational interviewing and involving patients in generating solutions.  I told the story of one of my patients'a woman who was having trouble remembering to take her pills.  I said, 'It sounds like you want to take your meds and have a hard time remembering. What might work to help you remember? And then I paused.  After a brief moment, she said, 'I'll put it on the Tide box.  I do laundry every day and I have the Tide detergent box.  I asked her how confident she was that this'll work and she said she was pretty sure it would.

The question I posed to the clinicians in the program was 'How long would it take you to come up with the Tide box?  Patient-generated solutions are more likely to succeed. If a patient or person cannot come up with any ideas there is a possibility that they are depressed. So asking for patient-generated solutions is also a quick way to do a preliminary screening for depression!

Gruman: That really requires a different approach: the clinician takes time to problem-solve with her patient'

Sobel: Physicians often complain that people are not motivated for treatment but don't look for what they ARE motivated about and for.  What really drives and animates a patient's life? We need to try to align the needed behavior change with peoples passions and aims.

I had been seeing a patient with diabetes for many years.  I really enjoyed him but his HgA1c was above 10 and I tried everything to help him work on it'  Nothing I said seemed to help him get it down.'  One day I asked him, 'What do you really enjoy? After a brief pause, he replied I love to go trout fishing. In that brief 30 second exchange many things changed: 1) I did a brief screening for depression (if he can't identify anything pleasurable then it is a signal that I should more thoroughly screen him for depression) 2) I no longer saw him as an overweight, diabetic, hypertensive, but rather the image I now held was of him in a river trout fishing, 3) Our treatment from then on was aligned with his internal motivation and our shared goal was to keep him healthy enough to continue to enjoy fishing, 4) He sensed that I cared about him as a whole person, not just a collection of problems, diagnoses, and symptoms, 5) I got for a brief few seconds to leave my world of patient problems, symptoms, and suffering and enter a pleasurable world of trout fishing.

I am now experimenting informally with asking selected patients what they enjoy. This is bringing some of my previous focus on Healthy Pleasures into the exam room for the benefit of both the patient and myself!

More patient engagement inteviews with our Ziff fellows by Jessie Gruman

More Blog Posts by David Sobel

author bio

David Sobel is Medical Director of Patient Education and Health Promotion for The Permanente Medical Group and Kaiser Permanente Northern California which serves over 3 million members. He practices adult primary care medicine at the Kaiser Permanente Medical Offices in San Jose. His research and teaching interests include medical self-care, patient education, preventive medicine, behavioral medicine and psychosocial factors in health


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Patient Engagement   Jessie Gruman   David Sobel   Find Good Health Care   Jessie - Engagement Interviews   Mental Health  


Comments on this post
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susan256 says
October 4, 2011 at 6:39 PM

Call it The Tide Box Approach, or whatever you want, but what it comes down to is nurturing the relationship between doctor & patient. A patient needs to know you are listening and hearing her, and the doctor needs to have the incentive (financial or passion) to spend the time it takes to engage with the patient. I like the idea of having patients make small changes that lead to success. Clinicians could take the same approach. http://whatstherealcost.org/video.php?post=five-questions

dirk says
October 5, 2011 at 1:03 PM

no doubt it is important to connect healthcare txs with the actual lives/interests of particular pts, but this of course assumes that pts have come to a place where they have accepted their conditions and are now motivated to adapt to their new realities, but for many folks with chronic (esp.life threatening) conditions this is not an easily achieved state of mind/being and providers must become much more adept at sorting out where people fall on the coming to terms spectrum and find additional help for people who are stuck and suffering because of it.

Isabelle says
October 7, 2011 at 9:38 PM

I'm the primary family caretaker for one of my aunts - she is 91 - so I have the advantage of being the outside observer of doctor\ patient exchanges. Most doctors or any health care providers are too pressed for time to listen to patients. Sadly many don't believe what the patient is telling them. My aunt is very much "with it" mentally, something that takes most HCPs by surprise. Believe me, the vast majority of people in the healthcare industry are extremely patronizing to elderly patients. Sometimes I'm actually embarrassed for them!
If all of a sudden they asked her a personal question she wouldn't be likely to response openly.

However, there are some wonderful dedicated professionals. Twice in the past year and a half my aunt had a major medical emergency on the weekend. Both times she got the on-call doctor and both times they were wonderful. She was in the hospital for a month and a half - including 26 days in the ICU - and is amazingly well. Both doctors were competent, professional, and always respectful to her. They actually looked her in the eye and addressed their comments and concerns to her, not the family member. So there is hope.

davidsobel says
October 7, 2011 at 10:11 PM

Susan256,
Thanks for the comments on my article. I watch the 5 question video you linked to and liked it very much. Sometimes doctors feel that patients want or expect more tests and more treatments. Fortunately, many patients realize the folly in this more means better approach. Asking questions such as "is this really necessary," "are there alternatives?" "what is the risk of watchful waiting?, etc can signal the physician of your engagement and concern. Though the focus of the video is on costs (as in dollars), there are many other costs (psychological distress, labeling, side-effects, time, complications, etc.) that can also be avoided by asking questions and not having unnecessary tests or treatments --even if they were "free" to you or fully covered by insurance.

davidsobel says
October 7, 2011 at 10:19 PM

Dirk,
I completely agree that there is a wide spectrum of how willing patients are to accept a diagnosis and their condition and subsequently take effective action. On the other hand, there are overzealous physicians and nurses and patients whose actions effectively work to get the entire patient's life revolving around the axis of their illness. Our goal (patient, doctor, healthcare team, and family) should be to do the absolute minimum to optimally manage the disease, and then help the person focus primarily on healthy living and the rest of their life. People are much more than their diseases, even though there may be periods of time when it seems as though the purpose of life is to manage a disease. That is why I am finding it useful to ask people what they really, really enjoy. This helps inform a broader picture of the person than that offered by the lab, exams, or even questions about where they work, how many children they have, etc.

davidsobel says
October 12, 2011 at 1:06 PM

Isabelle,

Thanks for your touching comment about dr-patient communication, especially with older people. As physicians, too often, we make shorthand assumptions about patients - these can be based on age, gender, ethnicity, education level, etc. While we may think it saves time, often it leads to ineffective communication. In a more ideal world, we would have more time to communicate but it is admittedly difficult in a busy primary care clinical practice. Ironically, specialists or hospitalists have more time to spend with patients than primary care physicians (a pet peeve and concern of mine as a primary care physician). Specialists who do procedures are not only paid more, they often have more time with patients compared to primary care clinicians who often are dealing with multiple concerns in less time.