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- Anthony N. DeMaria, MD, Editor-in-Chief, Journal of the American College of Cardiology* ()
- ↵*Address for correspondence to:
Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
As physicians, especially cardiovascular specialists, we routinely find ourselves trying to persuade patients, and sometimes organizations, to change their behavior. (In fact, I am often trying to change my own behavior, but that is for another Editor's Page.) The obvious example is in regard to risk factors; we are constantly trying to convince patients to stop smoking, lose weight, eat more fruits and vegetables, and partake in more exercise. We are also often challenged to persuade patients to adhere to their medical regimen. On occasion, we attempt to influence organizations to adopt healthier policies, such as providing more hygienic food choices at fast food restaurants. And of course, as exhibited by projects such as Get With the Guidelines, there are ongoing efforts to stimulate the profession to practice evidence-based medicine. In all such cases, we are trying to motivate people to alter the way that they are currently conducting themselves. Unfortunately, experience dictates that it is frequently very, very difficult to induce a change in behavior.
Recently, a group of us in San Diego have embarked upon a project to drastically reduce the incidence of heart attacks and strokes in our city. Our motto is to make San Diego “a heart attack- and stroke-free zone.” Our plan is to activate the public to undergo screening for risk factors, energize the medical community to achieve currently recommended risk factor goals (especially in regard to blood pressure and lipid levels), and to accomplish excellent and long-term compliance with the changes that are implemented. Although the entire medical community has come together to realize these goals, and we are giving the lay community ownership of the program, we are well aware that changing behavior among the public will not be easy. Therefore, our attention has become focused upon the general issue of how to motivate and achieve behavioral transformation.
In the course of working on this project I discussed the issue of change with one of my San Diego colleagues, Mimi Guarneri. She recommended a book entitled “Switch” by Chip and Dan Heath that deals with just this topic (1). Reading the book was fascinating; it made points about modifying conduct that are applicable to a wide range of activities. The authors begin with the concept that the choices we make involve both intellectual and emotional elements. The intellectual component enables us to know the most rational choice of action (e.g., sacrificing a current pleasure for a future good), whereas the emotional component is instinctive and is sensitive to pleasure or pain (I want that cheesecake now!). However, the intellectual part may be limited by procrastination and inaction due to overanalysis, while the emotional factor has the advantage of being able to stimulate action and accomplishment. These 2 elements are often in conflict, and the authors argue persuasively that behavior is best changed by addressing both. My own conduct has usually assumed that a clear explanation of the rationale for some recommendation will suffice in achieving acquiescence by reasonable people. Neglecting the importance of emotional motivation this has clearly been fairly naive.
Having established the basic roles of intellect and emotion, the authors recommend 3 general strategies to accomplish change: 1) configure the rationale; 2) motivate the emotion; and 3) create a path to achieve the modification. In terms of configuring the intellectual component, they advocate focusing on the specific behavior you seek to implement, rather than thinking too big with too many objectives. It is also recommended to identify and emphasize those existing activities that are of value in realizing the goal, and clearly defining the endpoint that you seek to achieve. We have sought to accomplish this in our San Diego project by focusing on a clear cut goal—to eliminate heart attacks and strokes in our community—and a clear cut action—know your numbers (blood pressure and lipids).
The second strategy advocated is to stimulate the emotion. The authors argue that knowing something is often insufficient to produce change, and that feeling something is more powerful. In appealing to an emotional trigger, they emphasize that it is important to reduce the anxiety that may be produced by change, and to cultivate a sense of identification and ownership. Our San Diego project has developed what has been termed the “Be There” campaign that exploits the concept that people are more apt to make change for a loved one than for themselves. Using images that tug at the heartstrings, multimedia materials urge that individuals change behavior so that they can survive to “be there” in the lives of their spouses, children, siblings, or other loved ones. In addition, we have strived to convey a sense of ownership of this project by the citizens of our region, as well as to engender a sense of commitment to their neighbors who are minimizing risk factors. We will take advantage of the pride they have in their community and desire to make it a model for others.
The final strategy is to structure an easy path to attainment of the goal. There exists something called a “fundamental attribution error” that consists of the mistaken attribution of an undesirable action to an individual rather than to the setting or circumstance that they are in. For example, it would be a mistake to fault patients for not eating healthier or exercising more if neither markets selling appropriate food nor facilities for exercise are available. The clear remedy for this problem is to recognize any impediments present in the path to a desired behavior, and to adjust that path to make the behavior as easy as possible. An effortless means to change behavior is also of great value in sustaining the change and in having it spread to other individuals. For our San Diego project we have discussed using paramedical personnel, such as pharmacists, and devices to measure blood pressure and percent body fat placed in drug stores or supermarkets so as to make the minimizing of risk as simple as possible.
I do not know how successful we will be in our San Diego Heart Attack- and Stroke-Free Zone Project; galvanizing an entire community to aggressively eliminate risk factors is a daunting goal. The effort, however, has given me a greater appreciation of the challenges inherent in changing individual and group conduct, and crystallized a number of strategies for modifying behavior. It remains a certainty that, as physicians, we will all be routinely confronted by patients in whom major change in behavior is needed. Recognizing the importance of both the intellectual and emotional factors involved in decision making should help us in achieving these transformations. To motivate change I plan on appealing to the emotion to the same extent as to the intellectual rationale. It seems clear that just structuring an easy path to behavioral modification could itself go a long way to accomplishing the goals. Whether trying to modify the behavior of a single patient or an entire city, utilizing the strategies delineated in “Switch” should stand us in good stead.
- American College of Cardiology Foundation
- Heath C.,
- Heath D.