EDITOR’S CORNER
Alfred A. Bove, MD, PhD
Editor-in-Chief, CardioSource WorldNews
The Behavioralist
A
fter practicing clinical cardiology for many
years—including invasive and interventional
cardiology, stress testing, heart failure, and
transplantation—I am now seeing patients in the outpatient 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
At some point
on this journey,
it becomes
apparent that we
as health care
providers [...] need
to move toward
a goal of being
a motivator of
patient behavior.
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CardioSource WorldNews
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. ■
Alfred A. Bove, MD, PhD, is professor emeritus of
medicine at Temple University School of Medicine in
Philadelphia, and former president of the ACC.
March 2016