Given enough time and access to the necessary programs and calculators, you could discover how likely you are to have a heart attack in the next few years, how much your estimated medical expenses are for 2018, and what your life expectancy is. You could collect a lot of numbers in ink on paper that is used to define who you are by a wide-range of individuals including medical professionals, insurance companies, and your human resources department (although those numbers won’t be tied to a name in this instance).
What no one can tell you, though, is what the magic key is for motivating you to change your attitude and lifestyle and improve upon those educated guesses. For some people, just being told that they have a 40% chance of having a major cardiovascular event within five years would be enough to inspire change. For a lot of people, it isn’t enough. Neither is a sense of accomplishment and mastery, monetary incentives, nor social acceptance likely to elicit any sustained metamorphoses. We know this, as a collective, because we have been throwing ideas at the wall for many, many years in a frenzied attempt to solve this puzzle, and nothing has worked. None of the flashy computer programs and gamification, gift cards, freebies, motivational interviewing, or SMART goals have really had any real effect on the rates of disease and sickness on the whole. This is why there is a billion-dollar industry devoted to convincing others that you have finally found the key. Eureka! You can bring down health care costs…” whoops, ok, well I didn’t mean bring down exactly. Can we send you a flyer or a brochure or something to engage your people and then circle back and see how that’s going?” That’s what the wellness industry is in a nutshell – circling back; we circle back all day, every day. Every “remedy” we contrive of will work for a small percentage of the population. And it will likely only work for a short period of time, generally until the novelty wears off or until the applause stops.
Some of us are motivated by money, while others would gladly expend money to save time. Some of us are driven by feeling better mentally or physically, but it’s easy to forget that others have been feeling bad for so long that the idea of anything different seems so unachievable that it fails to motivate.
As long as we furiously try to motivate others to make what we have deemed to be improvements for them, we will fail. Not only is the idea of motivating others laughable, but we also have no business constructing a list of goals for someone else. You can’t drive me to do a damn thing, and this isn’t because I’m more stubborn or obstinate than anyone else; I can’t motivate you either.
If Ann doesn’t think that her uncontrolled diabetes is having any adverse effects on her wellbeing, I’m not going to be able to convince her otherwise. I can yammer on about strokes and kidney disease and nonhealing wounds until my jaws seize up and Ann is going to look at me like I’m insane and wander away for a nice lunch of cookies and soda. Ann, it turns out, prioritizes eating cheaply and enjoying the foods that she considers tasty way above getting her diabetes under control. Ann does not have any kidney disease, and she doesn’t have any nonhealing wounds today. She has no reason to believe that it will be any different tomorrow or next week or next month. I could give her a $50 gift card for getting her labs done or seeing a dietitian, but Ann might not feel like $50 is enough for the hassle. Even if she does decide to go ahead and take that $50, what will change based on her lab results or her visit with the dietitian? Odds ratios and prediction would tell you what the chance is that Ann will both take the offer of $50 in exchange for behavior and will make a positive change to her lifestyle as a result of this encounter. It is very, very low.
People in the business of population health are told to ignore the people who are already doing well and focus instead on the individuals who have fallen into the gap. This is fine and dandy if you can safely assume that the people who are already doing well will continue to do well. Unfortunately, that’s not what research leads me to believe is going to be the experience of the majority of these people. These are humans that we are talking about here, so that’s a pretty brazen assumption to make. Not only are we likely to lose any headway made by this group of people who are actively trying to improve themselves today, but the people who have fallen into the gap will likely prove to continue to be unaffected by our attempts to inspire them to manage their health. In this scenario, we are clearly in the red at the end of the day.
Instead of spending our days essentially playing Whac-A-Mole with a large group of people who are certainly not going to be extrinsically motivated by anything or anyone, maybe we would be better served to focus more attention on keeping motivation high among the much smaller group of those who have had their lightbulb moment and are already in the midst of trying to better themselves.