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From Denial to Responsibility – Connected Health Can Make Us All Accountable for Our Care

December 2, 2014


My dad was a wonderful guy who could fill the room with his personality.  He grew up during the Great Depression and was a World War II veteran.  I was thinking of him recently while considering how much health care delivery has changed in the last 100 years.

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When asked about his health, my dad would always say, “I feel great.  I don’t have any aches or pains.”  This is telling. His generation equated pain with the need to seek care from an expert.  After all, he grew up before Penicillin was discovered.  During that time, given what we knew about health and disease and what we could offer for treatment, it makes sense that people sought the care of a physician when they ‘weren’t feeling well.’

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We’re now in an era where chronic illness management and prevention accounts for 70% of health care costs.  Of the forces responsible for illness — bad luck, bad genes and lifestyle — lifestyle is the predominant cause of chronic illness.

Our public health officials understand this important change, but consumers by and large still do not.  They still mostly seek care when there is some symptom or acute need. This is problematic because so much lifestyle-driven illness is silent for years (hypertension, pre-diabetes, obesity) and only generates symptoms when things are pretty far along.

The other interesting aspect of my father’s adage is the denial underneath it.  He was really saying, at some level, “If I don’t have any symptoms, I’d just as soon avoid the doctor so I won’t get any bad news.”  This psychology too is quite prevalent among consumers today, adding to the challenge of raising awareness of lifestyle-driven illness.  It is easy and human nature, to live in denial.

Another childhood memory I have is how kind my mom was whenever I was under the weather. She gave us extra love, as if that would help the illness improve more rapidly.  Given that most childhood illnesses are viral infections, I suspect her added affection didn’t change the course of any illness, but she made it tolerable to be sick.

We all want to be cared for.  This enables a child-like approach to the health care system.  It is common for patients to come to see us joking about non-compliance and begging, “Don’t yell at me.”  Likewise, they boast about their doctors, implying that they can put all of their worries aside:  “She’ll make sure I am ok.  I trust her.”

This triad of not thinking about health until symptoms arise, not wanting to hear bad news and abdicating responsibility for care to a health care provider accounts for a big part of why it is so difficult for physicians to get folks’ attention before they get sick.

Connected health can help us counteract these challenges.  The vast array of sensors now available and their attendant feedback loops make it hard to ignore when we’re not on track with our health.  Even if we don’t feel symptoms, we can be reminded several times per day of how we’re doing with respect to a given health parameter.  When these data are shared with a health care provider, it becomes more difficult for individuals to ‘abdicate responsibility,’ something we’ve called the sentinel effect. When patients know their objective health data is being shared with a provider, they naturally up their game to appear to be compliant and interested in their health.  No one wants to look like a slacker in front of their doctor.

But we still have challenges when it comes to denial and individuals abdicating responsibility for their health.  This is magnified because we live in a libertarian society.  It is our right to ignore our health if we choose to; and because our politicians want to offer us ‘coverage,’ we can still get our bills paid in the face of unhealthy lifestyle and behaviors.

What tools do we have to deal with this challenge?

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  1. Incentives/rewards.  We can offer individuals rewards for achieving health goals.  Our connected health sensors can be the source of objective data to automate decision-making around those goals.
  2. Penalties.  As a colleague recently said to me, “There is a continuum.  You start with encouraging your workforce not to smoke and offering them rewards for not smoking.  Next, you give them notice that those who continue to smoke will pay a higher insurance premium.  Finally, you institute a policy to not hire smokers.”

Should we follow this approach with other lifestyle/habits such as physical activity and diet?  Does it seem to invasive?  What do you think?

10 Comments leave one →
  1. Dana Jessup permalink
    December 2, 2014 11:32 am

    Great insight into the challenges of disease prevention and health promotion. And as a parent of young children, I find that positive and relevant consequences outperform penalties when it comes to behavior modification.

