By Mary McNeill, MS, RD, LD, CDE, MBA
As clinicians, we are told we need to engage patients more effectively to treat them successfully. Why does this often seem so difficult? Let’s dive deeper and evaluate certain myths around patient engagement.
Myth #1: Patients are not engaged.
On the contrary, the person in front of you in the exam room is very engaged. They had to evaluate their health, decide to make an appointment, give up their time to drive to your office, wait to be called back, and are sitting in front of you voluntarily. We don’t know what it took to get there: babysitters, rides, asking for time off work, coming up with the copayment, etc. However, there they are, against many odds. These series of steps translates into patient engagement or a desire for them to help themselves.
Myth #2: Patients do not think about their health.
Patients do think about their health, and the impact their condition might have on their lives in the future. They are involved in the decision making process around their health. They might have made the decision to seek out an opinion from friends or the internet, get their prescriptions refilled, or to ignore their illness. They may have decided to implement their care plan as they understood it from their provider, but stopped complying when they decided it was too difficult. Exercise may be hard to implement when a patient’s sleep apnea has not been treated, or their arthritis flares up, or if their children are sick, for example.
Myth #3: Once the patient knows their diagnosis, they will want to change.
Imparting wisdom may not necessarily motivate someone to make lifestyle changes. What appears very logical in our world may not appear the same way in the world of your patient. As an example, there was once a mammogram screening at where I worked, and several women did not sign up. A nurse explained that sometimes when female patients uncovered a negative result they felt disempowered. In other words, the mammogram presented the cruelty of a cancer diagnosis without the means to get well. Patients may feel the disease is a signal that they are a burden to their family and others, and so there is a possibility that they may deny they have the illness and/or may not choose to pursue treatment.
Another barrier that prevents patients from adopting lifestyle changes is the need to balance competing priorities, according to Maslow’s Hierarchy of Needs. This hierarchy portrays human needs in the shape of pyramid; the most basic needs are at the bottom and self-actualization – which deals with what a person can become- is at the top. In other words, patients may be so concerned with surviving daily challenges that it can be difficult for them to focus on setting health goals for the future.
Further, we must recognize that as healthcare providers, we do not have all the answers. The patient who faces a condition knows how that condition will fit in their lives. The best medicine in the world does work if the patient cannot afford it. The care plan may fail because it is not developed, co-jointly with patient and provider. Ask the patient. Solve the problem together.
Myth #4: Patients are ready to change.
What motivates patients? Fear can. Fear is a great short-term motivator but is rarely sustainable. Fear wears off and familiar habits appear again. Another great motivator can be “a big reward.” In worksite wellness programs, employees often change behavior temporarily to achieve a reward. It boils down to priorities. For example, suppose there was an employee who felt it was unreasonable to have her workday start at 9 am, unless there were a million dollars waiting for her at the end of a year. She said she’d set multiple alarms, and even sleep in the parking lot if necessary. The desired behavior was not unreasonable, but rather there were competing priorities such as “sleeping in.”
The same holds true for our patients—they are able to check their blood glucose or exercise or wear their CPAP. But what are their competing priorities? We need to identify drivers that ‘get them today’ instead of a possible future threat to their health.
Myth #5: We have the tools that patients want in order to engage.
Websites and online portals are often paraded as ‘patient engagement’. True, they can function as a messaging and appointment reminder application, or as a means to download results or respond to an email. However, once a patient logs out of your portal, how do you know they are still engaged?
Here is a familiar story that beckons:
A gentleman once decided to reduce his carbohydrate intake. He gave up sugar in his coffee, a big glass of juice at breakfast, ate lower sugar cookies, gave up pie after dinner, and many other changes. He sustained most of the changes. The one that he did not? Prepackaged peanut butter crackers. Surprised? Of all the goodies to that he could have enjoyed, why did he choose prepackaged peanut butter crackers? His answer was that he was simply used to eating them at his morning break. He had found acceptable substitutions for all of the other unhealthy habits except this one, and this habit had a strong pull on him.
Most changes are difficult to implement because they are inconvenient. Monitoring behaviors takes time. Having to track what you do commands loss of independence. When we turn our attention to changes people have made, technology plays a large role. Airbags can save lives and we don’t have to do anything. Wearable fitness devices can help us to determine how far we have walked, or how we are sleeping. Cloud computing improves access to health information. All of these tactics can be successful because they are nonintrusive and convenient. Finally, when we examine the factors that may cause our patients to miss our expectations of engagement, we should seek to understand the challenges and barriers they face. We should consider how it would feel to walk a mile in their foosteps. Now, where are my walking shoes?