Behavior and the Future of Health -Full video-

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Behavior and the Future of Health -Full video-

We’re all here today because we really believe that a lot of the future of health among our membership, in our communities and in the healthcare system depends upon behavior change All right, so we’re all here because we actually think in one way or another there’s a magic pill coming and it’s not going to come from the drug companies though there are many, many marvelous contributions that are going to come that way It’s not going to come from genomics although there’s a lot of foundational research being done that will transform healthcare But I think the magic pill that we’re interested in is this health behavior change And you’ve already seen and are well familiar with the data that it affects health status, medical utilization costs, productivity, health disparities But here’s one twist I’d like to present to you You’ve all been in the meetings where Kaiser Permanente is celebrated and praised for our accomplishments in quality and we deserve a lot of credit for that And I think the curves are widening between our ability to deliver quality and many of the other systems in the community At the same time when I think about almost all of our quality measures, at the end of the day, they rely on a behavior change made not by us but by our members And that is it’s our members who decide to get preventive services It’s our members who come in for PAP smears and mammograms, who return the fit kits that we mail to them It’s our members who take the prescribed medications that actually wind up showing up in better health outcomes, quality indicators And it’s our members who are really making the decisions that drive cost and quality in terms of deciding to come in for a particular symptom, to self-treat or to come in to late when it’s more costly and difficult to manage And it’s our members in terms of overall health promotion from self-management of chronic disease to exercise, diet, smoking, stress management and so on So, the bottom line for me is while we congratulate ourselves, one of the things we ought to congratulate ourselves is having the most engaged, most educated members of a healthcare system Patient behavior drives most of the outcomes and I think our members and patients deserve some of the credit because most of the quality measures really depend on them This is a wonderful report that came out from Ernst & Young who are really business analysts and they said changing behaviors represents the single biggest opportunity to improve health outcomes while bringing costs under control And I think that’s part of the belief that brings us together Here’s the problem It’s not easy to change behavior Give it to me straight, Doc How long do I have to ignore your advice? And as a practicing clinician I know what this feels like I know that that can be very, very frustrating I tell them to do the right thing They just won’t do it And, you know, when I self-reflect a little bit, maybe I’m not doing all the things I might recommend to my patients either And it’s very frustrating to patients to have repeated failure experiences And the patients are really saying well don’t tell me what I know what. Tell me how You know, I’d like to do this it’s just I’ve had so many failure experiences So we’re going to focus a lot on the how of behavior change And finally here’s a conversation between a doctor and a patient and it says there’s no improvement, Henry. Are you sure you’ve given up everything you enjoy? You know, sometimes I feel like I’m practicing medical terrorism That is if there’s any outbreak of a patient doing something that’s enjoyable or fun I’ll find some reason it’s bad for their health, bad for their heart, bad for the lab test results or at minimum, it’s fattening So how do we reframe that? And this is the problem is most of our models of education, including a lot of what I’m going to do now, are disengaging It’s like expert up here is going to tell people who know nothing, a patient, colleagues, whatever about how to do it the right way And I guess what I want to actually start off and just say is when it comes to behavior change, lots of theories, lots of science,

lots of evidence and, as far as I can tell, no one has found the holy grail in this area And so it’s a process of our discovery and our co-discovery First of all, when you made that change, raise your hand if you wrote out a specific plan and broke it down into very small steps Raise your hand. Okay Did a major life event or an epiphany or a breakthrough lead to the change that you made? Would you raise your hand? Okay Did you change because your environment either required that you change or just made it really easy for you to make the change? Raise your hand. Okay Did you change just because it felt good and you just did it without a lot of plotting, without a great epiphany and without huge environmental redesign? How many of you did that way? Okay So I think this is really curious because when we design for change, where do we spend most of the time and effort? When you change