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Part II

Designing Care to Address Obesity

Chapter 6

Changing Roles

Collaborative care is one cornerstone of the evolving chronic-care model (Wagner 2001). It implies a change in the traditional acute-care paradigm in regard to the roles and relationships between health care providers and patients (Anderson 2005). In chronic care, decisions about lifestyle change require the participation and input of the person doing the changing. Although health care providers bring their expertise to the planning, the patient is the expert on his or her life. Meal plans and physical activity are not like medications, which are simply taken at the proper time. Behavior change is useless until fully integrated into a person’s experience and adapted to individual circumstances. The patient is the individual most able to identify the causes of his or her problem, providing insight that ideally shapes the treatment plan. The patient and provider must become equal partners in a successful collaborative chronic-care model.

The key component of effective chronic-disease management is productive interactions between patient and provider. Productive interaction has implications for the role of the patient, the provider, and the system. It substantially changes the familiar style of the patient-provider relationship practice with “the need to alter reactive acute-care–oriented practice to accommodate the proactive, planned, patient-oriented longitudinal care required” (Glasglow 2001). New roles may be uncomfortable at first, but they are necessary to address the complexity, disability, and ongoing nature of chronic disease (Wagner 2001).

The Patient’s Role

The patient’s role is to become an informed and active participant in his or her own care. People who are obese must define the problem as it is relevant to them. Not everyone who is obese considers his or her weight a problem. Until and unless they do, no one can solve the problem.

For example, Sally knew how to eat well but ate more than she needed. She saw her excess weight as purely cosmetic. Considering other life challenges to be more interesting than working on her appearance, she made no attempt to lose weight despite periodic prodding by her physician. When diagnosed with diabetes, her priorities changed. After that, changing her eating and activity habits became a worthwhile investment, and she devoted the time and effort needed to improve glycemic control.

Not everyone will be able to define and solve their weight problem as independently as Sally did, but if the patient cannot clearly define the problem for him- or herself, it is hard to work toward a solution. Long-term efforts to change come from solving a personal problem, not from following directions or adhering to recommendations. If you have ever watched “the lights come on,” you know the difference.

The following example should illuminate that self-propelled action is much more powerful than adherence to directions and is integral to the model proposed here:

By the end of high school, Eric had no idea what vocation he wanted to pursue but set off to college because he felt he was supposed to do so. Eric’s interest in sports pervaded his life, from collecting cards and organizing the neighborhood to play baseball, to convincing friends to play new games he created and “broadcasting” games as he visualized them in his head. Sitting still and studying were never his forte, but he made friends easily and had a huge heart for a wide range of people. After several years of part-time college and working at a job with no future, he decided he wanted to teach physical education. This time, he had no trouble handling school, a job, and playing ball. The change in energy and commitment to accomplish his goal was extraordinary to watch. Now Eric has a job that matches his unique mix of skills, interests, and personality. He teaches physical education to 5- to 13-year-olds in an inner-city school and is still organizing groups, relating to a wide range of people, making up games, staying active, and getting paid for it.