Power to the People
February 15, 2021
My major criticism of modern medical care has not changed since 1970. It was apparent to me as a first year medical student that we had abandoned the most powerful tool that helps people stay healthy. Antibiotic use was exploding, “new and improved” anti-inflammatory drugs were surfacing daily and chronic disease care was emerging. Each of those examples required the addition of some substance to our ailing incompetent bodies. Any mention of promoting behavior change was generally pooh-poohed as “pie-in-the-sky” idealism.
Some remarkable successes with chemical cures such as hormonal replacements (especially insulin for “juvenile diabetes”), anti-bacterial drugs and vaccinations had captivated the biomedical establishment. We prescribe buckets of medications that reduce blood pressures, lower blood sugars and modify serum lipid components. We do not often concede that modifying such intermediate indicators may not correlate with improved health or longevity. We adore anti-depressants that possibly work slightly better than placebos. We dispense samples of anti-arthritic medications without measuring costs of their side-effects. We repeat the mantras of our medical ancestors. “We cannot help patients change behaviors so we must medicate”.
In 2012, I summarized a study by J. Michael McGinnis whose team sought to correlate health determinant factors with measurable health improvements (McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff 2002; 21: 78-93). That analysis suggested that the large healthcare industry on which we were then spending over 17% of our gross national product was only contributing about 10% to reduction of premature deaths. Larger contributions were coming from behavioral patterns (40%), genetic predisposition (30%) and social circumstances (15%). Environmental factors added another small fraction (5%). I suspect the study’s methodology could be challenged, but it seems reasonable to think that biomedical rescue technologies and pharmacology are relatively impotent approaches to improving population health. Exercise and dietary changes work better than drugs for the endemic triad of hypertension, type II diabetes and hyperlipidemia. Physical activity also improves symptoms and functions for people with painful joints and mood disorders. Wearing masks and social distancing are apparently effective while awaiting a vaccine to soften the current pandemic.
But doctors cannot impact behavior changes. Or can they? Psychologists William Miller and Stephen Rollnick observed that some therapists were more successful at promoting behavior change than others with similar training and skills. They studied the more successful therapists and developed a set of behavioral changing strategies that were teachable (Motivational Interviewing: Preparing People to Change, New York: Guildford Press, 2002). Their work cannot be summarized nicely in a brief blog, but motivational interviewing has been taught to many Family Medicine doctors over the last several years. Kerry Patterson and colleagues from an organization called Change Anything Labs have studied personal change behaviors extensively. Their 2011 book Change Anything summarizes a systematic approach to help people create strategies to change disadvantageous habits. These robust strategies go well beyond the trite suggestion of “will power”.
But why should family doctors and other physicians encroach on the field of psychology? Since behavior is the major component for modifying health outcomes, doctors should not exclude these tools. Family doctors have opportunities to utilize these measures because of repetitive encounters at dramatic times with people and their families. Their long term relationships with people and their communities help them choose the approaches that might prove most helpful for a particular person. It brings to mind an old adage, “it is more important to know the patient with a disease than it is to know the disease”. Peoples’ readiness to change can often be placed in a category.
For example, I recently heard about a successful business owner who defied local government mandates and forbade his patrons and employees from wearing masks and social distancing. When asked why by a reporter he said that he knows that masks do not work and he knows that over 400 thousand American citizens have not died as a result of COVID 19 infections. For this first category I say, he has chosen ignorance and behavior change efforts will not work. Let him be.
Some people change as soon as a trusted authority suggests change. A third category is people who want to know but do not know. They need teachers. Forth are people who hold strong beliefs. They will sometimes yield to loving advice from family members, friends and healthcare providers. The fifth grouping is people who want to change and tried, but failed. They need skillful expertise and guidance in addition to support. A good primary care doctor can make relationships with people, categorize them correctly, oversee or implement their efforts and succeed with some of them. Success is not guaranteed, but it is at least as good as the mediocre drugs on which we steadfastly rely. The change approaches could also help augment the current efforts to promote mask wearing, social distancing and vaccination. Primary care providers are not reimbursed for training, time and effort that is necessary to promote change. So we trudge on to the next exam room with prescription pad in hand.
[Parts of this article were excerpted from blogs I published in 2012. (http://frugalfamilydoctor.blogspot.com/2012/07/will-you-make-change.html?view=mosaic; http://frugalfamilydoctor.blogspot.com/2012/10/what-is-health.html?view=mosaic; http://frugalfamilydoctor.blogspot.com/2012/09/advocacy.html?view=magazine)]