From Prevention to Extraordinary

In my previous post I introduced the idea that health is a practice, not a destination – being healthy is what you do, not what state your body is currently in. extraordinary01I’d like to try to further develop this idea here and introduce some thinking as to how the healthcare system might reshape itself to encourage the practice of health.

But first let’s talk a bit more about this mindset of prevention and why it isn’t the path to curing our chronic disease burden.

Preventive medicine is of course a very broad concept and I’m not here to argue that flu shots and mammograms are not effective. When I use the term ‘prevention’ I’m talking about the philosophy and various programs designed to address preventable chronic diseases such as heart disease, type 2 diabetes, obesity, many cancers, and others. These are the diseases that are caused by bad lifestyle habits. According to the CDC these diseases are “the leading causes of death and disability in the United States” and “are among the most common, costly, and preventable of all health problems.”

The CDC’s National Diabetes Prevention Program (National DPP) is an example of the type of prevention program that I am referring to. The National DPP is a lifestyle modification program. And while lifestyle modification definitely is the solution, approaching this type of habitual behavior change with the goal or mindset of preventing disease seems destined to fail.

Prevention and Some Behavior Psychology

habits01‘Lifestyle’ in this case is just another word for a bundle of habits: eating habits, sleeping habits, exercising habits, leisure time habits.

How do we change habits? This is a highly researched and studied concept, both from a neuroscience and behavior psychology perspective. A commonly agreed approach to creating new habits suggests that instead of focusing on motivation, we need to start with the desired behavior and consciously link it to both a reliable ‘trigger’ to initiate the behavior and a reward that stems directly from completing it. Given these 3 components – trigger, behavior, reward – and enough regular repetition, our brains will wire the behavior into a new comfortable habit so that it no longer requires willpower to complete. Eventually the new habit evolves into becoming a part of our identity – it’s just ‘what we do and who we are’. As we over time incrementally build new positive/on-purpose habits, a new identity emerges.

In my experience, forming new habits that reshape identity this way takes years, not weeks or even months, but it is years of intrinsically rewarding work with decades of payoff. The common refrain that ‘behavior change is hard’ is true in that it takes persistence and time, but on a moment by moment basis, if you are taking small enough steps, it actually isn’t hard at all.

There are however some potential road blocks along the way to be aware of. One of them is the seemingly logical expectation that relying on motivation for a big, long-term future goal is the key to driving the desired behavior change. This approach however hurts more than it helps.

Hyperbolic discounting is a term psychologists and economists use to describe a cognitive bias that causes people to prefer smaller immediate rewards over future rewards, even if the future reward is substantially more valuable. To put it another way: trying to convince ourselves that we should sacrifice current pleasure for larger distant rewards may seem reasonable, but it is behavior quicksand.
NoPainAllGain_01Stay away. The easiest way to avoid this is to simply forget about future rewards and come up with a way to make the desired behavior itself be immediately rewarding.This is one of my personal 5 fundamental habit design principles which I call ‘No Pain All Gain’ and which I describe in this post: From Tiny Habits to Big Habits: My Five.

But back to prevention. When the long-term future goal of a new desired behavior is the prevention of a future disease, then we have complicated this hyperbolic discounting quicksand even further. This is because the future reward of preventing a disease is arguably not really a reward at all. If I’m not suffering with the disease today, the lack of future suffering is not a reward, it is simply the status quo extended in time. So not only is the prevention program asking me to sacrifice behaviors that I consider pleasurable right now for a long-term future reward, but that reward isn’t really even a reward at all.

Remind me again why I shouldn’t drink this can of Coke right now? Because at some point in the future I won’t have a disease that I don’t have now? And how long do I have to keep not drinking Coke in order to not get what I don’t want? Makes me thirsty just thinking about it.

Bottom line: Starting with the long-term goal of preventing disease is the wrong approach to inspiring behavior change.

Cultivating Extraordinary

growth01The concept of disease prevention is of course a natural product of a healthcare system that has disease at it’s core.

