I’ve stopped telling my patients to exercise
Have you ever told your patients they need to exercise? Have they ever nodded in agreement, but are no closer to their goal by their next appointment? There is robust evidence linking regular physical activity to a wide array of physical and mental health benefits1. But motivating patients to exercise regularly has proven difficult in the years since physical activity became a public health recommendation2. The efficacy of “health coaching” as opposed to traditional patient education has been widely discussed in recent years3. One strategy we suggest is to reframe barriers with a simple shift in semantics to discuss behaviour change with patients. That is why I’ve stopped telling my patients to exercise and now suggest training, instead.
Personal behaviour influences health and people can improve their health, by changing their behaviour. Approximately 7% of persons younger than 65 have a life-impacting chronic condition and 37% of persons older than 65 years have three or more serious chronic conditions4,5. The effective management of these conditions hinges on patients engaging in healthy behaviours6. Patients usually respond when their care provider addresses physical activity – those encouraged to exercise by a health care provider are 6 times more likely to participate in supervised exercise, and 12 times more likely to participate in exercise at home7. Implementing effective behaviour change addresses the Institute for Health Care Improvement (IHI) triple aim of improving patient and provider experience, improving the health of populations, and reducing the per capita cost of health care8.
Physicians are agents for change; they can promote a shift in attitude for patients from the passive sick role to an active participant in improving wellness, by changing themselves. Health coaches increase awareness, accountability, and access for “coaches” by working with patients to find achievable goals and iteratively following up on and updating these goals9. We suggest a simple language reframe which could prove effective. By using the word and paradigm of “training”, physicians would be instituting the coach-coachee relationship as well as a structured, goal-oriented, and iterative model for developing self-management skills. Exercise is out, training is in.
Health coaching assumes a collaborative approach, rather than a prescriptive one, where patients are engaged to develop their own achievable goals rather than directed to do certain things10. Health coaches work with patients to provide information, teach disease-specific skills, promote healthy behaviours, develop specific achievable goals, and follow up on those specific goals regularly3. Coaching has been shown to produce promising clinical benefits11-21. Physicians can begin to incorporate a coaching style by reframing the language they use in discussing lifestyle modifications. What do coaches do for coachees? They train them. What if patients began training their disease specific self-management skills? In fact, for this to occur, we must ‘train’ ourselves to use this language with our patients.
For chronic conditions like diabetes, hypertension, dyslipidemia, and depression, physical activity and diet form a cornerstone of management. The language of “training” can be used to present a universal paradigm for these “lifestyle management” strategies: Training for chronic disease modification. We contend a behaviour training plan consists of four domains: i) body, ii) mind, iii) nutrition, and iv) recovery. This training paradigm uses the framework from the Integrated Theory of Health Behaviour Change22 and begins with education about the patient’s disease and the ways these lifestyle modifications can impact it. We can then move forward to collaboratively develop a plan of action and promote behaviour change skills and attitudes.
Patients are presented with the domains of training and examples: training the body with the goal of increasing strength to weight ratio, training the mind through mindful meditation, eating a healthy balanced diet and identifying which foods and volumes improve their health or make them feel ill, and identifying recovery methods that improve health like sleep, relaxation, and fun, social activities. These suggestions require training our self-awareness.
Within each of these domains the practitioner works with the patient to develop achievable short- and long-term goals. Short term goals can be reviewed at the next follow up appointment; long term goals provide direction. The patient leads in developing their change plan and by focussing on short term goals, may not feel as overwhelmed by the changes required to affect their health. The training framework is also a simple model that is easy to comprehend and keep in mind throughout one’s life; there are at least four specific achievable domains to cultivate. The provider is the patient’s coach and will be present to support them, all the while reframing, encouraging, and affirming their patient that they already have the skills necessary to reach their goals. If they don’t have the skills, it will be necessary for their patients to train to acquire the skills necessary to reach their goals.
Training for chronic disease management is a simple pragmatic paradigm for lifestyle modifications that incorporates evidence based techniques from theories of health behaviour change and motivational interviewing. Training implies a process that requires goal setting, and iterative cycles of trial and error. Let’s lower the stakes for our patients by using language that supports and encourages them through their illness experience. Instead of brandishing them for lack of compliance or adherence, consider re-framing their experience as an opportunity to improve their skills through training. This language might provide an opportunity to explore their barriers and facilitate the change they really need. This paradigm can be applied to all chronic illnesses that respond to lifestyle modifications. It is a simple way of permitting a patient to form achievable goals and report back to their physician-coach who will support and facilitate their behaviour changes along the way.
