Case Scenario

Joe is a 40-year-old insurance salesman who has been married for three years. He presents as a new patient with a mild ankle sprain. His blood pressure is 154/80 mm Hg, and he has a body mass index of 35 kg per m². Joe's in-office A1C level is 5.4%. His father had type 2 diabetes mellitus and died from a myocardial infarction at 65 years of age. Joe tells you that he usually skips breakfast and eats fast food for lunch. He and his wife eat out three times per week and otherwise have canned soup and bread for dinner. Joe adamantly refuses to take medication for his high blood pressure despite his physician's warnings of the consequences. Unknown to the physician, Joe's father experienced erectile dysfunction while taking blood pressure medication and “had a heart attack anyway.”

The physician recommends that Joe exercise 150 minutes per week, eat more vegetables and whole grains, choose low-sodium soups, lose 10 pounds, and follow up in three months. Sound familiar? The physician does not notice that Joe rolls his eyes at these recommendations.

Odds are that Joe will not make the recommended lifestyle changes or return in three months. Why would someone not do everything necessary to be healthy?

Clinical Commentary

Joe has elevated blood pressure and several other cardiovascular risk factors, and he refuses to take antihypertensives. Evidence suggests that he would benefit from lifestyle changes, including those recommended by the American Heart Association/American College of Cardiology for nonpharmacologic control of hypertension^1,2:

• Eat a diet that emphasizes vegetables, fruits, and whole grains and limits red meat, sweets, and salt (DASH diet).

• Limit sodium intake to 2,400 mg per day.

• Do not add extra salt.

• Use spices, lemon juice, and herbs to flavor food when cooking.

• Read labels on prepackaged foods, and choose low-salt or low-sodium foods.

• Do not use tobacco products.

• Exercise three or four times per week, averaging 40 minutes per session.

• Limit alcohol consumption to two drinks per day for men and one drink per day for women.

• Manage stress using techniques such as biofeedback, which has been shown to be beneficial.

• Self-measure blood pressure.

Physicians have limited time and often go straight to telling patients what to do without listening to what the patient thinks or is willing to do. Typical one-year medication adherence rates for conditions such as hypertension are 50% to 60%.³ Because the rate of adherence to a treatment plan is more than two times higher if the physician is a good communicator,⁴ it is important to resist “treating the numbers” right away during the visit. Instead, physicians should get to know the patient's story and health goals, even if a few more visits are needed. The physician might have learned about Joe's father's health history and experience with hypertensive medication if the physician had spent more time with Joe. Asking about a patient's feelings regarding a possible treatment can unearth opinions formed from the direct or shared experiences of the patient—including opinions from the patient's family, coworkers, and friends. Prior knowledge of adverse events, such as Joe's father's erectile dysfunction and heart attack, can impact a patient's willingness to adhere to lifestyle changes or medications.

Medical care contributes 10% to the prevention of premature mortality, compared with a 40% contribution from individual behavior.⁵ The meaning of this statistic is clear: what happens between visits is more important to the patient's health than what happens during the visit itself. The management of medical conditions such as mild hypertension, for which the first-line treatment is nonpharmacologic interventions, is particularly dependent on the patient's engagement.

According to research on which physician characteristics are associated with better patient outcomes, five key behaviors increase patient activation and improve self-management⁶: (1) emphasizing patient ownership—work on patient goals; (2) partnering with patients on what they are willing and able to do; (3) identifying small steps to ensure success; (4) scheduling frequent follow-up visits to cheer successes or problem solve; and (5) showing care and concern for the patient. A physician skilled at motivational interviewing is more likely to achieve the first three behaviors. Implementing these key behaviors takes more time initially, but the physician is much more likely to be clinically successful in the long run.^7–9

Peer support programs, such as Better Choices, Better Health or the Chronic Disease Self-Management Program, have also been shown to promote healthy behavior.^10,11 Participants set health goals and achievable action plans, enhance their ability to communicate with physicians, share knowledge about how to live with a chronic health condition, and support each other in making positive behavior change.^10,12 Local resources can be found on the Evidence-Based Leadership Council website: http://www.eblcprograms.org/evidence-based/map-of-programs.

Resolution of Case

How might things have turned out differently? Let's imagine that Joe's physician begins by asking Joe what he knows about hypertension and then learns about Joe's father's experience with medication and subsequent heart attack. Joe also tells his physician that he was frustrated that his father did not try to lose weight to preserve his health.

When asked about his own experience losing weight, Joe says that he has never really tried to lose weight. After eliciting from Joe that his goals are to live longer than his father did and to preserve his sexual function, the physician explains that diet changes, such as cutting back on salt and eating more vegetables, and increasing physical activity can help with weight loss and control of blood pressure, possibly without medication. When asked what he would like to do, Joe responds that he could walk the one-half mile to work on Mondays and Wednesdays and eat a salad for lunch at least three days per week. Joe agrees that the medical assistant can check with him every two weeks by phone to support his action plan.

The visit concludes after the physician examines Joe's ankle and discusses what to do for a mild sprain. Joe leaves the office feeling happy that his physician listened to him and is optimistic that he will succeed with the first step of his action plan. At Joe's follow-up visit in six weeks, the doctor will see whether Joe might be interested in the Chronic Disease Self-Management Program offered at the community center to help support his behavior change.

The Lown Right Care department project was supported with funds from the Robert Wood Johnson Foundation grant 75223.