The Behavioralist

Editor's Corner | Alfred A. Bove, MD, PhD, MACC, Editor-in-Chief, CardioSource WorldNews

After practicing clinical cardiology for many years—including invasive and interventional cardiology, stress testing, heart failure, and transplantation—I am now seeing patients in the out-patient setting to solve the usual myriad of issues that come under the rubric of clinical cardiology.

There are distinct groups needing different types of care from their clinical cardiologist. The extreme elderly, with some mental impairment and ambulatory problems, require strong social support, while younger patients—usually with minimal symptoms and low risk of significant cardiac disease—benefit from guidance on lifestyle management.

But the largest and growing population of patients is now the middle-aged man and woman who is overweight (maybe even obese), often overworked, somewhat depressed, and negligent of lifestyle goals to manage their personal health. Many have two jobs and relieve stress by increasing food intake.

Those carrying excess weight eventually develop the well-known complications of hypertension and diabetes: the metabolic syndrome. We know that this combination increases risk for coronary disease at a younger age, in addition to furthering the risk of chronic kidney disease and stroke. So our approach is to provide medications to move the patient toward lower CVD risk. We prescribe antihypertensives to lower blood pressure to goal, provide statins to get lipids in line, and prescribe hypoglycemic agents to normalize blood sugar. That part is easily accomplished with a few key strokes to send the pharmacy the patient’s medication prescriptions. And our job is done!

Not quite.

We know from studies over the past 10 years that the therapeutic intervention approach gets us about half-way toward the goal of reducing cardiovascular disease. The other half has clearly been shown to require lifestyle change, but that is not accomplished by the polypharmacy we like to use. The disappointment comes when the patient returns 3 or 4 months later for follow-up with little improvement in their numbers and no changes in their lifestyle or behavior.

While some patients are refractory to the usual doses of medications, the more common reason for not reaching goals is the lack of adherence to a routine for taking medications. At some point on this journey, it becomes apparent that we as health care providers, physicians, and mentors of health need to move toward a goal of being a motivator of patient behavior; to get more engaged with the patient, to make the patient understand that the need to achieve successful therapeutic goals is a partnership between the physician, nurse, and patient. By developing this relationship, the patient becomes more committed to a patient-provider team approach where the individual patient goals become a matter of working together for the common good of better health. We give this behavior names like “patient-centered care” and “shared decision making,” but the words are meaningful only if they become our operating standard in caring for this large group of patients who, without intervention, experience early coronary disease, years of disability, and will be an enormous cost to our health care system.

The question is: can we realistically accomplish these goals in an office practice with the pressures of seeing more patients with less encounter time, not to mention a general lack of expertise in managing lifestyle and diet for these patients?

Recent data suggest that a team approach is needed to engage the patient with nurses, dieticians, and physicians in the practice. Frequent communication helps, and is now greatly facilitated with smartphones and mobile apps. Organizing a program to keep patients engaged should be a goal of cardiology practices to be sure we are intervening appropriately in the lifestyle and the medical care of our patients.

Yes, we are interventionalists and we have many devices and methods to improve cardiovascular health, but the device of motivation must become an intrinsic part of our toolkit. Otherwise, we will see an expanding number of our patients who develop serious cardiac disease on our watch and our role in preventing this most common cause of death and disability will be seriously questioned.

Keywords: CardioSource WorldNews, Cardiovascular Diseases, Patients, Patient Care Team

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