Here are a few common assumptions about health care that reflect it’s disease-centric nature:

  • The primary purpose of healthcare is to predict, treat and hopefully cure sickness and disease.
  • Healthcare and health status is a very private interaction between a patient and a doctor.
  • Young and healthy people don’t really need healthcare.
  • Medical doctors are the ultimate and definitive source of guidance for all health issues and are thus at the center of the healthcare system.
  • Pharmaceuticals or procedures/operations are the solution to most health problems.
  • Healthcare services are paid for by a health insurance plan as the services are rendered.

The reality is that this doctor-led disease treatment model, paid for by insurance companies on a visit-by-visit basis, was not designed to be effective in helping people change their lifestyles. And this is of course reflected in the fact that preventable chronic disease is an ever-expanding problem despite the growing focus on prevention.

But is health really just the lack of disease?

I think as humans, with these fancy evolved brains of ours, we can do better than ‘not-disease’. We should set our sites on becoming extraordinary, not just not-sick. Why not set our sights on being able to go sailing, traveling, learning a new language, and hiking in the mountains on our 85th birthday – instead of aiming for not getting diabetes at 50 and heart disease at 65.

As I described in my previous post, I believe health is a practice, not a destination. Continuously improving our well-being and living an ever-expanding extraordinary life should be the goal of healthcare. This is a fundamental mindset change – from ‘getting better when we are sick’, to just ‘getting better all the time’ – including the times when we are sick. Can our healthcare system change it’s mindset?

Starting Over

sunrise01Shifting our healthcare system to a mindset of continuously improving well-being requires that we start over and reimagine what healthcare can be. The healthcare system doesn’t need to be disrupted in a way that puts existing participants out of business, but it does need to be reshaped and augmented – in-flight.

We still need physicians, hospitals, disease diagnoses and treatment of course. And we still need insurance to pay for the potential catastrophic costs that arise from disease care. But a new engagement and business model that starts with a mindset of continuously expanding well-being and includes doctors and hospitals when necessary, instead of the other way around, is needed.

Where to start? Three initial ideas or principles that I believe need to be factored into a new approach to healthcare are: 1. Membership 2. Coaching and 3. Social Collaboration. Each of these is worthy of it’s own book, but I’ll try to briefly introduce what I mean by each.

Membership

membership04Our current healthcare system is very transactional – we contact our doctors and pay for expensive services as infrequently as possible. This approach and business model doesn’t sync with a mindset of continuous incremental improvement which is characterized by ever-evolving and expanding daily healthy habits.

Membership to me implies purposely joining a club or organization that I derive satisfaction, belonging and measurable value from. It implies community, social acceptance, friendship, cooperation, and participation – all very important factors in influencing behavior change.

From a business model perspective it implies access to included or reduced-price goods and services – for a monthly or annual fee. Important in this concept is also the notion that I am not necessarily establishing a relationship with just one doctor, but instead with a group or a community of people and services, which includes a doctor when necessary.

I wrote a post a few years ago exploring some ideas for what a health plan membership could ideally be (Image If Your Health Plan Was…). In that post I described a ‘wellness club’ as “a community with tools, expertise and social engagement opportunities to enable members to work together in order to live healthy and happy lives”. I no longer think that insurance companies are where this type of a ‘well-being practice’ should live, but many of my thoughts in that post for what a health membership could be apply directly to this discussion.

Who pays for this membership? I do. Possibly it is a benefit funded by my employer in a tax-beneficial way or subsidized by the government when appropriate. But this is not directly linked to my ongoing employment with a specific companty and it is not a benefit of my health insurance. Health insurance is for unexpected expenses associated with treating disease, this membership is not for disease, it is for becoming extraordinary! Ideally my health insurance premiums would be reduced as long as I am a member, but there has to be enough no-brainer value for me to want to pay out-of-pocket.

Coaching

coaching02In today’s healthcare environment, about the only durable relationships we have are those with our physicians. And while these feel like long-lasting and meaningful relationships, they commonly amount to maybe one 15-minute in-person discussion every 6 to 12 months. We frequently have the opinion that our doctors are the final voice of authority for all decisions related to our health. But should we be spending those precious 15 minutes discussing strategies for getting more magnesium in our diet? Is a medical doctor really the best source of nutrition guidance? Interpreting blood test results: yes; kale vs spinach: no.

