FORUM On MODELIng

EDITOR Hugh Dubberly [e-mail]

from others. When we feel afraid, we may hand
responsibility to a confident expert. In a medi-
cal emergency, letting a physician take charge is
probably the surest way to stabilize things and
return to normal.
A heart attack requires quick action; it’s not
the best time for discussion. The time for discus-
sion is before a heart attack occurs—and after—
finding ways to avoid the heart attack in the first
place or at least avoid another one.
Yet the language of acute conditions (the
frame of healthcare) is ill suited to managing
chronic conditions or preventing disease (often
framed as behavior change). The American Heart
Association reports, “The No. 1 problem in treat-
ing illness today is patients’ failure to take pre-
scription medications” [ 7]. Patient behavior does
not change on a physician’s orders. To expect
behavior change on command is to misunder-
stand human nature. To blame patients (who
respond to the very present pressures of busy
lives rather than less tangible long-term risks)
is unhelpful, unkind, and perhaps unethical.
(Blaming patients—or clients—suggests that one
doesn’t understand or respect their context and
constraints and doesn’t share responsibility for
outcomes.) According to social epidemiologist
Leonard Syme, “We need to pay attention to the
things that people care about, and stop being
such experts about our risk factors” [ 8].
may lead to
The language of acute conditions (the frame of
healthcare) limits what we imagine. Discussions
about improving healthcare focus mainly on
improving assessment of patient conditions,
improving HCP education, and improving thera-
pies—since surviving a crisis depends mainly on
the patient’s condition, the HCP’s skill, and the
medical technology at hand.
We debate how to have more of the same
rather than something new. We debate how to be
more efficient and reduce cost rather than radi-
cally increase effectiveness and eliminate causes.
Our goals remain modest. We seek little more
than increased patient compliance and more
knowledgeable consumers. We can do better.
The language of acute conditions (the frame of
healthcare) is ill suited to achieving well-being
(the frame of self-management). By its very defi-
nition, healthcare almost assumes both a pres-
ent problem and an expert who intervenes. In
that sense, well-being lies outside the scope of
may lead to
Context
change:
physical
+social

may prompt
Condition
change:
ongoing
in body

may be disturbed by
Regimen
change:
manner
of living
Stage 4
Stable health:
feeling well;
self-management
becomes routine

requires
supports

makes
possible
Stage 2
Habituation:
new regimen
becomes routine
Experimentation
and pattern
recognition
lead to...
Stage 1
Reconciliation:
acceptance
of conditions
and regimen
enables
Adherence
to regimen
leads to...

Stage 0
Unstable health:
conditions may
often be ignored,
regimen erratic
Emotional
acceptance
leads to...

• Continuous Cycle of Health-Self Management