A reframe of how we look at these activities will allow for increased self-awareness and improved decision making for ourselves; as well as a more achievable and goal-oriented approach to exercise and wellness for patients.
Challenge
We challenge you to train your reframing! Try reframing someone's frustration into an opportunity to learn and train them to improve their situation. Who knows, you might be a better coach than you think, and if you’re not, keep training.
Tom Yeates is an MD candidate at the University of Toronto. He is passionate about preventative medicine in the domains of mental and physical health.
Sabrina Kolker, MSc, MA, MD is a resident in Family Medicine at the University of Toronto. She is a 2-time Olympian where she represented Canada in the 2004 and 2008 Olympics in women’s rowing. She continues to strive to find unique ways that will keep patients both interested and motivated to move more in order to improve their overall health.
Jeremy Rezmovitz, MSc, MD, CCFP is a staff physician at Sunnybrook Academic Family Health Team. He is an Assistant Professor in the Department of Family and Community Medicine, University of Toronto. He is interested in finding better ways to engage patients in their health. Coaching is a #tool_for_engagement.
References
1. Pate, Russell R., et al. "Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine." Jama 273.5 (1995): 402-407.
2. Richard, M., et al. "Intrinsic motivation and exercise adherence." Int J Sport Psychol 28.4 (1997): 335-354.
3. Bennett, Heather D., et al. "Health coaching for patients with chronic illness." Family practice management 17.5 (2009): 24-29.
4. Center for Disease Control. Chronic Disease Program. Chronic disease overview. [March 28, 2008]. http://www.cdc.gov/print.do?url=http://www.cdc.gov/nccdphp/overview.htm.
5. Committee on Communication for Behavior Change in the 21st Century. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. The National Academies Press; Washington, DC: 2002. p. 1[Executive summary]
6. Lorig, Kate R., et al. "Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial." Medical care 37.1 (1999): 5-14.
7. Hirvernsalo, M et al. The Effect of advice by health care professionals on increasing physical activity for older people. Scand J Med Sci Sports. 2003; 13 231-236
8. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. May/June 2008; 27(3):759-769
9. Liddy, Clare, et al. "Improving awareness, accountability, and access through health coaching." Canadian Family Physician 61.3 (2015): e158-e164.
10. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469–2475.
11. Turner BJ, Weiner M, Berry SD, Lillie K, Fosnocht K, Hollenbeak CS. Overcoming poor attendance to first scheduled colonoscopy: a randomized trial of peer coach or brochure support. J Gen Intern Med. 2008;23:58–63.
12. Vale MJ, Jelinek MV, Best JD, et al. Coaching patients on achieving cardiovascular health (COACH): A multicenter randomized trial in patients with coronary heart disease. Arch Intern Med. 2003;163:2775–2783.
13. Holmes-Rovner M, Stommel M, Corser WD, et al. Does outpatient telephone coaching add to hospital quality improvement following hospitalization for acute coronary syndrome? J Gen Intern Med. 2008;23:1464–1470.
14. Whittemore R, Melkus GD, Sullivan A, Grey M. A nurse-coaching intervention for women with type 2 diabetes. Diabetes Educ. 2004;30:795–804.
15. Engel L, Lindner H. Impact of using a pedometer on time spent walking in older adults with type 2 diabetes. Diabetes Educ. 2006;32:98–107.
16. Gary TL, Bone LR, Hill MN, et al. Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. Prev Med. 2003;37:23–32.
17. Two Feathers J, Kieffer EC, Palmisano G, et al. Racial and ethnic approaches to community health (REACH) Detroit partnership: improving diabetes-related outcomes among African American and Latino adults. Am J Public Health. 2005;95:1552–1560.
18. Fisher EB, Strunk RC, Highstein GR, et al. A randomized controlled evaluation of the effect of community health workers on hospitalization for asthma: the asthma coach. Arch Pediatr Adolesc Med. 2009;163:225–232.
19. Coleman E, Parry C, Chalmers S, Min S. The Care Transitions Intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822–1828.
20. Foster G, Taylor SJC, Eldridge SE, Ramsay J, Griffiths CJ. Self-management education programmes by lay leaders for people with chronic conditions. Cochrane Database Syst Rev. 2007;17(4):CD005108.
21. Gensichen J, von Korff M, Peitz M, et al. Case management for depression by health care assistants in small primary care practices. Ann Intern Med. 2009;151:369–378.
22. Ryan P. Integrated Theory of Health Behavior Change: Background and Intervention Development. Clinical Nurse Specialist. May 2009; 23(3):161-170