you don’t do it that way Okay? When you change you don’t necessarily write out your plan and break it down into small specific steps and so on So there’s a whole lot of change going on related to health and there are many pathways to change So, first of all, my favorite way to change is pleasurable change And that is we evolved over millions of years to seek out certain things that pleasurable, avoid other things because they were potentially toxic And in seeking out things that were pleasurable they were often good in terms of improving or promoting our health and they were intrinsically rewarding, reinforcing and we just did them and continued often to do them Second is breakthrough change And I want to say I think this is the type of change we understand the least about We all have known either in ourselves, our families or patients that we work with, they’ll hit a life crisis, they’ll hit bottom, they’ll have the major heart attack, something and suddenly without a lot of plotting, planning they change massive things in their lives Similarly, it can be a positive experience I walked in to see a patient, he was sitting there, he had a smile on his face, everything was different I don’t know. He was exercising He had changed his diet and so I said you know it’s not like we haven’t tried to do these things together I said what’s your secret? And he smiled and he said I fell in love I want to bottle that I want to put it in the pharmacies I want it on the formulary because the breakthrough can come from a very positive experience The birth of a child, for example, pregnancy often leads to a lot of changes and those changes are often breakthrough changes Then there’s environmental change and I want to recommend to you a book, Switch How many of you have read Switch by the Heath brothers? Highly recommend it I knew a lot of the stuff in Switch but what I love is there’s a whole stream of behavior change in there which is about clearing the path, making the change easier, changing the environment to support the change And I want to that this is an extraordinarily important thing for us to do because we are constantly taking our cues from the not only physical environment but the social environment what we consider normative When it becomes normative to do instant recess, you just do it because that’s part of the culture, that’s part of the way we behave And then finally there’s incremental behavior change, right? That’s the baby steps, small steps, simple steps, tiny steps, starter steps, success steps That’s the one you use least but that’s the one we’re going to concentrate on, because some of these– a lot of our effort still goes into helping set people up for success experiences by breaking down big changes into very small changes The other thing I just want to tell you is sometimes the environment itself doesn’t have to change What changes, our perception of the environment and I’m going to take a minute to tell you about one of the best examples I can think of this is a very simple exercise called the gratitude exercise Have you heard of this? Has anybody tried it? Okay There’s studies now that show that you can measuredly improve

health outcomes as well as happiness and life satisfaction if you do a simple exercise At the end of the day you sit down and write down three to five things that happened during that 24 hours that you’re grateful for, okay? Now I tried the exercise and I was Pleasantly surprised that while I’m writing and thinking about the things I’m grateful for, of course I’m going to feel in a good mood What I had not anticipated is what it does through the rest of the 24 hours You see, tonight I’m going to face a blank sheet of paper and I have to come up with three to five things that happened during this day that I’m grateful for I’m getting a little nervous We’re already at eleven o’clock Have I found anything yet? Okay? So suddenly my antennae go up I begin to filter my environment, my experience and the people around me to discover and identify the things I’m grateful for And so the environment hasn’t changed These things have been going on every day all the time What’s changed is my cognitive frame and the way I perceive the environment And so a very important way to approach environmental change is actually by changing people’s conception of the environment I have a friend, Nancy Bruning, who’s written a book, 50 Things You Can Do On A Park Bench I love that title. Isn’t that a great title? Fifty things And suddenly I can’t walk by a park bench without thinking and looking at the park bench in a different way These changes in cognitive frame are extremely powerful I went to buy a car. This was some years ago And the guy said well, what else are you looking at? And I told him I was looking at this Chevrolet or something and he suddenly stopped and he looked at me and he says you know the problem with that is nobody under the age of 50 should buy that car Now I knew what he was doing He was manipulating me towards selling his car but I’ve got to tell you, we’re 30 years later, I cannot get that thought out of my mind I now look at the Chevrolet and I’m going you know, I’m over 