The Power of 'Why' in Health Behavior Change

Cate Collings, MD


January 05, 2023

Cate Collings, MD

Here's a sobering statistic for physicians and other health professionals. Clinical care is estimated to account for only 20% of health outcomes, whereas health behaviors and social determinants of health account for the remaining 80%.

At one time, I found it easier to prescribe and titrate a medication rather than navigate the complexity of health behavior change and the social determinants of my patients' lives. Explaining to patients the proven benefits of healthy eating, exercise, sleep, and stress management could feel like a low-return investment.

Conversations about behavior change became much easier and rewarding after I learned to do less directing and telling and more asking and listening. Just as this approach enriches our personal relationships, asking and listening can do the same for our doctor-patient relationships. The start of a new year is the perfect time to begin asking patients questions that activate discussions about health behavior changes.

Key to those conversations is asking open-ended questions about why patients want to improve their health. What would it mean for them? You know what's important about their health but asking them is an opportunity to discover their internal motivations.

During a presentation at the American College of Lifestyle Medicine conference in November, a colleague physician shared a good example of the immense of power of discovering the "why" a patient wanted to be healthy. For example, consider Mrs C: a 65-year-old woman with obesity, type 2 diabetes, hypertension, and advanced knee arthritis. She used a walker and slept about 5 hours at night, usually after falling asleep in front of the TV. In conventional terms, behavior change might seem unrealistic given the reality of managing these complex comorbidities. But the doctor structured their conversation around determining specifically why Mrs C had come to her for help improving her health.

After thinking about it, Mrs C said, "You know, I want to be able to go on a trip with my friends to Atlantic City, like I have in the past. My knees are so bad now. If I could just do that."

Visiting Atlantic City is probably not a goal a doctor would set. But it was Mrs C's "why" and it motivated her to enter into a partnership with her physician and achieve her goal. It led her to embrace lifestyle behavior changes in her diet, sleep, and physical activity. It encouraged her to be resilient after setbacks and eventually make that trip to Atlantic City with her friends.

These conversations may sound uncomfortable. So conditioned are clinicians to the unrelenting pressure of patient volume that we instruct rather than listen and acknowledge our patients' hopes and dreams. So accustomed are patients to doctors telling them why they need to improve their health that many have not contemplated the question themselves. Simply being asked "why" is healing to a patient who instead of feeling frustrated by their health, begins to feel inspired and empowered.

A body of scientific literature supports the psychology and the logistics of behavior change and health coaching. Research suggests that motivational interviewing, coaching, and other foundational methods in behavior change can be more effective than sharing didactic materials to help patients achieve specific outcomes. Asking "why" is a great first step to recognize the patient's autonomy and uncover their intrinsic drive.

The next steps are translating the "why" into iterative behavior change. Those steps include identifying the patient's strengths, confidence, and readiness to change and the ability to set SMART (specific, measurable, achievable, relevant and time-based) goals. It may help to bring others, such as health coaches, into the clinical team. In 2023, it's hoped that the adoption of reimbursable CPT codes will make it easier to integrate health coaching into clinical care; however, you can already find information on behavior change methods in many lifestyle medicine educational courses and curricula as well as in a chapter of a lifestyle medicine supplement to the Journal of Family Practice titled "A Coach Approach to Facilitating Behavior Change."

Make your 2023 resolution to discover your patients' "why." Record the details to resume those conversations at future appointments and monitor progress. You may be surprised at how much the answers inspire you and your patient to transform their health behaviors together.

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