Wellness Whac-A-Mole

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, what your life expectancy is, and how much your estimated medical expenses are for next year. You could collect a lot of numbers 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).

However, no one can motivate you to change your attitude and lifestyle, except for you. 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. As a collective, we know this because we have been frantically trying to solve this puzzle for many years. None of the flashy computer programs and gamification, gift cards, freebies, motivational interviewing, or SMART goals have had any real effect on disease and sickness rates. This is why there is a billion-dollar industry devoted to convincing others that you have finally found the key. Every “remedy” we contrive of will work for a small percentage of the population. And it will likely only work for a short period, generally until the novelty wears off or until the applause stops.

We will continue to fail as long as we furiously try to motivate others to make the improvements that we have determined will improve their lifestyle. We have no business constructing a list of goals for someone else. It’s easy to forget that some people have been feeling bad for so long that the idea of anything different seems so unachievable that it fails to motivate. 

If Ann doesn’t think that her uncontrolled diabetes has 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 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 to get her labs done or see 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 predictions would tell you the chance that Ann will both take the offer of $50 in exchange for behavior and make a positive change to her lifestyle due to this encounter is 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 advice if we can safely assume that the people already doing well will continue to do well. Unfortunately, that’s not what research leads us to believe will be most of these people’s experiences. If we ignore them, we are likely to lose any headway made by this group of people who actively try to improve themselves today. Simultaneously, the people who have fallen into the gap will likely 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 mostly 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 trying to better themselves.

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