A coach is a guide with expertise in a specific domain of living such as behavior design/habit creation, nutrition, exercise, meditation and sleep. In addition to their area of expertise, coaches are skilled at encouraging and coaxing behavior change. Coaching is not something I pay for at the individual transaction/encounter level and it doesn’t necessarily require certified clinical professionals. In fact, certified clinical professionals have to provide certified clinical guidance, and with the pace of research in nutrition, that just may be based on old thinking and science.

Another characteristic of coaching is that it is often times not a one-on-one experience, but instead one coach working with me in a group of my peers. This enables the coaches to scale their expertise more effectively, and it allows the group members to learn from each other as well as the coach.

Day-in and day-out behavior change guidance doesn’t require an MD, it needs coaches.

Social Collaboration

collab01The most important and powerful of these 3 principles is social collaboration. Humans are social animals. Our success as individuals, organizations and as a species is directly the result of our collaboration and cooperation skills. Einstein did some powerful thinking and contributing on his own, but he was only able to do that because he was standing on the success of those who came before him and because he didn’t have to spend his time hunting, making clothes and building a house to live in.

In order for healthcare to make an exponential leap into a new level of effectiveness in addressing this problem of preventable chronic disease, we need to leverage this principle of social collaboration. It is our ultimate super power as a species and we need to exploit it to solve this problem.

Social collaboration means many things including using social rewards, cooperation in larger-than-self outcomes, accountability, gamification, and of course, is a key underlying component to the principles of membership and coaching already discussed.

There is a basic unquestioned assumption of the need for privacy in healthcare that I believe needs to be challenged because it potentially limits our thinking on how to leverage social collaboration. The boundaries of our willingness to share and sacrifice privacy are being tested in domain after domain with astonishing results. But in healthcare, the default mode is often to limit our expansion of collaboration in the name of privacy. We need to build opt-in social experiences that let people share and give so that we can ignite the power of intrinsic social rewards that are native to all human beings.

A concrete example of a social collaboration powered experience I have been experimenting with is my ‘Step To Give’ program which leverages the power of small group engagement, individual accountability, and a greater-than-self sense of meaning to encourage increasing daily activity/walking. I have blogged about Step To Give in these posts: Step To Give, An Activity Tracker Engagement Experiment and Step To Give Results: Fun, Engaging, Rewarding. This is just a small experimental example of how we can leverage social collaboration to help us change our behavior and create new habits. It would have been even more powerful if everyone on the team were also sharing their daily fasting blood glucose levels and working together to meet a team blood sugar goal along with the team step count.

In Summary

OPERATION IRAQI FREEDOM (FOR RELEASE)

I don’t accept the assumption that as humans it is our destiny to get diabetes and suffer unless we take steps to prevent it. I do believe that it is our destiny to continually evolve and grow. The healthcare system can help us shift to this new mindset by encouraging habits that power continuous incremental progress towards extraordinary well-being. Health is a daily practice, not a destination, and the healthcare system must change its business model and combine principles such as membership, coaching and social collaboration to help.

 

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Practice Health, Not Prevention

healthWhat is ‘health’?

What does it mean to be healthy? If I’m not sick, am I healthy? As long as I’m not sick, does it matter?

Health is a complex concept, it means different things depending on the context. Our health care system seems like an obvious starting point as I try to think about health and being healthy. The health care system of course includes health insurance plans, doctors, hospitals, drug prescriptions, and more. In this system I pay insurance premiums and copays, go to the doctor, get a blood test, take prescribed medications, etc. Is this what it means to care for my health?

Is my doctor caring for my health? Or is she primarily there to help me feel better when I get sick? Is taking a pill something I do for my health or for my disease?

Our health care system seems to be primarily focused on healing or managing poor health.

But if health care is mostly about healing disease, then I’m still stuck trying to understand what health is. Is it really just the state of not having any disease? If I don’t currently have any disease does that mean I am healthy and don’t need health care right now?