50, I could buy it now but I’m looking at that car and I’m thinking I can’t buy that car It’s this framing and allowing people to see the world differently is an underutilized, and I’m going to come back to that, in terms of supporting behavior change This is an instant focus group we’re going to do Is the baby in baby steps? You’ve heard the term baby steps You’ve probably even used it Okay, is that empowering, inspiring and engaging? That’s A. Or is it patronizing, condescending and a little bit insulting? So let’s do an A/B test right now How many of you think A? Raise your hand on baby steps Okay. How many think B? Uh-huh. Okay So we need to do a little research on how we label and frame these because if I say to a patient I really want you to take baby steps that actually feels to me a little condescending It’s not inspiring to them. Baby steps? No, I want to take a big leap in improvement All right. So do you prefer baby steps? We did Or simple steps, small steps, tiny steps and so on? And I think we have to be very aware of our language because to the degree that we talk with our patients, our members and so on about baby steps we may have an opportunity But if we’re going to talk about small steps I am going to present something that is heretical What if the small steps do not lead to sustained behavior change and ongoing habits? What if, oh my god, shall we give up our work? Is it all for naught? Because the holy grail, okay, among behavior change is how do I get people to change and how do I get them to sustain that change in an ongoing way? Well I’m going to suggest to you that it’s not a complete failure if people change and then they change something else and then they change something else and the changes aren’t sustained What do I mean by that? Well, I’m going to tell you a story It’s the story of Mullah Nasruddin and Nasruddin is a Middle Eastern teacher, joke figure, everyman and many stories are told about Nasruddin Now in this story, Nasruddin was a smuggler

and a very, very good smuggler He got richer and richer And he would cross the border and the border guards would go nuts Every time he came across they would unload his donkey They would take all the sacks apart They’d almost strip search him. They’d look in his turban They could never find out what Nasruddin was smuggling And years later he retired and he was sitting at a small caravanserai and one of the border guards came in and was sipping tea with him and said Nasruddin, we know you’re a successful smuggler We never caught you. What were you smuggling? And what did Nasruddin say? Donkeys Donkeys, and the reason I say that is we really want to change behavior And we are looking for the jewels and the contraband and the exercise and the diet, addiction, medication, adherence, smoking and so on And sometimes we so overload behavior change that we miss that where some of the real value is, is actually in the success and process of changing behavior, namely how does behavior affect health? Well there are direct effects and yes, we all want our members and patients to exercise more, to follow a diet, smoking, medication adherence and so on but there’s also indirect effects of successful behavior change, namely enhanced mood and confidence And, in fact, I got started on this because I read a study in 1989 that stuck for me This was about the Arthritis Self-Management Program by Kate Lorig and later I got to work with Kate and developed the Chronic Disease Self-Management Program but the surprising finding is the people who went through this program had improved health outcomes And when they tried to show the association between changing their behavior and the improved health outcomes, the Stanford statisticians’ huge database came up with we’re able to demonstrate only weak, if any actually, associations between change in behavior and change in health status I was blown away by that because, you know, my whole focus of my work was trying to get people to change their behavior and yet health outcome was improving and it wasn’t explained by the behavior change So you go to the people in the groups and you say why did you get better? And they said I felt more confident I felt more in control And you go to the people who didn’t get better and they say it doesn’t matter if I change my behavior I feel hopeless, helpless and not in control The primary predictor of the improvement of health status was not the behavior change but it was feelings of confidence and in control And since they were at Stanford and Al Bandura is a psychologist there it was called self-efficacy And that’s actually some of the earliest studies that were shown of the relationship and importance of self-efficacy with improved health outcomes So I had the opportunity to work with Kate and the team down there on the development of the Chronic Disease Self-Management Program which we’ve actually done a study of disseminating within Kaiser Permanente and these are lay leaders who get together in small groups The focus of it is increasing people’s sense of confidence and control I know this is strange, we don’t care what behavior they choose to change or work on It’s