The Power of Positive Patients
Four years ago, Sarah McMahon (not her real name), then 83, suffered a heart attack and had surgery to implant a stent, a tiny, balloonlike device that expanded to increase bloodflow through her coronary artery. Afterwards, she was told to watch her diet, take her medications and – because physical activity has been shown to significantly reduce death rates following stent surgery – exercise regularly.
But where most patients struggle to keep to such a regimen on their own, McMahon, who lives alone in Eastchester, New York, joined a follow-up study that evaluated ways to get patients to exercise. She signed a “contract” to try to meet certain exercise goals. She tracked her progress with a pedometer and in an interactive workbook about self-managing heart disease. And, in an unusual twist, the research team helped her identify personal associations, positive thoughts and proud moments that would motivate her to exercise. Twice a month, team members called her to remind her of these strategies. They also mailed her occasional small gifts.
“It was wonderful,” recalls McMahon. “When I volunteered for the study, I was just so pleased to be alive. It was gratifying to think I might be doing something useful, particularly at my age. And then, the girls who called me were so lovely, and I enjoyed speaking with them.”
With people 65 and older expected to constitute nearly 20 percent of the population by 2030 (up from 13 percent now), the United States is becoming a nation of Sarah McMahons – older people with multiple ongoing health problems. In 2005, 133 million Americans, or nearly one in two adults, had at least one chronic illness, and 7 in 10 deaths were due to longer-term conditions such as cancer, heart disease and stroke. Treatment costs were estimated at $1.7 trillion annually.
Faced with these trends, health care experts increasingly agree that traditional medical approaches no longer suffice.
“We’ve had enormous success with medical discoveries – they’ve led to advances such as statins, beta-blockers, clot-busting drugs and continuous refinements in procedures such as angioplasty [stent surgery] and coronary artery bypass surgery,” says Susan Czajkowski, a scientist at the National Heart, Lung, and Blood Institute (NHLBI) who is an expert on psychosocial aspects of illness. “They’ve extended life. But many of the critical issues we now face are related to behavior. The key is to help people quit smoking, maintain a healthy weight and diet, stay physically active and, if they are taking medications, adhere to treatment.”
Doctors tell patients to do these things all the time, but ensuring compliance is much easier said than done. For example, as many as half of all stent patients stop exercising within four months, and one-fifth experience a new adverse event within a year after surgery. What’s needed, then, are care managers who can get inside patients’ heads – master motivators who are as much Phil Jackson or Vince Lombardi as they are Ben Casey or House M.D.
“It’s not sufficient anymore for a doctor to simply dispense advice and prescriptions,” says John Allegrante, Professor of Health Education and Deputy Provost at Teachers College, and editor of the journal Health, Education & Behavior. Allegrante and his former TC student Janey Peterson, a health researcher at Weill Cornell Medical College in New York City, were part of the investigative team that designed the study that Sarah McMahon participated in. “What’s emerging is a more motivational, intervening type of practice, in which the physician is better at listening, at discussing patient preferences and approaches to a problem, and at building patients’ confidence in their ability to change how they live.”
In the tool kit wielded by this new breed of doctor, positive emotions loom large.
“You can threaten patients with the consequences of failing to take care of themselves, but that’s not enough,” says Peterson, a former cardiothoracic intensive care nurse. “They need a positive reason, something that comes from within and that can be self-induced.”
Psychologists such as Daniel Kahneman, Amos Tversky, Martin Seligman, Edward Diener and Alice Isen have long focused on the power of positive thinking. They have argued that optimism and happiness are learned skills requiring practice and that a positive outlook can change behaviors ranging from making purchasing decisions to processing information about medical risk.
In 2003, NHLBI issued a nationwide call for proposals for studies to apply such findings to improving patient outcomes.
“Many scientists were doing excellent basic behavioral research, focused on understanding why people act, think, feel as they do, but they weren’t applying what they found about human behavior to specific clinical problems,” says Czajkowski, who spearheaded the Institute’s effort. “So we asked teams of basic and clinical behavioral scientists to work together to tackle pressing clinical questions in the heart/lung/blood realm.”
The team that included Allegrante and Peterson – headed by Mary Charlson, Chief of the Division of Clinical Epidemiology and Evaluative Sciences Research at Weill Cornell – received funding to conduct a set of studies aimed at developing and refining a behavioral intervention, culminating in three randomized clinical trials involving 1,000 patients. One trial focused on boosting physical activity among asthma patients; another on getting African American patients with high blood pressure to adhere to prescribed medication (African Americans have substantially higher rates of hypertension than other ethnic groups); and a third on getting stent patients like McMahon to exercise.
In each study, a treatment group and a control group received state-of-the-art instruction and tools for managing their own care. The treatment group also received a motivational intervention, delivered by phone, that included using positive thoughts and recalling proud moments. Gifts were delivered by mail. The studies tested the power of both “positive affect,” defined as “a state of pleasurable engagement with the environment [that] reflects feelings of mild, everyday happiness, joy, contentment and enthusiasm,” and “self-affirmation,” such as using memories of past accomplishments, to “preserve a positive image and self-integrity when one’s self-identity is threatened.”
The results of the studies – the first clinical trials to test the power of induced positive affect in patients with a serious medical condition – were published this past year in The Archives of Internal Medicine.
In the trial involving stent patients, 55 percent of those who received the motivational intervention increased their expenditure of kilocalories by at least 336 per week, versus just 37 percent of the control patients – the equivalent of walking 7.5 miles weekly versus walking 4.1 miles weekly, says Peterson, who authored the angioplasty manuscript.
In the hypertension study, adherence to medication after 12 months was 6 percentage points higher in the intervention group than in the controls (42 percent vs. 36 percent) – a gain “consistent with some of the most effective interventions available,” according to the journal Cardiology.