If I am healthy then how do I go about staying healthy? What about this thing the health care system calls ‘prevention’?

Prevention

prevention

With preventable chronic disease now consuming more than 3 of every 4 dollars spent on health care, there is a growing focus on prevention. New insurance claim codes, for example, allow health plans to pay for lifestyle change programs designed to help prevent pre-diabetes from developing into a full-blown type-2 diabetes diagnosis.

But health plans only spend about 3% on prevention. And while prevention seems like a logical solution to our growing chronic disease crisis, it doesn’t make much sense to expect a system that gets paid $3.3 trillion per year to treat disease to be responsible for implementing programs to prevent it. That’s kind of a ‘fox guarding the hen house’ problem.

And the reality is that prevention isn’t working anyway. Obesity rates are not going down. The total per capita cost of health care continues to increase. Type-2 diabetes is preventable, but the situation is getting worse not better. Some estimates suggest that 1 in 2 adults in the US are now either pre-diabetic or already have type-2 diabetes, many without even knowing it.

I believe that there is a an even more fundamental problem with the concept of prevention. Prevention is a life-long journey, not a 16-week billable health care encounter. But who wants to go through life ‘preventing’? That doesn’t sound like any fun.

Practice

practice

OK, so our health care system exists primarily to help me get better when I’m sick, but health is not just the lack of disease and attempts at prevention don’t seem to be working. Back to my original question: What is health?

Health may not really be a thing, or state that I can ever achieve. I can never really declare victory and claim that I made it, that “I am healthy!” No matter how much weight I have lost, or how good my lab results look, I’m never done. This brings me to the conclusion that health is something I do, not something I have.

Disease is something I have but health… health is something I do.

Health is about behavior, habits, lifestyle. Health is a way of living, not a goal or a destination. It is a practice.

Practice is a funky word too. I grew up thinking of practice in the context of little league and basketball practice. We had to practice if we wanted to play in the game at the end of the week and have a shot at winning. But let’s face it, practice sucked!

I’m not talking about that kind of practice. When I think of health as a practice, I’m talking about practice as a regular, habitual component of my life – a part of my identity, of who I am. So when looked at this way, when I claim that I am healthy, what I am saying is that I purposely live ‘healthily’, I practice health – not that my lab results and weight have reached certain thresholds.

This concept of practicing health – as opposed to preventing disease – is actually very profound, not just a new semantic. It starts with understanding and accepting that your identity is both determined by and reflected in your habits, and that you have the ability to purposely carve these identity-defining habits into your life. Habits are. That is just the way the brain works. Habits are the autopilot that run about 40% of your show. So you are either running on an autopilot programmed by people and circumstances you didn’t purposely choose or you are running on an autopilot that has been programmed on purpose, by you.

So stop trying to prevent disease and instead begin practicing health. Don’t worry so much about the outcome, focus on the practice. Eat on purpose, sleep on purpose, exercise on purpose, every day, make it a habit – practice health.

Maybe some day we will have a health practice system to complement our health care system. Employee-sponsored heatlh wellness benefit programs may be where this health practice concept starts. But if it is going to last, we can’t make the mistake that many critics of employee wellness programs are currently making and give up if we don’t see health care costs going down before the next earnings report. The goal is the practice, not who win’s the game on Saturday.

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Staying Engaged: How To Use Streaks and Weekly Goals

Establishing new behaviors that eventually become habits that can lead to a new identity or sense of self can be hard. Two techniques that have worked to help me stay engaged as I work towards creating new habits are streaks and weekly – as opposed to daily – goals.

streaker-banner

not wearing a Fitbit!

Just to be clear, a streak is just a number of consecutive times in a row that you have met a goal (I don’t want to get you arrested!)  The typical default step count goal in an activity tracking app like Fitbit for example is 10k steps per day, so a streak of 14 days would be 2 consecutive weeks of meeting the goal every day. Streaks are interesting to me because they leverage this cognitive bias that behavior researchers call “loss aversion”. Continue reading

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A Small But Significant Patient-Centered Example

Digital health solutions that facilitate patient engagement must put the patient in charge, not the physician. Outside of the clinic, where health happens, in the day-in, day-out lives of people, we have to let the patient take ownership of and decide how they are going to engage and be “compliant” (I hate that word).