irrelevant What we care about is how do we help them identify something they want to change that they care about and break it down into a very small step that they are 70 to 80 percent confident they can have a success experience with and then celebrate that success So, what am I saying? Small steps can lead to sustained health habits like exercise, eating, smoking preventive care, and that does lead to improved health However, let’s remember that small steps can also create a success experience or as I’ve come to call it more recently, due to BJ Fogg’s work, success momentum and that increases confidence, optimism, sense of control and that itself can improve health outcomes Does that make sense? But it’s very different because I would ask you what happens when we prescribe failure experiences for our patients and our members? What happens when we set ourselves up for failure experiences ourselves? Well, there is a strong emerging literature as well that shows

that just a sense of confidence or a sense of happiness and well-being and positive mood is correlated with better health outcome Seven types of evidence are reviewed indicating high subjective well-being like life satisfaction, optimism, positive emotions is correlated with better health and longevity Another example, are happier people healthier? During the last four weeks have you been a happy person? Or all things considered, how satisfied are with your life? The answers to those questions actually predicts future health People with higher satisfaction, two years later they report 50 percent better health than those who are not And finally do you know about the nun study? I love this. Okay They studied nuns and the diaries of nuns during their training when they were in their 20s and then 20, 30, 40 years later they analyze those And the nuns who wrote in their diaries and autobiographies, at a young age, they wrote about happiness and joy and hope had 2.5 less likelihood of dying than their gloomier counterparts So not only do you get to lead a richer more enjoyable life and thrive but you also get to live longer So behavior does matter Please do not– I’m going to focus on behavior Behavior really does matter but also mind matters and mood matters And those are ways to also improve behavior All right, let me just show you how much mind and mood matters If you look at depressive symptoms, this is sub-threshold depression, people don’t even qualify for a diagnosis of depression, it has a bigger impact on physical and social functioning than many of the chronic illnesses that we really focus on and put our attention and resources on I’m not saying ignore those medical problems but when people are not thriving and they have this low level of depression, that actually affects their health almost as much or more than many of the chronic illnesses All right, how do we prescribe confidence and success spreading? Okay, so here’s our donkey and the question is somebody comes in and they’ve got problems in all those areas Are you going to attack them all at once? Maybe not There’s a wonderful study out of New Zealand in which they encourage people to exercise They did not mention any other health or life outcome They only focused on exercise And what they found out is when you increase people’s confidence in one area, in this case exercise, they notice that smoking goes down, alcohol goes down, perceived stress, procrastination, and they’re eating healthier, they’re keeping their appointments, they’re studying better and they can focus better None of that was mentioned in the intervention The focus was on increasing self-regulation or a person’s sense of confidence in one domain and I think that there’s hope that it can spread to other areas of behavior without ever having to directly address those All right, so are people unmotivated? Hm, well we have that attitude pretty prevalent within our healthcare system, and the consequences of that is we try to focus on motivation, get people pumped up and increase their motivation We also tend to prescribe for them lots of behavior change and create failure experiences for them And then we become very frustrated because people won’t change and very cynical They’re really unmotivated people and they don’t know what’s good for them But a couple of questions, do we really know what motivates people? Have we discovered that? How do we make it easier for people to do the things they already want to that they’re motivated to do? And have we really identified and celebrated the successes when they are successful at doing something? I think that’s an antidote as we answer those questions to the usual approach we take to prescribing failure So here’s the question We’re all concerned about obesity, where should we focus? Which part of the curve? Do you focus no that part of the curve, the most difficult, recalcitrant, difficult to change? Or do you focus on shifting the population curve where you have

