Getting from Intention to Action

Many of the most pressing problems in human health are not a direct result of genetic error or environmental insult, but rather human behavior. We know quite a bit about how to be healthy: eat less, exercise more, don’t smoke, and seek high-quality medical care when you need it. Judging by the prevalence of obesity, sedentary lifestyle, smoking, and inappropriate and/or poorly delivered care, this is apparently easier said than done. The problem of health-related behavior (which includes the behavior of health professionals as well as patients) is, in large measure, a matter of motivation. We have good intentions aplenty. What we need is action.

So how do we motivate patients and the health professionals who care for them? Several articles in this issue of JGIM address this perpetually challenging question. Two papers focus on clinician education and skill building. As demonstrated in the observational study by Boissy et al.,¹ it’s hard for burned-out physicians to motivate patients. A relationship-centered communication skills course not only increased empathy and decreased burnout in physicians, but the patients of these physicians reported improved satisfaction with care. And in a randomized controlled trial conducted by Jerant et al.² (full disclosure: RLK is a co-author), the authors evaluated a new approach to communication skills education called “SEE-IT” (self-efficacy-enhancing interviewing techniques). In contrast to more traditional forms of continuing medical education (CME), SEE-IT training was performed “in situ” within physicians’ offices, and resulted in significantly higher use of recommended interviewing techniques such as negotiating goals, assessing readiness, and checking for understanding.

Can bribery get couch potatoes off the couch? Sometimes. The paper by Patel et al.³ riffs off recent popular fascination with the emerging field of behavioral economics, where prior work has shown that financial incentives can motivate patients to alter health behaviors. Patel et al. took this one step further (pun intended) and looked at whether individual- or group-based financial incentives better motivated patients to increase their physical activity. The investigators randomized 304 adults (divided into 76 four-member teams) to individual incentives only, individual incentives that were contingent on team success, and control (daily feedback on performance). Only the combined individual and team-based incentive program was more effective than control. An editorial by Hoch and Dewa examines the findings in detail, raising many questions for future research on the complex relationship between rewards and healthy behaviors.

Should doctors get out of the motivation business altogether? That’s what some payers and policymakers believe, leading to programs that pull responsibility for key clinical tasks completely away from physicians. One example is the use of health plan-delivered care management. These programs attempt to improve chronic disease management through frequent telephone contact, usually by nurses, with patients at high risk for adverse outcomes or extreme costs. In contrast, many primary care practices have incorporated chronic care management as they work towards establishing themselves as “medical homes.” In a quasi-experimental study directly comparing these two types of programs for patients with one or more chronic illnesses, Luo et al.⁴ basically called it a wash. However, there was substantial heterogeneity in primary care management plan implementation. As Luo et al. rightly point out, more research is needed to understand the implications of these differences.

Despite impressive developments in the behavioral and managerial sciences, most of the variance in clinician and patient behavior—perhaps akin to the mysteries of the human heart—remains unexplained. JGIM acknowledges these mysteries most directly through our humanities section, Healing Arts, which is currently co-edited by Audrey Young, Jeremy Graham, and Anna Reisman. In this issue, we’re pleased to present the first essay⁵ in our newest article type, which we call “The Spark.” The Spark features stories of powerful patient experiences that have influenced non-clinical careers in general medicine. The “spark” of The Spark was Dr. Nancy Rigotti’s acceptance speech at the 2015 annual SGIM meeting, after winning the John M. Eisenberg National Award for Career Achievement in Research. In her speech, she vividly described how a single interaction early in her career with a patient, a pregnant young woman who was a smoker, sparked her decades-long interest in smoking cessation research—and sparked ours in creating a column for inspirational stories like hers. We are thrilled that Dr. Rigotti accepted our invitation to write the first Spark column, and we hope that her story will inspire those of you whose careers are shaped around research, advocacy, or policy to muse on the patients who inspired you to choose your path within our splendid field.