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Stopping on Green 

By Laurie Gelb, June 9, 2014

The intersection greets you with a green light, but an accident blocks your lane. You brake instinctively, disregarding an official signal to proceed. Contradictory stimuli define our lives. 

Cut to health care’s adherence doctrine. “Ask your doctor. Take your medication as prescribed.” In what other subject area is it optimal for end-users to follow instructions without having internalized a rationale and therefore knowing when and how to ignore them? If you’re repairing something and the instructions say “use an inch of duck tape” and it takes two, do you stop working or use more tape?  You make a split-second decision in the moment. 

We expect to kludge. Every day, most people take action that is unprecedented for them, slightly different, under new circumstances or seen in a new light. When a wall-mounted sink falls off, most of us can imagine that we should use the main water shutoff even if we’ve never used it before. And if we came to a screeching halt at every choice about food, drink, OTC, rx, exercise, surgery, medical equipment, caregiving, parenting, safety, environmental controls, etc., we couldn’t function. Certainly, some health decisions merit more than a second for consideration, but that doesn’t mean they get it, whereas some receive more consideration than they deserve.

You might ask, why is understanding the rationale for and exceptions to instructions so important, considering that patients can consult a clinician that knows both well? But you know the answer: seldom is the clinician or the network next to patients as they make critical choices to act, avoid, deny, even everyday re-evaluation of instructions about meds, diet, exercise, procedures, lifestyle, rehab.The vast majority of decisions that drive health outcomes are unknown, unseen and uninfluenced by content and service providers. And our constituents, knowing their own context better than anyone while facing their own toppled sinks, must often take what is for them unprecedented action. 

As the green light illustrates, we haven’t abstracted information until we can act optimally when things go wrong, or when conditions differ from a perfect world. The necessity of lifelong learning applies to health care in spades, while the evidence base for preaching “follow” (along with paternalistic clinicians and arsenic cosmetics) reeks of mold.

Memorizing that 2x2=4 doesn’t mean that you understand arithmetic. When a toddler repeats words, she hasn’t yet learned the language. We should want health care choices made by reason, not rote. Since any ongoing regimen, including observation, should be re-evaluated periodically, the notion of “set it and forget it” doesn’t apply. 

Few life choices entail a greater emotional investment than your own and loved ones’ health, while typical messaging dispassionately informs you that following the rules offers the best odds.  Yet the “exceptions” are so ubiquitous as to be cliché. Long-distance runners drop dead of early MIs as grizzled sun-worshippers light up into their 80s.  The “what you get is what you follow” thesis merits growing skepticism as truisms (fats block arteries, calcium strengthens bones, exercise prolongs life) emerge as increasingly complex and non-curvilinear propositions. Moreover, today’s patients face competing risks and lifestyle choices that their ancestors never knew. 

Instead of preaching reliance on catechisms that may or may not apply to a given situation, how about skill-building in decision-making directly, including the rationale for caring at all, transcending health calculators and guidelines. Economic studies show lower costs for the “engaged.” It can’t be an innate urge to obsess about health care that engages them, since hypochondriacs entails higher costs. The truly engaged understand enough to add value to their care.

Let’s not seek “informed consumers” a la the cereal aisle, who can only consume the information and care we provide, but informed patients, caregivers, clinicians, administrators and payors, who can collectively lift all boats. Clinicians can ask better questions to optimize outcomes, while EHR designers find better ways to incorporate the answers. Payors can better align provider and patient incentives. Patients and caregivers can ask better questions as well, while acting optimally on the stimuli life presents. 

Our “best” patients are not necessarily the most compliant with our every word. Instead, they ask realistic questions and probe for the best kludges so they can best apply what they know to what they don’t. Indeed, exploring disease information on one’s own has been associated with greater adherence in the traditional sense, time and again. Our “best customers” and the caregivers that support them understand that intention is not action, there is no free ride in health care and sometimes they must preserve their own health and even lives by stopping on green. 

Last week’s Modern Healthcare piece on the Cleveland Clinic illustrates, hardly for the first time, that even marquee institutions mislay part of the achievable.  By the same token, the lives we can save or improve by helping decision-makers to do their best work are incremental to the followers who leave more to chance.

Next installment: what are quick wins for patient satisfaction [sic], disease management and e-health if/as we rethink the adherence doctrine?

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