C Remmers

D Mechanic

DM Berwick

Dominick L. Frosch

GC Williams

Glyn Elwyn

HA Dam van

JH Hibbard

KS Yarnall

M Fishbein

M Korff Von

ML Parchman

S Greenfield

SH Kaplan

SM Campbell

T Doran

T Ostbye

English

PubMed

Springer - Publisher Connector

I Believe, Therefore I Do

Frosch, D.L.

Elwyn, G.

Radboud Repository

I believe, therefore I do

Crossref

Journal of General Internal Medicine

Frosch, Dominick L.

Elwyn, Glyn

Online Research @ Cardiff

I believe, therefore I do [Editorial]

EDITORIALS
I Believe, Therefore I Do
Dominick L. Frosch, PhD1,2 and Glyn Elwyn, MB, BCh, FRCGP, PhD3
1Department of Health Services Research, Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA; 2Department of Medicine,
University of California, Los Angeles, CA, USA; 3Department of Primary Care and Public Health, Cardiff University, Cardiff, UK.
J Gen Intern Med 26(1):2–4
DOI: 10.1007/s11606-010-1560-1
© The Author(s) 2010. This article is published with open access at
Springerlink.com
“C ogito ergo sum”—“I think, therefore I am” was RenéDescartes’ most famous dictum. But perhaps a more
fruitful line of inquiry would have been—“I believe, therefore I
do”; a brief summation of what behavioral science has taught
us about behavior change. Our beliefs are powerful predictors
of how we act. This important insight has been given additional
relevance in the work by Street and Haidet in this issue of
JGIM, showing how poorly physicians seem to do at predicting
the belief structures of their patients, and by implication, how
poorly they are able to anticipate their intentions and actions,
never mind how best to support them in managing their
illness.1
In the late 1980s Greenfield and colleagues published
several seminal studies that demonstrated the powerful
potential effects of a patient activation intervention on chronic
disease outcomes.2–4 In one of these studies, patients with
diabetes who were randomized to an activation intervention
prior to a consultation were more active in negotiating
decisions with their physicians and subsequently had HbA1c
values that were 1.5% lower than those in the control group.3
These studies are among the most widely cited ones in the
larger literature on patient-centered care. Although subse-
quent studies have not always demonstrated the same
powerful effects,5,6 researchers have shown considerable
interest in fostering patient activation. Several recent studies
have continued to generate evidence in favor of fostering
patient activation to improve health outcomes, especially
among patients with diabetes.7,8 Nevertheless, patient activa-
tion interventions have yet to be widely implemented in our
health care system. Part of the reason why these interventions
have not been widely disseminated may be that the mechanism
of the activation intervention is unclear. What might lead an
activated patient to have better long-term outcomes? A recent
observational study found that patients who were more
activated had better subsequent adherence to their treatment
regimens, leading to better outcomes.7 But why would an
activated patient become more adherent?
The paper by Street and Haidet begins to suggest an
explanation for why patient activation might be so powerful.
In a clever and elegant study, they measured patient’s health
beliefs as well as their physician’s personal beliefs and
perceptions of their patient’s health beliefs. These parallel
three-way assessments yielded some striking findings. Patients
generally were more likely to believe that their disease was their
responsibility than their physicians thought and perhaps more
importantly, something they could control. Contrary to their
physician’s perceptions, patients were less likely to endorse a
biological cause for their condition. Moreover, physicians
seemed to think that their patients were more likely to believe
in a biological cause than the physicians themselves, perhaps
suggesting that physicians think that patients don’t believe
they can control their illness. Somewhat surprisingly, physi-
cians who had a longer standing relationship with their patient
did not show more accurate perceptions of their patients’
beliefs. However, physicians whose patients were more acti-
vated—meaning that they asked questions, communicated
their concerns and acted assertively in their consultation—had
significantly more accurate perceptions of their patients’ health
beliefs.1
The study by Street and Haidet did not address how
congruence in patient beliefs and physician perceptions could
be related to subsequent adherence and treatment outcomes.
But 40 years of theoretical and applied work on health
behavior gives some guidance. Several prominent health
behavior theories identify beliefs as the key underlying
construct that drives people’s behavior.9 Fishbein and Ajzen’s
Reasoned Action Approach to health behavior provides a
detailed explication of the link between beliefs and behavior.10
This theory has been successfully applied to countless inter-
ventions aimed at changing a wide range of health behaviors.9
According to the Reasoned Action Approach, a behavior is
likely to occur if a person has formed an intention to do so. If
one doesn’t already have an intention to perform a given
behavior, the intention can be predicted by measuring the
person’s attitudes, perceived normative pressure and self-
efficacy about engaging in the behavior. Underlying these
constructs are the patients beliefs about their outcomes
expectancies, normative and efficacy beliefs. Although much
of this cognitive process is often unconscious, if made
conscious, one could articulate the following questions from
the patient’s point of view: (1) what are the advantages and
disadvantages of taking this new therapy?, (2) do others who
are important to me or like me think that I should or should not
take this new therapy?, and (3) what might help me or stop me
from taking this new therapy?
What follows from this theory is that to change someone’s
behavior (e.g., convincing a patient to take a prescription drug
that will lead to improved outcomes, if taken as directed) one
must either change the patient’s beliefs or understand them
sufficiently to ensure that the intervention one is prescribing
JGIM
Published online November 9, 2010
2
fits with the patient’s beliefs. Beliefs are ultimately an
interpretation of the known world. Exploring the patient’s
interpretation—understanding the underlying beliefs—can
help the physician uncover misconceptions and false inter-
pretations of events that may stand in the way of adhering to a
therapy that could be effective, if used correctly. Thus, a
physician working in partnership with an activated patient is
more likely to recommend a treatment plan that fits with
patient’s health beliefs, which in turn improves the likelihood
that the patient will follow through with the treatment plan,
thereby leading to better long term outcomes.
Some have suggested that the lack of readily deployable
interventions to activate patients has held back the full
implementation of the chronic care model.11,12 The ever
growing burden of chronic diseases on health care expendi-
tures makes these issues all the more urgent. What then can
be done to increase patient activation? Although patient
consultations haven’t necessarily gotten shorter in recent
decades, what has increased is the number of issues a
physician has to cover in the same amount of time.13–15 This
could understandably lead one to wonder how physicians
could possibly fit an assessment of a patient’s health beliefs to
this already overcrowded agenda.
As noted by Street and Haidet a number of interventions
have been developed and tested that could be used efficiently
before a consultation to activate patients. And a systematic
review of activation interventions for patients with diabetes
found that interventions targeting patients were generally more
effective and efficient than interventions targeting physician
behavior.16
But what is perhaps also needed is a much more funda-
mental change in physicians’ understanding of the role of
patients in developing treatment plans. To borrow from a legal
analogy, it is probably fair to say that we don’t yet have
evidence beyond a reasonable doubt that developing a better
understanding of patient beliefs will lead to better adherence.
But the circumstantial evidence is mounting and one has to
ask how long we are going to continue waiting before we change
our fundamental views of the roles of physician and patient in
negotiating treatment plans.
Despite a few decades of progress and movement toward
more patient centered care, the prevailing model is still one
in which the physician is viewed as the expert who assists
the patient who needs help. We have frequently found
ourselves struck when listening to discussions about patient
centered medical homes, one of the latest buzzwords in
primary care, how much attention is focused on reengineer-
ing practices and redistributing tasks. Yet very little atten-
tion is paid to orienting in an entirely different way toward
patients.
As the study by Street and Haidet demonstrates, physi-
cians are not experts in their patient beliefs. Patients are the
experts in their beliefs. Physicians can wait for patients to
tell them their beliefs, or they can become more systematic
in asking patients what they are. Not only is it the right thing
to do, but it will likely lead to that which we all value and
pursue with our work—helping patients achieve better
health.
Performance measures could be developed to start measur-
ing how well physicians explore their patients’ preferences and
belief systems, and how well they support their patients in
deliberating together about which interventions are best suited
for them. Most performance measurement applied to date in
clinical practice has been focused on outcomes based on either
management priorities (such as efficiencies regarding waiting
times and other such targets) or on clinical measures which
relate to biomedical proxies (blood pressure, blood sugar, or
similar assessments) whilst the imperative of working to
provide patient-centered care, based on dialogue, on the
exploration of what is truly important to the patient, is largely
rhetorical and goes without any measure whatsoever.17–19 If
medicine wants to place the patient at the center, then the
structural issues that limit the ability to provide information
prior to exploring preferences, that do not allow patients to
have time to deliberate after they have received information
and that put a low price on the willingness and ability of
clinicians to support their patients to understand the levels of
uncertainty that permeate medical practice, need to be
addressed. Systems are perfectly designed to deliver the results
which they produce—and if we want different results—we need
to address system issues and not just suggest that these issues
can be delivered by inserting narrowly focused interventions
alone, however well designed they might be.20 Physicians want
to perform well, for the well-being of their patients and their
own sense of professional accomplishment. We know that
involving patients in decisions requires exploring their belief
systems as well as providing them with information—and that
these in turn lead to many good outcomes in the long run—we
have plenty of evidence for this. We therefore need to measure
whether clinicians do both these tasks. We should incentivize
and reward them for having the courage, confidence and
curiosity to explore what their patients believe and truly involve
them in decision making. We need to recognize when they get it
right and reward that work—for it really is hard work to get it
right.
Open Access: This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
Corresponding Author: Dominick L. Frosch, PhD; Department of
Health Services Research, Palo Alto Medical Foundation Research
Institute, Ames Building, 795 El Camino Real, Palo Alto, CA 94301,
USA (e-mail: froschd@pamfri.org).
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4 Frosch and Elwyn: I Believe, Therefore I Do JGIM