    • December 2, 2014 11:38 am

      I think so too, but at some point the penalties seem necessary.

      • Manoja Lecamwasam permalink
        December 2, 2014 3:01 pm

        While I support instituting positive and relevant consequences to change behavior, I don’t think we will see long-term behavior changes unless there are negative consequences for propagating bad behaviors.

  2. Tony permalink
    December 2, 2014 5:15 pm

    We live in a society where good health care is considered a right. I like to think that we all are responsible for the well being our neighbor. Which means we have a responsibility to take of our health. Not everyone shares this ideal. Therefore penalties are probably necessary.

  3. jeffwphillips@gmail.com permalink
    December 2, 2014 5:25 pm

    As a PCP, this is where the growth opportunity lies. I’d much rather spend my time preventing disease than prescribing pills and insulin. Using connected tech to monitor this (at the patients request) seems smart. We should be moving towards intermittent asynchronous communication with our patients rather than 20 minutes, once/yearly, as the current model allows. Greater forces are at play as well- in many ways, society and the food industry makes it “easy” to be inactive, eat poorly etc. I think positive reinforcement is the way to go here. After us, it’s up to each individual to want to change their unhealthy behaviors….

    • December 2, 2014 5:36 pm

      Great to hear from the leading edge thinkers in primary care!

  4. Jim Reid permalink
    December 2, 2014 8:59 pm

    When I was in sixth grade they brought a laryngectomy patient into “health class” to “talk” to us about how smoking cigarettes caused his cancer. Using an electrolarynx, that altruistic patient gave a vibratory caution that left an indelible impression on all of us. I’d be willing to bet that none of the twelve year old students in that class EVER smoked.

    I too have struggled with the positive vs negative reinforcement arguments for changing poor lifestyle behaviors. The bottom line is different people respond differently and both strategies can be successful and both can fail. One can argue that if hypertension or type 2 diabetes caused pain like a migraine or a broken arm, people would be much more likely to avoid those things that cause them. Shortening the feedback loop with near realtime data as Joe suggests has also been shown to improve patient accountability – no question. Inch by inch.

    However, the real bottom line is to not have to treat chronic diseases but to avoid them completely. What children see around them every day is what they come to recognize as “normal.” My obese brother-in-law has three obese children. Kids that are raised eating high fat, high carb, low nutritional value foods feed them to their kids. Kids raised around smokers, smoke, and drinkers, drink. I think there is a lesson for all of us in the laryngectomy anecdote. “Get them while they’re young.” David Katz MD and others have it right. EARLY education and intervention around lifestyle choices that expose children to healthy values and lifestyles, and the consequences of neglecting them, will over time – perhaps over generations, reframe “normal” in a positive direction. I am very encouraged by the multiple fronts where this approach is now taking form!

  5. Jim Hutchinson permalink
    December 3, 2014 9:06 am

    Just as with smoking, human nature is slow to react unless a “black swan” appears that causes a sudden shift in one’s personal position. The solution to stop smoking may have been obvious to some, but most felt it was their right to smoke as they saw fit. As you mentioned this has changed. Penalties get moved into the picture slowly as public opinion gradually shifts. That’s exactly what we see happening here. Perhaps sensors will hasten this change, as they make us more aware of our health practices, positive or negative, but don’t hold your breath expecting rapid change.

  6. Kathleen Repoli permalink
    December 16, 2014 5:58 pm

    As pointed out above, modifying human behavior is tricky. The carrot or the stick? A combination of both – each responds differently. One thing Joe pointed out, that I’d like to pull out is “we all want to be cared for”. The need for compassion, gratitude and authentic caring for one self is often overlooked by each of us. The on-going studies to support mindfulness, for example, is a tool that is not expensive or time-consuming but can begin to foster some self-caring and lead to healthier choices. Changing behavior is an evolution and I look forward to seeing where we are in twenty years as a nation. The shift has begun and is quite exciting!

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