Answers: Should Physicians Create Lifestyle Plans?

Last week I gave my thoughts on whether physicians should be the ones creating lifestyle programs. Below are a handful of responses that were sent in by readers that I thought were interesting.

Lifestyle interventions take a long, long time

Omada co-founder here. Your typical "person needing a lifestyle intervention" works full-time to support their family, has kids they need to run between home/school/soccer practice/etc, is responsible for feeding their family, doesn't have time to cook for themselves let alone exercise, has lost family members to diabetes and is resigned to facing the same fate, and uses food as a coping mechanism - their morning milkshake / afternoon candybar / evening bag of chips is their only bright spot in an otherwise stressful and demanding day. They know full well they need to make lifestyle changes to prevent serious health issues but not only is it their lowest priority, they think they'll fail even if they try.

No recommendation or conversation is going to change this. It takes intensive coaching over many months to make any lasting impact. It takes motivation, cognitive reframing, motivational interviewing, problem solving, regular health tracking, family support, peer support, learning how to exercise, learning how to cook, learning how to read food labels, learning and practicing new coping strategies, learning how to manage difficult situations, ...and I could go on. Plus, this needs to be delivered in such a way that it fits into someone's already busy life without being overwhelming.

Sorry to be long-winded, but it's easy to underestimate the challenge of implementing lasting lifestyle change in the real world. So I 100% agree with the OP in the Twitter thread. It doesn't make sense for physicians to deliver lifestyle interventions.

-Andrew DiMichele

[NK note: Figuring out how to make healthy behaviors convenient is the only way this is going to work. In the "food as medicine" post I suggested that the sell of "saving time" via healthy prepared food might actually be a better sell than anything else.]

 “Knowing when and who to hand-off to is still providing care.”

“The short answer:  the physicians who want to, should, and the ones who don’t, shouldn’t. Hahaha.

I’m a clinical social worker and program manager at a public healthcare system, I know very well that lifestyle counseling requires a lot of time, follow up, and patience. The majority of doctors in high volume clinics do not have time to help patients create goals, assess motivation, identify barriers to completing goals, and follow up. I don’t believe lifestyle counseling requires a very specialized skillset. However, the time to do this counseling and willingness to do it are needed. So, if doctors want to work closely with their patients and can make the time to do so (all physicians reading this will be rolling their eyes reading that sentence, I am aware), they should give it a try. They will most likely see good outcomes and have better relationships with their patients (not sure if that matters to all physicians). 

However, a hand off to someone else, who may have more time, patience, and who has a strong understanding of case management/social determinants of health, might be better equipped to help patients with lifestyle counseling. Knowing when and who to hand-off to is still providing care. As long as the provider clearly verbalizes the importance of following up with the coach/case worker/health worker.  Saying something like “a really fantastic colleague on my team is going to call you. I work very closely with them and they have been super helpful to some of my other patients. I think they could really help you too”.  The perception of someone caring can motivate patients to comply or engage more actively in treatment. Physicians should reinforce the care team idea to the patient, which means they should know who is on their care team.

On a side note, this topic reminded me of the time when I did my own scheduling and reminder phone calls for my therapy patients. They almost always came. At some point, when I had other responsibilities added to my plate, I had the front desk staff handle my scheduling. My no-show rates increased. I then chose my favorite clerk and asked them to do all my scheduling. I gave them scripts on what to say and had them practice. In session with my patients, I would drop my scheduler’s name to reinforce that we worked closely together…that we were a team. After some time, my patients ended up developing a good relationship with my scheduler and appreciated having them available to take messages and manage their appointments. It was wonderful!”

-Anonymous 

[NK note: If you want to make sure things get done at a clinic/provider, you need to bring the front desk staff into the loop and giving some incentives never hurt. The ROI on buying morning coffee is very high here, just saying.]

Even within physicians, who should have the discussion?

“Hey Nikhil, practicing ER doc in NYC here, longtime OOP subscriber. I think you actually nail the tradeoffs pretty well here - totally agreed that Twitter is a horrible place to have these sorts of discussions.

The only thing I'd add is that different types of physicians are going to have various levels of comfort with lifestyle discussions. When I get a patient with run-of-the-mill MSK complaints (back pain, knee osteoarthritis, neck pain being some of the most common), I intentionally refer them to physiatry or sports medicine over orthopedic surgery unless I think they have a true surgical need. They can all handle it, but in the MSK space, I've found physiatrists to just have way richer discussions with patients about their imaging results, the role of PT, stepwise interventional solutions etc than the surgeons do. 

 In the same vein, a ton of patients with nonspecific abdominal pain ask me for advice on their diet once I rule out dangerous causes. I'm admittedly bad at this discussion! On the other hand, there are a lot of docs in a variety of fields -- addiction medicine, heart failure, good PCPs being a few -- who get a ton of gratification out of talking through these issues with patients.”

-Rishi Khakhkhar

[NK note: Anecdotally this is something I hear a lot in pain management in particular, where patients want to try as many non-surgical and non-medication interventions if they can.]

Can we integrate coaches if we don’t have a good understanding of chronic disease progression? 

What's really missing in the ecosystem right now is how this coaching is actually integrated into clinical workflow. Hard to say in broad strokes that physicians should start and coach to implement without understanding how certain chronic conditions develop (and also how handoff/scope is defined between coaches vs physicians). Take two examples:

1. Depression: Most patients start with talk therapy before seeking help from a physician and now less than half of psychiatrists actually do talk therapy. Think this type of “coaching” has existed for a while for therapists and this new category of mental health/peer support coaches - similar upscaling approaches I see for sleep therapists and sleep medicine folks.