NARCIS 

A primer on leading the improvement of systems.

Are patients’ office visits with physicians getting shorter?

Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care.

Collaborative management of chronic illness. Ann Intern Med.

Effects of pay for performance on the quality of primary care in England.

Expanding patient involvement in care. Effects on patient outcomes. Annals of Internal Medicine.

How Well Do Doctors Know their Patients? Factors Affecting Physician Understanding of Patients’ Health Beliefs.

Interventions before consultations for helping patients address their information needs. Cochrane Database Syst Rev.

Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes?

Is there time for management of patients with chronic diseases in primary care? Ann Fam Med.

Lessons from major initiatives to improve primary care in the United kingdom. Health Aff (Millwood).

Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomesintype2 diabetes:aSTARNetstudy.AnnFam Med.2010;8:410–417.

Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes.

Predicting and changing behavior - the reasoned action approach.

Primary care: is there enough time for prevention? Am J Public Health.

Promoting glycemic control through diabetes self-management: 3 Frosch and Elwyn: I Believe, Therefore I Do JGIMevaluating a patient activation intervention. Patient Educ Couns.

Provider-patient interaction in diabetes care: effects on patient self-care and outcomes. A systematic review. Patient Educ Couns.

The role of theory in HIV prevention.

Using systematic measurement to target consumer activation strategies. Med Care Res Rev.

What ‘patient-centered’ should mean: confessions of an extremist. Health Aff (Millwood).

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