In the asthma study, a subgroup of severely asthmatic patients who received the intervention exercised more than their counterparts in the control group.
None of the three studies demonstrated improvement in patients’ health, but previous, longer studies have established that exercise and adherence to medication create better health outcomes.
“These studies are revolutionary,” says Czajkowski. “They show that this kind of approach can be done and that it is fruitful.”
For Allegrante, the studies are significant because they demonstrate that positive affect enhances the power of patient self-management. “The control group itself received a pretty robust intervention – it was no straw man,” he says. “We built the best mousetrap we could and then gave additional positive affect and self-affirmation components to the treatment arm, so that we’d have a good test of the added value of focusing them on positive emotions. And the results were remarkable.”
But can self-management techniques, including positive thinking, be broadly implemented in a health care system with a marked preference for a pound of cure rather than an ounce of prevention? The evidence suggests that such techniques are cost-effective. For example, in a 1999 study of the Chronic Disease Self-Management Program (CDSMP), a well-known group program created at Stanford University’s Patient Education Research Center to increase patients’ confidence, skills and social support, health care costs for the patients who received CDSMP were $820 lower (even accounting for the intervention’s cost) than for patients who did not, primarily due to reduced days of hospitalization. Health care expenditure savings for the intervention group were roughly 10 times the cost of the intervention.
But David Sobel, M.D., Ph.D., Director of Patient Education and Health Promotion for the Permanente Medical Group and Kaiser Permanente’s Northern California region, sounds some cautionary notes. For behavioral programs to be better integrated into clinical care, Sobel says, we need “good evidence of effectiveness in real-world settings and aligned financial incentives – or at least an absence of disincentives. With medications, there is a whole industry and strong financial drivers to promote their use. How can the drivers for non-pharmacological and behavioral interventions be mobilized?”
Unlike most insurers, Kaiser Permanente does not reimburse physicians on a fee-for-service basis, Sobel says. Kaiser clients – an employer, a university, an individual – pay a lump sum for improved health outcomes, and Kaiser can use whatever evidence-based approaches it believes will work best.
“If we can better manage high blood pressure through a body-mind program, we’ll do it, whereas a doctor in a fee-for-service practice has to bill an insurance company for an office visit, which might be the least effective thing for controlling high blood pressure,” says Sobel, a practicing physician who helped develop and evaluate CDSMP in real-world care within the Kaiser Permanente system.
Sobel believes more traditional insurance companies would be receptive to self-management approaches supported by good evidence for quality of care and improved outcomes. Right now, though, “there are very few evidence-based self-management programs that have been evaluated,” he says. “It’s one thing to do an evaluation in a clinical trial under specialized circumstances and another to replicate the program in a real world care system. Often, you can’t just extrapolate from clinical trial data to ‘This will achieve a reduction of X number of days in the hospital.’”
Costs, though, are only one piece of the puzzle. How to change the operating style of doctors and other care-givers working on the front lines?
Allegrante believes the effort must begin in medical schools.
“To date, we prepare doctors largely to be biomedical scientists, not applied behavioral scientists, which are what’s really needed in an era when behavioral management of chronic disease is critical,” he says. “If we’re going to get the outcomes we want, and that insurers demand, we need both.”
Janey Peterson believes nurses could be key change agents in making behavioral interventions a bigger part of medicine.
“In the 1980’s when I worked as a bedside nurse in psychiatry and the cardiothoracic intensive care unit, I learned how to connect on a personal level with patients and their families at a very vulnerable time in their lives and address their psychosocial, educational and health care needs,” she says. “Hospitalization created a teachable moment when many patients were more open to receiving health information that could significantly affect the rest of their lives.” Today, she says, when nurses can practice as clinicians, researchers, scholars and educators, there are greater opportunities to “make the world a better place for our patients.”
And Kate Lorig, Director of the Stanford Patient Research Center, believes that the move toward motivating behavioral change could take place even farther away from care centers.
“People spend 99 percent of their time outside the health care system, and it’s what they do there that determines their health and their quality of life,” Lorig says. “In lots of parts of the country, community organizations teach self-management. Your doctor says, ‘There’s a Jewish community center a few blocks from your house. You’re not interested? We’ll contact you when we learn of something more to your liking.’”
Meanwhile, in 2009, NHLBI issued another research solicitation for behavioral intervention studies, this time focusing on obesity and obesity-related behaviors. A second effort, taking in a wider range of health-related behaviors and involving several organizations within the National Institutes of Health, is getting under way.
“We really need to keep increasing the pool of efficacious interventions for behavioral health problems,” says Czajkowski. “It’s like drug development – even when we have drugs that work, pharmaceutical companies continue to use findings from basic biological science to make better ones. Behavioral scientists should be doing the same.”
Peterson finds the analogy with pharmaceuticals particularly resonant.
“A few months ago, one of the attending physicians in the class I teach told me that he dispenses written prescriptions for physical activity,” she says. “That’s incredibly powerful, because that’s what physical activity is – it’s medicine, and often it’s as least as strong, if not more so, than many pills people take.” Motivating people can be “so delightfully simple and easy. Instead of asking people to sit through weeks of therapy or classes, you can induce positive affect as easily as by telling a joke, or smelling some nice perfume, or keeping pictures of your grandchildren by your bed.”
Sarah McMahon, the patient in the positive affect study, agrees. “When you get to be this age, your children have their own lives, and you’ve really got to find ways to take care of yourself. When the people from the study would call, they’d always ask me about the staircases in my house. It took me a while to catch on, but what they were really saying when they’d ask me about them was ‘Use those stairs. They can help you.’ And they were right.”