a lot of people who are ready and willing? They just want to know how They just want– and my advice right now is if we just focused primarily, I don’t say ignore other people, but focused on the people who are ready and willing and want to make a change and help make that change easier and more successful for them we are likely to shift the population curve and get much more area under the curve than if we focus all our time and resources on thee most difficult to change Does it make sense? Okay So what do people care about? I mean, we say they’re unmotivated so we come in and we’re talking about preventive screenings and exercise and healthy diet and when you survey people what do they really care about? Well I call it the three Ss They care about stress They care about sex And they care about sleep Now they’re not unrelated to the other side but in real life, okay, these are some of the primary concerns In fact a study was done of young Kaiser Permanente members and they called these health hassles. Okay These are the things they don’t think of going to the doctor for but the things that are really bothering them, stress, sex and sleep So a study was done by Eliza, which is an IVR company, they do a lot of research on interactive voice response, and they surveyed about a thousand people And they kind of asked them what are your major concerns? Okay And interestingly enough they find money concerns, unhealthy sex life, relationships, caregiver stress, job stress, diet and exercise, okay Now I find that kind of interesting, okay So where do we focus most of our attention? We focus it on diet and exercise And what are they concerned about? And remember, we’re calling them unmotivated, okay, but they may be motivated because of pressing concerns in these other areas So what does that suggest to us? It suggests that our interventions, if they’re going to engage people, also need to address some of the areas of stress, sex, sleep with behavioral and health coaching type interventions and other things that we could do I’m not saying ignore it And the other thing is we call them unmotivated and then we dump on them a hundred thousand things to do and overwhelm them So, for example, Montori has done a wonderful thing called Minimally Disruptive Medicine If you haven’t heard this go search YouTube for Minimally Disruptive Medicine There’s a wonderful little video in which it talks about you take somebody who’s kind of demoralized, coming into the healthcare system They’re overwhelmed with stress They’ve got teenage daughters, job is not going on well and so on and we say to them here are the 15 things we want you to do to manage your diabetes, okay And we have added to their burden So, for example, when they surveyed patients with Type II diabetes and they surveyed diabetes educators and they asked them what are all the things that a patient should be doing? and it would take about two hours a day more to do all those things the diabetes educators thought they should do Well what’s wrong with that picture? Who has two hours extra? One of the major obstacles that most of the patients say back I don’t have enough time to do all that, and the implications are we need to help prioritize, consider patient preferences and really respect time and help guide them to the things that are likely to have the highest payoff We need to be far, far more engaging We are boring Now Thrive has come along and I have to say that has been really exciting It’s like the organization went from black and white to color within a couple of years. Like the TV got turned on But by and large, when you look at what we have done in terms of behavioral interventions and health education, we’re pretty boring Why should I be tested for colorectal cancer screening? Now I just– I mean I just want to tell you because that came out of my department and so on, what are we up against? What are we competing with? We’re competing with this, okay Now, if I were doing one of those psychological studies where I could measure your eye tracking movements, my guess is you’re probably more engaged by what’s going on, on the right-hand side of the screen than the left-hand side of the screen

Now I don’t think we can go as far right as that, okay, but couldn’t we be a little more engaging and a little less boring? Well, let me give you an example of something that we really want to try It may be a little more lighthearted I was asked to consult on the redesign of letters going out to patients from their physician to remind them to get their lab test results, you know, if they had high cholesterol and diabetes and so on And we revised the letters We used principles of social influence and made each letter stronger and more directive and whatever and I said you know, it strikes me if people have gotten a second letter, sending them another letter of the same ilk is not likely to engage them So couldn’t we try something different? So, we’re drafting this and they try to test it Hi David, this is your heart checking in It’d be great if we can get an update on our cholesterol levels and blood sugars To be honest, I’m not really sure how well we’re doing and by the way I also heard from your kidneys and they are asking for a lab update too Dr. XYZ has already ordered some routine tests and they’re waiting for us at any Kaiser lab When do you think you might meet me there? Today? This