Are You Ready to Engage? (Part Three)

Patient engagement is trending all over the healthcare world, whether we call it “shared decision making”, “patient involvement”, “patient-reported outcomes”, or a number of other phrases. Many studies and book chapters have been written to support the idea that patients generally enjoy better health outcomes when they are more “connected” to the choices and behaviors associated with their care. However, are our direct-care employees ready to engage? Patients come in all shapes and sizes, with different attitudes and expectations, and providers must have the right perspective to be most helpful to those that they serve.

This is the third of several posts that will explore the knowledge and skills that providers will need to successfully engage patients in their care.

Key Idea 3: Where some see opportunity, others see danger.

It is tempting for medicine to think about patients mechanistically, since the biological systems that health care professionals repair are, of course, organic machines. But the human experience, the part of our humanity that psychology studies, is a Gestalt. Our perceptions are always greater than the sum of the elements that formed them, even though the machine that creates these perceptions (our wonderful and intricate brain) is becoming less and less mysterious in its functions.

One aspect of the human experience that is derived from our neural activity is our personality. Psychologists have spent decades struggling with the reality that personality can be seen, but is inordinately more challenging to quantify. We see personality as a collection of traits, distinct and relatively stable constellations of behaviors/attitudes/emotions that not only inform our decisions about what kinds of environments we prefer, but also our perceptions of the incentives (unrealized outcomes) that we encounter. Two of these traits, Extraversion and Emotional Stability, are potentially important as we engage with our patients because they relate directly to how a patient will perceive an opportunity to share decision authority about their health – either as a potential reward or a potential punishment.

The prefrontal cortices (PFCs) are integral to this idea. Neuropsychologists such as Gray have argued that the human brain is asymmetrical with respect to hemispheric PFC activity. An individual who is right-asymmetric will emphasize the potential rewards of approaching an incentive (i.e., making a decision about one’s health care). An individual who is left-asymmetric will emphasize, in contrast, the potential punishments associated with the incentive. Further, the Extraversion trait is associated with reward sensitivity, whereas the Emotional Stability trait is associated with punishment sensitivity, or inhibition. When all of these data are assembled into a model, we should expect that personality may influence each patient to either perceive “patient engagement” as either an opportunity for a rewarding experience OR an opportunity to demonstrate incompetence, make poor choices, and generally do things wrong.

Since it is not feasible for practitioners to measure each patient’s personality (although there are brief measures available; i.e., fewer than 10 questions), clues to these traits can be seen by the careful and knowledgeable observer. Below I have listed some of these possible clues:

Extraversion – these persons want stimulating environments. They may want to ask a lot of questions about their situation, really dig into the details, and talk to every staff member they can find. They will be less able to tolerate long waits in the examining room and more likely to do multiple things at once (i.e., talk to the doctor while looking up data on their phone). They may be somewhat impulsive and jump to conclusions about their care before you have finished giving them all the important information. They might make the decision more “life or death” than it actually is, because that will increase the emotional arousal they experience (the “melodrama” effect). They can usually handle a lot of arousal and stress, so don’t be as afraid of overwhelming them.

Emotional Stability – here we are looking for those persons who are low in the trait (unstable). Watch for how they communicate – usually their first reactions will be focused on what could go wrong. They will attempt to blunt the emotions they feel, especially since there is more commonly a background sense of anxiety in everyday life with which they contend. They may want to make a decision with you, but the strong inhibitions they feel may stop them from ever settling on an option. Safety will be a paramount (and perhaps even a little irrational) concern, and they are likely to ask many questions about safety during your consultations. Engagement with these patients must be slow and steady – give them too much and they will most likely disengage and give the opportunity back to you.

In short, everyone you treat is PFC-asymmetric in some way — so are you. This will impact whether the person perceives reward or risk in the chance to engage their own health care options. To be successful, you must develop a sensitivity to these fundamental differences.

Are you ready to engage?