Getting to the ‘Why’ of Behavior Change

In his book Start with Why: How Great Leaders Inspire Everyone to Take Action¹ and in his well known TED talk, Simon Sinek, leadership author and consultant, argues that what distinguishes great leaders and organizations is their focus on the ‘why’ of the work and not just on the ‘what’ and the ‘how’. In fact, great leaders and organizations start with the ‘why’ and then move to the how and the what—while more conventional organizations move the other way; they start with the ‘what’ and then move to the ‘how’ and may never get around to the ‘why’.

Sinek gives the example of Martin Luther King, Jr., who has inspired millions with his words. Dr. King’s ‘what’ was to eliminate race-based disparities and discrimination; others shared the same goal. His ‘how’ was through non-violent protests, a tactic he borrowed from Gandhi and others. However, It was Dr. King’s articulation of the ‘why’ that made him one of the great leaders of the twentieth century as illustrated by his “dream” that some day his four children would be judged not by the color of their skin, but “by the content of their character.”

Sinek points to Apple as a company that built its success by starting with the ‘why’. Apple products fundamentally perform the same functions as their competitors (the ‘what’), and while Apple may pay particular attention to the design (the ‘how’), these features do not distinguish Apple products from those of Microsoft, Samsung or others. What distinguishes Apple, in Sinek’s view, is their attention to the ‘why’. He argues that Apple starts with the premise that to use their products is to challenge the status quo. He puts it this way in an imaginary ad from Apple: “With everything we do, we aim to challenge the status quo. We aim to think differently. Our products are user friendly, beautifully designed, and easy to use. We just happen to make great computers. Want to buy one?”

So what are the lessons for the work we do in general internal medicine? In this issue of JGIM, several papers describe different approaches to working with patients around behavior change. To be effective, each must help patients imagine a future that is different and generally better than what they are currently experiencing or they will not be inspired to change. In this issue, Palacio et al.² report on a systematic review of the effectiveness of motivational interviewing (MI) on medication adherence. They point out that lack of adherence to medication is a major problem in the US causing excess morbidity and mortality and contributing over $1 billion to health care costs. Motivational interviewing is a non-judgmental technique that helps patients to change destructive behavior by facilitating and engaging their intrinsic motivation. In a sense, it helps patients imagine what change would be like by allowing them to get in touch with their own personal motivations (their ‘why’) and to consider what would be different with change. Overall, Palacio et al. found that MI improves medication adherence, especially in minority populations, although there was significant variation in mode of delivery and adherence measures that may limit the generalizability of their findings.

Danan et al.³ report on a randomized trial of 3006 current smokers at four Veterans Affairs Medical Centers (VA). The intervention arm included proactive outreach consisting of a mailed invitation followed by telephone outreach to participate in smoking cessation services as well as access to pharmacotherapy. The usual care arm had access to the usual VA smoking cessation services as well as telephone quitlines. They were interested in the relationship between the baseline stage of change treatment use and smoking cessation. Perhaps not surprisingly, the uptake of smoking cessation treatments increased with higher baseline stage of change (smokers in contemplation were more likely to engage in treatment than pre-contemplators) as were smokers in the ‘proactive’ (intervention) arm regardless of the stage of change. They conclude that proactive outreach to smokers, even those not planning to quit, is an effective strategy to enhance smoking cessation.

In spite of significant technological advances over the past decade, organ transplantation continues to be stymied by low rates of organ donation. As Thornton et al.⁴ point out in this issue, many patients die while waiting for a transplant. The decision to donate is deeply personal and driven by values as well as by more pragmatic factors such as accurate information to address generally unfounded fears. The authors report on a randomized trial of an organ donation video conducted just prior to a primary care visit. They randomized 915 patients who had not previously consented to organ donation and randomly assigned about half of them to watch a 5-min educational video about organ donation and then were prompted to talk with their provider about it vs. control patients who had a routine appointment. They found that intervention patients were more likely to discuss organ donation with their provider and more likely to consent to donate organs. Interestingly, intervention patients were also more likely to discuss end-of-life care with their providers. By prompting patients to reflect on the practical question of organ donation, this simple intervention presumably also prompted them to reflect on the core values that governed their views of life and death, indirectly getting to the ‘why’ of their existence.

As general internists working both in the clinic and in the hospital, one of our main tasks is to work with patients to promote healthy behaviors or avoid unhealthy ones. By focusing not just on the ‘what’ (the behavior) and the ‘how’ (the intervention or treatment) but also on the ‘why’ (the underlying core values), we will have more success in supporting behavior change and in the process will find more meaning in the work for ourselves.