week? And I think I know the results could help keep my arteries open and keep you feeling well and keep us on the right path Now I don’t know if this is going to work It’s testable though I’m fairly certain that the third form letter from your doctor is not going to work And what if this turns off some patients? Well, those are the ones who probably came in on the first or second one anyway and if you can adjust that We need to make this a little bit more fun But the other thing is this is actually a behaviorally designed intervention What do I mean? Well, there are principles of influence like the ones Cialdini has done and this uses the authority principle because it is signed by their doctor It uses social proof, and I’ll show you that in a moment, and it also uses consistency and that is people tend to be consistent with their image of themselves or their previous behavior So how does this work? Here’s another example Set completion. Okay. We like things to be complete So for example there’s a wonderful example of you go to a car wash and they give you a ticket that says if you get 10 car washes you get a free one And then they tested that against giving people the ticket with 12 slots on it and they put two punches in the first two and said you’re already on your way You’ve got two. We’ve got you started Well people like to finish the set and they also really like the idea they’ve already accomplished it — I hardly want to throw away my credit for two car washes I’m the kind of person who’s going to finish this Now how does this work? So for example what if we’re sending out a reminder to patients who are unmotivated, right, to get preventive screening? Congratulations on getting your mammogram and your PAP smear You have only two gaps remaining to complete your preventive care Check, check Oh colorectal, flu The majority of my patients are up-to-date Please join them When do you think you might complete your preventive care? Now this is carefully designed to take advantage of principles of consistency You’re the kind of person who gets mammograms and PAP smears Why not be consistent and get the rest of your preventive services? Set completion, to complete the set Social proof, that is, we look to other people and norms around us The wonderful ad for Kaiser Permanente which said Kaiser Permanente women get mammograms How powerful that is to normalize that that’s what’s expected, that’s the norm And finally, the authority principle, having it come from your doctor So I guess what I’m saying is when we go to design our interventions, and we’re going to do more about this later, when we go to the cost of poorly designed messaging is at least the same in terms of paper, opportunity costs, time, printing and so on as a carefully constructed message And, in fact, a poorly constructed message will often discourage behavior and not get people to do some of the things that we want And if you change the response rate just by a few percentage points, remember that’s shifting that curve,

you can get a huge return on investment And so we need to try these small tests of change, iterate on them, change them, learn from them as we go ahead And finally, how do we prescribe success? Well, the literature suggests there’s a couple of ways First of all, persuasion And that is, if I say to you gosh you can do it I have confidence in it Go ahead. Go forth. You can do it That works but it’s the least powerful way of increasing a person’s self-efficacy or confidence Second is modeling And that is when we see other people who we identify, not superheroes but real people like us and we go well, if they can to it I can do it, and it increases confidence So, for example, when a person with cerebral palsy climbs El Capitan, Wampler, Steve Wampler, I hear about it, I marvel at it but it doesn’t increase my confidence one bit that I can climb El Capitan He’s like in another league. He’s a superhero When I heard that my neighbor Joe who’s out there mowing the lawn climbed El Capitan I go whoa, you know, he’s like me. Maybe I could do it too Cognitive reframing we talked about a little bit earlier is in terms of the way we see our environment, the way we see ourselves being able to shift that cognitive frame is very powerful And finally, mastery experiences, those are the small steps, simple steps When you have those and you have success experiences it builds your confidence You’re more likely to continue that or take on other challenges So mastery experience. So I like to frame this about how do we prescribe failure because I think we– I have a master’s degree in prescribing failure I have graduate work I’ve done 30 years of prescribing failure experiences for my son, for my wife, for my patients and for myself So let me share with you the ingredients of prescribing failure First of all, make it prescribed That is, tell someone else what they’re supposed to do Trust me, after the age of two that usually builds resistance Two, make it really general or global, not specific Say, you know you have to lose a lot of weight, okay Three, make it pretty difficult, you know, really challenging Four, make it long term. I’m not talking