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. I’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
‘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.
Stay 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.
The 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?
Shifting 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.
Our 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.
In 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.
The 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.
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.