2. Cardiac Rehab: have seen firsthand a discharge workflow for newly diagnosed congestive heart failure (CHF) that has to meet and schedule a follow-up with a "CHF discharge team" led by a NP but staffed by dieticians, and exercise therapists. Funded by a strategic revamp to tackle all day heart failure readmissions that the hospital was performing pretty poorly in.

One anticipated pushback might be - therapists and PTs have specialized training that health coaches do not which trains their clinical gestalt to know when to refer up the food chain. Well, I think that's where coaching is headed - we may start to see more dedicated "coach" schools and training programs as well.

[NK note: This is an excellent paper that looks at a lot of the different potential issues with a heart failure discharge and how integrated care teams can try and “see around corners” to anticipate them]

Creating better systems and internal motivation > coaches/clinicians

After spending several years building "digital therapeutics" and other lifestyle modification apps -- I'm of the opinion that even "coaches" aren't the ones who should be building / pioneering lifestyle interventions, let alone doctors.

When we talk about "lifestyle interventions" we are really talking about completely rewriting our daily habits and rewiring our brain pathways. Whether that's food habits (what to eat everyday), movement habits (exercise etc) or mental health habits (thinking patterns) -- these are all everyday behaviors that literally need to get overwritten / changed / modified and then sustained for life. In other words - this is not just a short term change -- these interventions need to result in lifelong behavior change, and really if you think about it, identity change. And that's super freaking hard to do. 

If we want these lifestyle interventions to scale, it's not just about hiring a bunch of "relatable" coaches and then getting them to tell patients they should eat better. I think we need a different approach: we need 1) expertise in habit formation science -- what does the science say about how habits are formed? And how are habits changed? and 2) behavior change design -- purposefully designing interventions around this science of habits. 

The actual experience  -- including or excluding relatable coaches -- needs to be designed using habit science as a framework. Design choices in the intervention itself should provide the scaffolding required to change habits. So instead of just building in the usual "reminders" feature to tell patients to go take a walk -- how might we design an intervention that creates an actual "cue" for daily walking (for example maybe the cue is a physical object in the house)? Or how might we design an intervention that makes daily walking enjoyable and fun? (things that are fun get repeated). 

-Ambika Gopalan

[NK note: No joke, the way I have managed to maintain somewhat regular exercise is by intertwining it with my deep annoyance of losing money. With ClassPass if you don't cancel your class, they charge you a ton. So I force myself to go because I refuse to let that happen. Gotta use your core deep-seated issues in positive ways, yah mean?]

Splitting it up into 3 buckets

The Innovator's Prescription by Clayton Christensen lays out three business models- solution shop (ie diagnosing complex disease), value added process (ie straightforward diagnosis and treatment, think flu test), and facilitated user networks (ie chronic disease management). The lifestyle discussion occurs in the Networks bucket of chronic disease. Arguably, chronic disease can be treated on a scalable level with data (think dashboard with pertinent values) and a high touch care team (health coaches and nurses) with doctors outlining the treatment protocols for the stable patients and dictating, then treating, when a patient needs to escalate to physician evaluation and management before returning to the pool of stable patients. 

Your last pitchfork meme is a good one. This controversy around mid level encroachment mainly involves conflation of tasks and skills. Too many doctors wanting to (and enjoying) extensive lifestyle counseling which we have little to no training in, and too many mid levels trying to diagnose and treat the undifferentiated patient. 

-Kenneth Qiu

[NK note: I really need to actually read this book. Or any book really.]

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It’s gotta be you

Expensive chronic disease patient chiming in…. 

Everyone except you is crap at integrating perspectives and inputs to make a 360 care plan / lifestyle plan. It's one thing to give advice — i.e. eat more veggies! Lower your sodium intake! Be less stressed! Meditate! — and another to integrate said advice inputs into an actionable  360 plan for your life. ** Note: this perspective is when tackling chronic illness, managing to maximize health NOT in acute settings like you have appendicitis and you need a surgeon stat. 

You've gotta be your own quarterback, advocate and CEO of your health. Everyone else, be it MDs, naturopaths, social workers etc are inputs and perspectives for you to bring in. The idea that anyone except you can be the "quarterback" of your care just isn't realistic or possible in my experience. No one except you can see all the pieces, values all the perspectives (i.e. acupuncturist favors herbs to western interventions etc), has all the knowledge or knows what you value sufficiently to integrate them fully. 

If you take fee-for service reimbursement models, our financial reimbursement covering some things (i.e. statins) but not other things (i.e. gym memberships, personal trainers, nutritionists), and the fact that no one player in the healthcare space has all the knowhow — you're the one left holding the bag deciding what works for you, what you value, what you want to invest in (cause a lot of these tools ain't cheep) and ultimately what works for you. It's your life and your quality of life at the end of the day. No one else is as incentivized as you to maximize it. 

So my question back to this community is, how can we help people be CEOs of their own health? Make it easier? Make it less financially burdensome? 

-Sophia Cornew

[NK note: While I think it might be hard for patient's to know exactly what their care plan should be, giving them tools to know when to push back or ask questions still feels like a big opportunity especially in areas where there's going to be lots of competing advice.]

Nikhil aka. "I'm uncoachable, I'm unsociable"

Twitter: @nikillinit

IG: @outofpockethealth

Other posts: outofpocket.health/posts

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