Here’s a simple example:

I’m working with a start-up who is shipping a remote patient monitoring and engagement tool. One feature of the experience enables patients who opt-in to be able to communicate with the clinic by receiving text or smart phone push notifications from the clinic with test results and instructions to modify medication dosage regimens. This an on-going, monthly process for patients on this specific long-term therapy.

A physician who recently started using the tool wanted to work through his list of new test please_do_not_disturb_signresults in the very early morning hours before he went into the office for the day – but didn’t want to bother the patients with notification messages before 9am. So, he requested a simple feature to allow him to delay the outbound patient notification a number of hours, depending on when he was working through the list. This way he knows that all of his messages will be received by his patients at 9am or later.

On the surface that makes sense, and sounds very empathetic – let’s give the physician the ability to adjust his workflow to best work with his schedule while not bothering the patient at odd hours of the morning. Providing the physician this lever to make that work sounds kind of patient-centered, right? Continue reading

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From Tiny Habits to Big Habits – My Five

On my journey to learning some of the neuroscience and behavior science research behind these things we call “habits”, I decided to put the theory to a test and see if I could turn what I considered to be a big, hard to achieve behavior – going to the gym every day – into a habit. Along the way, I found it helpful to distill what I was learning into a few key mantras that would be easy to remember and keep in mind. So here they are, the 5 key principles I used to turn exercise into a habit – I call them “My Five” (warning, I’m an engineer, not a poet!).

1. Not a Freak, Predictably Unique
NotAFreak

It all starts with the realization that there is a high probability that my brain is extraordinarily average and that most of this research I was learning about is actually applicable to me too. Leverage the science, don’t fight it.

2. No Pain, All Gain

NoPainAllGain_01

Do not make the behavior you want to turn into a habit a willpower challenge – which I define as a task that is painful today but will pay off in the future. Instead, completely forget about any future goals or rewards and find a way to make it immediately rewarding on it’s own.

3. Crave The Wave

wave01Consciously cultivate a craving for the behavior. Take time every day to pause and look forward to the next chance to do it again.

 

 

4. Get It Done With The Sun

GetItDoneWithTheSun

Do it in the morning, before the day gets “started”. The first hours of the morning are the only truly predictable part of the entire day, so leverage that time to create new big, hard habits.

 

5. Lose the Virtue, It Will Hurt You

DropTheVirtue_purchased

It’s just a habit – avoid the dangers of what psychologists call “moral licensing” and don’t brag about it or give yourself any extra credit for getting it done every day.  Just do it and get on with your day.

 

 

Those are my five guiding principles for creating big, hard habits. (I warned you… I’m not a poet, but the rhyming thing makes these very easy for me to remember and keep in mind on a daily basis.) Either stop reading now, or get comfortable, because I’ve got a whole bunch more to say on the topic. Continue reading

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Big Data or Tiny Habits?

To repeat the oft-quoted words of Aristotle: “We are what we repeatedly do. Excellence, then, is not an act, but a habit.”

I believe that wearable activity tracking devices can be powerful habit transformation tools and I’m frustrated to see instead the huge emphasis that is being placed on the hopes of the “big data” insights to be gleaned from their use.

dilbert_big_data
Continue reading

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Step To Give Results: Fun, Engaging, and Rewarding

The Step To Give experiment was fun, engaging, and for me personally it was surprisingly rewarding.  Big smile, very big.

smile

Nine of us paid $10 each and worked together as a team for 21 days to meet the team total step count and therefore make a donation to the Alliance For a Healthier Generation – to help fight childhood obesity.

The total team commitment added up to just over 1.5 million steps and we ended up walking more than 1.8 million steps. That’s about 900 miles!! (read more about the mechanics of the Quest here, and have a look at the team tracking spreadsheet that I updated 3-4 times per day here) Continue reading

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