Behavioral change requires clincal systems that support tracking and follow-up over time.
Growing up in Oklahoma surrounded by the petroleum industry, I was surrounded by geologists. Geologists, on the whole, are persons who revel in the bigger picture of life, live within the grand sweeping landscapes that fill our world, and are thrilled with pursuing answers to how our natural world came to be. Their clocks tick in millennia, and they perceive the fluidity of rocks, earth, wind, and water in larger time scales. They also understand the enormous power of small pressures applied gently and persistently.
I need more geology in my practice. People today are faced with moving mountains-eating healthier, exercising, putting down their cigarettes. Our health care system has evolved behavioral treatments that address each of these, but our efforts often fall short. The evidence-based treatments we employ are predicated on minute bursts of energy, like TNT, that barely scratch the cliffs of granite our patients are holding onto. We’ve demonstrated that many patients will consider making lifestyle changes when a physician recommends it-so we’re told to briefly counsel our patients on dieting and exercise and smoking cessation. Some may move towards enacting that change, but in the busy day-to-day of clinical care, such interactions are rarely recorded and even more rarely followed up systematically.
Energy toward behavior change is spent in a frenzy and exhausted, leaving patients and providers demoralized and defeated, often with nothing to show for it. Many will relapse in their smoking cessation, many will gain back the weight they pledged to remove. We enact large-scale programs to help address these challenges (diabetes education groups, smoking cessation groups) that similarly promote a flurry of activity that is rarely long-lived and only gets to some in need.
In clinical medicine, I need systems in place that support tracking and follow-up over time. Systems that help my patients and me set goals for care and measure their incremental improvement over large scales of time. These goals need to be collaborative and patient-centered. They need to be iterative, and beyond the bounds of a 15-minute visit. They need to be gentle, yet persistent and sustainable. Like a river eroding bedrock.
Delivery of care in this way would take nothing short of a revolution in reimbursement, training, and organization. As an outcome-driven health care system evolves, we have to ask ourselves what kind of outcomes we are looking for, and within what kind of time scales we’re expecting those outcomes to be delivered. Clinical trials aren’t patient enough to observe results over a decade, much less even a year.
In our haste to show results, are we making pock-marks on a mountain and saying we moved it?
Millions of people visit our national parks every year. Millions stare at the enormous beauty and awesome power of the world in which we live. If we are to ever move the mountain of health behavior change, we must set in place the systems necessary to harness the geophysical energy of time and persistence.
In doing so, we could better realize the inner geologist in everyone.