Getting Patients in the Habit of Doing the Right Thing

Quite frequently, after long-term patients come in for their annual physical examination, the next morning their blood test results appear in my EHR in-basket, and I will send a portal message to let them know what was up: “Looks like your cholesterol is still way too high, the overall profile is not favorable. Given your family history of heart disease and other risk factors, the levels are such that you should probably consider taking medication for this.”

Shortly afterwards come the replies. “The past couple of months have been tough, what with the holidays, work has been crazy busy and stressful, I’ve definitely been comfort eating and haven’t been to the gym in a while.” Then the pledge. “Can I commit to making some serious changes, and then we can recheck in a few months?”

Helping Patients See Patterns

My standard reply is something like, “If that’s what you want to do, then it needs to be some serious changes you can stick with, and we can recheck in about 6 months with a fasting blood test to see your progress.” I will often send along some additional nutrition information, along with an offer for them to see a nutritionist through video visits (which is often declined).

I will put a future order in the system for a fasting lipid profile, along with some additional testing that might help us further risk stratify them, and then send a message to the scheduling team to make sure to schedule a lab visit in 6 months. And then I figure it’s pretty much done.

However, occasionally I get that nagging feeling that this sounds familiar, that we’ve had this conversation before. When this happens, I will pull up the old portal messages for a patient and look back over the previous years. It looks like we’d often had this exact same conversation, every year. Year after year.

My next step is to call them on the phone, tell them what I’d found, and then somewhat sheepishly I will hear, “Maybe it’s time to admit I need to take a statin after all.”

During our brief visits with our patients, the best-laid plans often go awry. What annual visit doesn’t end with patient advice and education about keeping hydrated, making healthy lifestyle choices, getting plenty of sleep, exercise, stress management? And now they get a copy of this advice and recommendations in their after-visit summary through the portal, as well as being able to read our notes in their entirety and see what we thought they should do. But how much of it makes a difference? How much of it sticks? How much of it leads to long-lasting change?

Easier Said Than Done

Just the other day, I attended a fabulous lecture from the head of our sleep medicine group that went into incredible detail on the harms of poor sleep and the benefits of good sleep. She offered up amazing advice, useful tools we could give to our patients (and use ourselves). But this, like so many other things, is so hard to carry through on, to follow up with, to stick with. It’s hard to resist the lure of doom-scrolling on your phone, or watching the news late at night in bed, or maybe just one doughnut or a handful of cookies to ease the stress of the day.

That very night, after her wellness lecture, I watched two episodes of “The Lincoln Lawyer” on Netflix, and stayed up way past what would have been a reasonable bedtime. Sure, I should wake up 30 minutes earlier and use that rowing machine in my spare room, or stop at the gym on the way home and do a set of the exercises that my trainer (who I’m paying for this advice) wants me to do a couple of extra times in addition to our one weekly session together. Might there be some ways that we can use things like remote patient monitoring and digital technology to find better ways to ensure that our patients heed our advice and stick with it?

Some of this might feel like nagging — which it might very well be. People have tried all sorts of ways to send patients messages, emails, texts, to remind them and goad them, to send them positive messages or guilt them into doing things. There are also apps out there that reward patients — the more you exercise or less you eat, the more badges you get, the more credits you get to redeem at your gym or on Amazon or for something else that might motivate you.

Maybe someday we’re all going to have a virtual assistant, either a robot or some sort of device in our home that was listening in when we went to the doctor, or reads that after-visit summary and takes it on itself to become the one to make sure we follow this advice and stick with it. Would our patients listen if Alexa or the Echo device on the kitchen counter scolded us for opening the freezer and taking out a pint of ice cream, or give us points or other credits towards future purchases when we get on our exercise bike instead?

No One-Size Solution

Smart containers that can track our hydration, smart toilets that track how much we pee. Intelligent pill tracking devices that see when and if we’re taking our medication, and know just the right ways to get us to be more compliant.

There is going to be no one-size-fits-all solution. Every patient will likely respond differently to different levels of suggesting, pressuring, goading, and disciplining. Some may even choose a device that delivers a little zap of electricity when they don’t follow their doctor’s advice. Reminders like this might help because the vast majority of our patients’ lives are spent out from under the influence of their doctors and the commonsense wonderful advice we give them during the brief moments when we have them needs to be converted into action for the rest of the year.

Right now, my Apple smartwatch gives a little celebration of flashing lights when I close one of my Exercise, Movement, or Standing rings. Sometimes, the next morning, if the day before wasn’t a day for closing rings, I will get a message that says, “Looks like you didn’t do so well yesterday. Let’s try harder today.” This has yet to make me stand, move, or exercise more. But if we could find better motivational tools across a spectrum of possible interventions — maybe something that a patient sets at a level that makes them happy and comfortable (or maybe a little bit uncomfortable), then maybe we’d all end up with better results.

This year, and the next one, and the next.

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