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Wednesday, April 23, 2014

Health Coaches - Bridging the Primary Care Gap

As I set foot into medical residency in July, one of my biggest concerns is the amount of time that I'll have to discuss diet, exercise, sleep, and stress with my patients.  My frustrations in medical school were the driving motivator to establish Sweat and Butter.  A physician is neither trained nor incentivized to promote lifestyle change in their patients.  Health coaches, on the other hand, have the training that the healthcare system currently lacks in preventing the nation's most expensive diseases.  Normally, I write lengthy pieces focusing on the science behind lifestyle change, but this time around I'm going to keep my post short and sweet. 

When Sweat and Butter speaks to groups of health care professionals (e.g. physicians, nurses, nurse practitioners, and physician assistants), the idea of a "quick fix" is the first thing that we feel compelled to dispel.  If you have ever tried to lose weight yourself, you know that it's more complicated than following a simple "eat this, not that" list.  Physicians and patients alike continue to exhibit silver bullet syndrome in their search for easy solutions to complicated, ingrained problems. 

The tendency to seek a quick fix is a big problem.  The willingness of health care professionals to treat symptoms pharmaceutically without simultaneously treating the underlying causes for their unhealthy lifestyle is a Gordian knot.  In many rheumatology clinics, for example, patients would prefer to continue to take strong, expensive medications for their joint pain and skin flare-ups as opposed to transition to a gluten-free diet in an effort to curb their symptoms. On the other hand, some conversation with patients around the barriers that they experience regarding cutting bread and pasta out of their diets might make this a less daunting task.  Pharmaceutical companies and health insurers have catered to an increasingly impatient population of sick people who have now come to expect a quick solution to their multi-faceted problems.  This is a positive feedback cycle with no end in sight, and, as the cost of treating obesity-related disease eclipses $200 billion annually in the coming years, we need to reassess our approach.

Sweat and Butter's approach to helping clients lose weight has several advantages over the typical support provided in an outpatient clinical setting.  

First of all, health care professionals don't have sufficient time with patients to fully elucidate a particular patient's obstacles to developing lasting, healthy habits.  On the other hand, our health coaches spend sixty minutes on average during their first session with a client. During this session, which we call a "health history", we direct our questions to unveil the client's fears and their preconceptions about what it means to live a healthy lifestyle.  We get to know every detail of the client's life as it pertains to their lifestyle goals. In the clinic, you simply don't have the time required to understand these barriers.  

Second, you can't bill insurers for the effort required to build deep relationships with patients. Currently, a few major health insurers cover health coaching, but the programs are usually insufficient.  At Sweat and Butter, several of our clients have come to us skeptical of health coaching because the coaching service provided through their health insurer was less than adequate.  It isn't the advice that is lacking; it's the approach.  An occasional, impersonal phone call isn't going to build trust or keep patients accountable.  Our coaches meet with clients in person or on an internet service like Skype every two weeks, enabling us to gradually develop a trusting relationship.  It is important to recognize relationship-building as an important aspect of behavioral change for your patients.  Once we have proven that personal health coaching is a potential means of reversing preventable disease, health insurers may improve compensation.  

Third, in the short time allotted to counseling patients, health care professionals are probably giving incomplete advice.  In preparing his presentation for the 2014 PaleoFX conference, a friend asked me to browse my entire medical school curriculum to gauge the amount of training that I had received on counseling patients in lifestyle change.  My search revealed a paltry three lectures, and they were outdated, focusing on BMR and "calories in, calories out" as opposed to the science behind behavioral change.  When health care professionals do manage to squeeze in some advice in the outpatient setting, it's hasty and generalized.  For various reasons, patients have begun to tune physicians and other health professionals out. Furthermore, because it is reserved as an after-thought in the outpatient setting, weight loss and dietary advice is met with defensiveness.  Is it any surprise that your patients return six or twelve months later without having lost weight or without having made any lasting changes to their diet?  It shouldn't be.  If an engineer fails to complete a task with a specific type of valve, for instance, the failure doesn't trigger her to think, "Oh!  Maybe I should just use two of these valves."  She is more likely thinking, "I guess that won't work.  Time to try something new."   Likewise, in an effort to motivate patients to change their lifestyle, you are using an approach that has failed time and time again.  Instead of continuing to blame your patients for their failure to practice a healthy lifestyle, let's change things up.

As health care professionals, it's time to admit that you need help in the area of lifestyle modification.  As medical school curricula attempt to accommodate the rapidly expanding field of medicine, the study of behavioral change is being crowded out.  Health coaches are a special breed that can connect with your patients in ways for which you have neither the time nor training.  At Sweat and Butter, we are collecting testimonials and data that lasting lifestyle modification is possible for even the most difficult patients.  

The advice that we provide our clients is similar to the advice that you are hopefully providing in your office, but getting patients to change their ways will likely require much more than that. Your patients need to be heard, and you need to respect the complicated nature of behavioral change.  Some of the obstacles that we reveal in our clients have nothing to do with diet and exercise.  In our practice, we work with clients on five factors: sleep, stress, movement, diet, and relationships.  Some clients seek weight loss; others are chronically stressed out and sick because of it.  Regardless of their goals, they need help in prioritizing their lifestyle to feel better.  

A cookie-cutter approach isn't going to work.  Health coaching is a resource that needs to be tapped into as a bridge between patients and their primary care clinicians.  At Sweat and Butter, we have an approach that has been proven through experience to meet your patients' needs between office visits.  We help to foster lasting, healthy habits by challenging clients to make small, realistic adjustments, one baby step at a time, which allows for sufficient reflection on successes and failures.  This is the missing piece in your efforts to motivate patients to live a healthier lifestyle.  If we collaborate, you will gain time, insurers will save money, and your patients may achieve lasting well-being.   


Nathan Riley is a 2014 MD candidate at Temple University School of Medicine.  He writes about food, movement, sleep, relationships, and stress in order to bridge the gap between his patients and evolutionary theory and clinical evidence. You call follow him on Twitter @BeyondtheMD.  He can be reached at nathan@sweatandbutter.com.  You can also connect with him on Google+. 




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