about now I’m not talking about next week We’re talking about lifelong change here and plus mine is make it pretty unpleasant to do and I can almost guarantee you, you will have created a failure experience Now we don’t really want to do that and, in fact, I think that’s behavioral malpractice but we do it all the time You know we’re supposed to at least do no harm but here we are prescribing failure So how do we prescribe success? First of all, a person has to choose the behavior, okay It has to be really personal to them And I can’t tell you what somebody else is going to choose Two, it has to be really specific And in the latter part of the workshop we’re going to get really crispy and specific on the behavior, not general It has to be something easy to create a success experience and usually we use the confidence test or use 70 to 80 percent confident because if people are below that chances are they’re going to fail and maybe they could reshape the goal or the step a little bit so that they’re more confident I like rapid change with rapid feedback There’s a wonderful book called 59 Seconds by Richard Wiseman, I recommend it to you, he was a psychologist and one of his patients came to him and said do I have to go through 20 years of psychotherapy before I can feel better? And he was challenged by that and he went back through the literature and harvested a lot of really rapid change techniques that can be used like the gratitude exercise and so on and pulled them together in a book And to the degree that the change can be something pleasurable, sometimes it can, sometimes it can’t And then finally we’ve got to celebrate success and I’m going to illustrate that in a moment I’m going to talk about trout. I’m going to talk about tide And I’m going to talk about tires Let start with trout Okay, so this is a patient of mine Well, actually it’s not a patient of mine

Anybody know who that is? Paul Giamatti, yes For confidentiality purposes and HIPAA violations I could not put my patient’s picture there but suffice it to say he looked a lot like Paul Giamatti I learned a good HIPAA joke Knock, knock. Who’s there? Can’t tell you. (laughter) All right So Paul is a patient of mine I’ve been working with eight to ten years He’s overweight. He’s sedentary Has diabetes Type II, has hypertension, hypercholesterolemia When we test his hemoglobin A1C which measures the control of his diabetes it’s usually about 10.2 Sometimes after a lot of effort it’s 10.1 and so on Now, we’d like to have it eight and below, seven and below depending upon his age and other risk factors It’s not good for his brain. It’s not good for his heart It’s not good for his kidneys. It’s not good for his legs All right, it’s not like I hadn’t tried I mean I had tried motivational interviewing, brief negotiation, goal-setting, couples counseling I had tried– I even tried Jewish mother guilt induction (laughter) This is a technique I learned at a very young age I pulled out my quality scores and I said hemoglobin A1C 10.1, you’re pulling down my quality scores Can you help me out here? If you won’t do it for yourself will you at least do it for me? Nothing was working Finally I said to him one day, what do you really enjoy? And I realized I was clueless about that I had no idea. I could tell you his hemoglobin A1C I could tell you where he worked I could tell you how many children he had I couldn’t tell you what he really enjoyed because I thought he was unmotivated And suddenly his whole face changed He smiled and he said trout fishing I love standing out in the stream casting I don’t care if I catch anything I just love being out there At that moment, and that was 30 seconds, at least four or five things changed First of all, I realized that I didn’t know this patient I mean, how could I work with him for eight to ten years and not understand something about his whole life apart from his diseases, social history and so on? Number two and I had just done half the screening for depression, okay, that is, if he would have looked at me and said there’s nothing I enjoy I cannot think of one thing I enjoy Then you have to think depression and finish the screening for depression And we all know if the patient is depressed their likelihood of changing all these behaviors and doing the disease management and so on is very, very unlikely Third, I now understood that hemoglobin A1C didn’t mean anything to him. Trout fishing meant everything How could I connect hemoglobin A1C with keeping him out in the trout stream doing what he loves to do as long as possible That became my clinical and communication challenge And finally, and this is really interesting, you see I’m in adult medicine practice primary care and most of my day is back pain, dizziness, headache, chest pain, mucous, diarrhea, shortness of breath, acting out teenage children, I mean that’s like my day It’s not a real cheery picture, to be honest And for a moment when I asked a patient this question I get to be in a trout stream fishing For a moment I get to be repairing children’s dolls and donating them to charity For a moment I get to be on a play ground on a swing with a grandchild For a moment I get to be painting a 1967 cherry red Camaro and restoring it to pristine condition You see, for a moment it’s a bright spot in my day and it reconnects me with why I went into medicine You see, I don’t want my tombstone to say he got great quality scores on hemoglobin A1C That is not my life purpose and meaning Hemoglobin A1C doesn’t mean anything to me Keeping people healthy with their legs on, with their eyesight and vision so they can do the things they love and are passionate about

