"Patients are the most underused resource in health care." — Dr. Warner Slack
Each year, according to the Centers for Disease Control, obesity costs the US healthcare system $147 billion. Diseases caused by smoking account for $170 billion in direct medical costs. Lack of physical activity costs the nation $117 billion for related healthcare. The toll that chronic disease takes on patients and their families' quality of life is heartbreaking, though more difficult to quantify. If most patients want to be healthy and gain the energy to do the things that give life meaning, why do so many fail to follow "doctor's orders" for lifestyle changes that are within their control to make? What can be done to set patients up for success on the road to better health?
Modern healthcare sits on a solid scientific foundation of excellent surgical, drug, and other technical interventions that save lives every day. The US healthcare system deploys a top-down approach to administer these technical interventions, with the provider most often in a position of authority to educate and advise the patient.
When technical solutions like surgery or prescription medication are all that is required for healing, this top-down approach works effectively. But in cases where more adaptive changes (weight loss, stress management, smoking cessation, etc.) require patient motivation and mobilization, our system falls short.
Most providers do not have the time or the training to support their patients to develop the new mindsets and patterns of behavior necessary to achieve their goals. What’s needed are integrated care teams that leverage the support of a health coach with the expertise of the provider to drive positive health outcomes by putting the patient in the driver's seat of their wellness. The health coaching process helps patients have more realistic expectations of themselves and their care teams while gaining the confidence to achieve better health.
According to Dr. Ronald Heifetz, Harvard Physician and Leadership Expert, it’s essential to distinguish the care team's technical work on behalf of patients from the adaptive work that only the patient can do. In other words, care teams must have the necessary resources to help patients take the wheel on their part of the treatment plan.
A broken arm is a classic example of technical work:
The problemis clear (radiology shows a fracture in the bone)
The solutionis clear (bone will be set and stabilized)
An expert will do the work (a specialist handles the case)
The work is approached withconfidence and skill (a skilled physician administers an evidence-based treatment)
The expectation is thatthe problem will be fixed (the bone will heal)
The timeline isefficient and clearly defined (6 weeks in a cast)
Most adaptive challenges include some technical aspects (calories burned must exceed calories consumed to lose weight). The adaptive challenges make the work of behavior change difficult, and even more so when they are overlooked.
Let’s consider weight loss as a classic example of adaptive work:
Understanding the problemrequires curiosity and learning (What are the foods, habits, or medical conditions that contribute to my excess weight?)
Discovering the solutionrequires curiosity and learning (How much exercise do I need, what eating plan is best for me?)
The patient will do the work with the support of their team (It is the patient, not the provider, taking action each day in the kitchen or at the gym)
The work is approached asexperimental, with setbacks expected (Patient may try many different ways to make exercise a habit and several eating plans before discovering what works)
The expectationis to make progress (Focus is more on step-by-step implementation of healthier habits than on reaching the goal weight)
The timeline is longer and less certain (A process of experimentation with setbacks takes time)
Because our healthcare system trains patients to expect technical solutions, many try and fail to exercise the patience, persistence, and self-compassion that’s needed to develop and maintain healthy lifestyle changes.
For example, many patients come to coaching with histories of repeated failure to lose weight or of regaining lost weight. Some have experienced weight shaming in a medical setting by providers who fail to recognize the adaptive challenges the patient may face. Sadly, many have internalized these setbacks as personal character flaws and lack the self-confidence to try again. Without a clear roadmap that addresses the adaptive challenges involved, reaching a provider-prescribed weight loss goal can feel impossible.
A skilled health coach gives the patient space to begin to understand and approach healthy lifestyle changes through the lens of adaptive problem-solving. The coaching process:
Creates a safe space to engage in the curiosity and learning required to define the problem
Provides a goal-focused structure through which the patient can explore possible solutions with support
Sets clear expectations that the patient will do the work within and between sessions and that they take ultimate responsibility for plans, timing, and actions taken
Normalizes the process of experimentation, reframing would-be failures and setbacks into opportunities to try a new approach
Celebrates patient progress with an emphasis on changing behaviors that will lead to better health over time
Creates a compelling values-based vision to sustain self-motivation over a longer timeline
According to Deci and Ryan's self-determination theory, autonomous self-regulation of behavior is most likely to occur when the patient's primary psychological needs for autonomy, competence, and relatedness are met. Coaching puts the patient in the driver's seat by acknowledging that the patient is in control of their own destiny.
A health coach supports that patient to build confidence as they move toward their goals — providing social support and connection from the passenger's seat. With a coach by their side, a patient can access their own internal creativity, motivation, and resources to map a clear route, successfully negotiate detours and speed bumps along the way, and ultimately reach their destination of better health.