That makes me want to get up in the morning and go to work So I see this as a way of also connecting passionately with what we are about as a healthcare organization I had a patient who was hypertensive and was not taking her antihypertensive medication She knew she had the disease. She actually wanted to take it That was all clear. She couldn’t remember So what’s my usual response? Take your medications, for god sakes Number two, provide a tsunami of solutions Do you brush your teeth every day? Put it next to the toothbrush Put a note on the refrigerator and so on And the patient will sit there and go yes, doctor which is a way a patient says no to you Yes, doctor whatever you say and then they don’t do any of the things Or I paused for a moment and I said to her well it sounds like you really want to take your medications What do you think might help? Pause Now, I’ve learned in the exam room pausing is not like a life-threatening hemorrhage, okay But we don’t pause She reflected for a moment to what she thought might work and she said Tide I’ll put a note on the Tide box I do laundry every day When I go out there the box will remind me to take my medication I said that sounds like a fabulous solution How confident are you that that will work? Eighty to ninety percent. I said that’s great When I see you back I want to find out how well the Tide solution worked for you Now here’s a question How long do you think it would have taken me to come up with the Tide solution? (laughter) I don’t do laundry I do windows on a computer, you know The point is that often patient-generated solutions are much more likely to be successful If she could have come up with nothing, first of all, screen for depression, okay, because sometimes they can’t come up with anything because things just look hopeless and I can’t think of anything so you screen for depression And the second thing is you say well, my patients have come up with some other solutions Would you like to hear any of them? So I’m not saying that it’s all hands-off but it starts with what do you think might work for you? Discovering their solutions. And finally, celebrate success So a quick story. I took my car in for service Nothing was wrong with it. It just needed an oil change The service attendant walks around my car He inspects the tires, the rims and so when he comes back to me and said you know, you have done a fabulous job of protecting your tires and rims At this mileage I would have expected to see a lot more wear and tear, nicks and scuff, marks on the rims You’ve done a great job Well, I gotta tell you, he made me feel really good, okay He made me feel good. I had done something He had discovered something I had done that I’d been successful in and he had reinforced it and celebrated it with me And he had changed my self-identity Now, when I drive down the road I’m going I am a protector of tires and rims Careful, slow down around that corner, I don’t want to wear out that tire It’s a change in conception and a celebration of success So, how do we engage people in successful change? Three tips for you First of all discover their passions Find out what they really enjoy Discover their solutions. That’s the starting point It’s not necessarily the end point And third tip is celebrate the success You know the rational part of our brain, and it took me a while to come to the word celebrate, it was acknowledge Ugh, you know, no guts, no life to it It was praise, condescending, pretentious Celebrate is a mutual activity, something you do together in relationship and so I like celebrate success and that furthers the success momentum we’ll talk about So the bottom line on the presentation, this part one if you will, there is a science to this It’s an incomplete science but a science nonetheless that we can harvest behavioral principles and integrate them

into the messaging and the work we do Number two is for the most part people are not unmotivated They may be unmotivated to our priorities and what we want them to do but nine times out of ten we don’t know what motivates and animates them or how to link to that And so discovering what they really enjoy, what animates and motivates them, is an important part of us addressing and the health promotion doesn’t have to be so prescriptive, boring and dull. We can design for joy Can you stand up for a moment? Has everybody seen this? This is a wonderful t-shirt. Look at that, design for joy We can design for joy In fact, if I could borrow that I may re-label the whole presentation design for joy And these are some of the principles that we can use in our very practical work and in self-prescribing for ourselves