Clinician Intervention

Leveraging Social Networks to Improve Health: A Simple, Clinician-based Intervention

The people close to us can shape our health behaviors. In light of prior studies that have highlighted the importance of social networks to health, we propose that physicians or other clinicians conducting a patient interview should advise patients to encourage someone among their family, friends, and community to engage in a healthy behavior. This intervention can be formally incorporated into the end-of-interview, or “closing,” segment of the physician-patient interview when physicians counsel patients to either improve or maintain their health behaviors (e.g. reduce smoking, maintain smoking cessation, eat healthier, increase exercise, etc.). The widespread adoption of this simple, brief clinician intervention may add a minute or less to the patient interview but potentially help build a community-wide culture of health that can eventually lead to healthier behaviors and outcomes.

The following two examples illustrate the opportunities our proposal creates.

  1. A patient visits a clinician for an annual physical. She has a 12 year pack history of smoking and successfully quit smoking nine months ago. At the close of the physical, which produces no new illnesses or concerns to address, the clinician congratulates the patient for quitting smoking given the difficulty of such a change (positive reinforcement), encourages the patient to keep up the smoking cessation (homework), and invites the patient to encourage a family or close friend who is a smoker to quit as well (intervention). The physician adds that the patient already knows how difficult it was to cease smoking and can be a resource for a family member and/or a close friend as well (intervention). [Note: this example intervention was actually performed and timed on a simulated patient and added between 15-20 seconds to the encounter.]

  1. An elderly patient presents to her physician with concerns about a two-week history of coughing. The patient, citing a prior history of smoking and a family history of lung cancer, wonders if she might have lung cancer. The physician believes the patient is suffering from a lower respiratory tract infection based on the patient’s fever, other recent history of illness, and the patient’s denials of either unexpected weight loss or coughing up blood. As the patient asks the physician if she might have cancer, the physician can (A) simply claim that the likelihood of cancer is low, though not completely ruled out, and move on, or (B) recognizing a patient education opportunity, explain that the likelihood of cancer is lower, though not completely ruled out, because of the absence of unexpected weight loss and coughing up blood.

While Option (B) may represent a brief and routine response to a concerned patient’s inquiry, this patient educational moment sets up an opportunity for another instance of our proposed intervention. Now that the patient knows that unexpected weight loss may be an important indicator of cancer risk, and if the patient appears sufficiently relieved or  less distressed that the likelihood of cancer is low, the physician may then briefly invite the patient to keep an eye out for family members or friends that might experience rapid, unexplained weight loss or perhaps “clothes that don’t fit anymore because they are suddenly and unexpectedly loose.” This simple and brief intervention may empower a patient to act as a possible cancer screener, where none existed before. The educated patient may also easily inform others to watch out for unexpected and rapid weight loss among their close contacts as well. The healthy behavior now being spread in the patient’s network is cancer surveillance. Because of an additional few seconds added to the clinician-patient interaction after a physician’s routine yet educational response to a patient’s question or concern, a person-to-person spread of a cancer risk-screening question may not only help identify an otherwise undetected instance of cancer, but also represents yet another small step towards building a culture of health through patient education, empowerment, and community screening/surveillance.

Behavioral change can be very difficult. Substantial amounts of time, money, and other resources have already been spent trying to identify and test various individual, interpersonal, and contextual factors that can lead to behavioral changes. We would be naive to claim that our simple communicative intervention would immediately lead to significant behavioral changes. That is not our point and misses the opportunity.

Rather, the simplicity of our proposed clinician intervention allows it to be intentionally agnostic and complementary to various other more involved efforts to produce behavioral changes. Our intervention would simply alter the baseline environment, the cultural context, to one of increased interpersonal (network-driven) encouragement for healthier behaviors. This would create a social support starting point, or a local or focal culture of health, within which more involved behavioral change strategies and mechanisms, some perhaps still unknown, may further promote healthier behaviors. Our modest proposal is therefore based on the assumption that this brief, relatively costless and effortless clinician intervention can create small pockets of social support for behavioral change to occur, a baseline starting point or “new normal” slightly more supportive or advantageous for healthier behaviors than our current baseline in which clinicians do not intervene in this manner.

A number of studies support the link between social networks and health behaviors. Research has shown that obesity, one of the most pressing public health challenges today, can spread from person to person via family relationships and close friends (Christakis & Fowler, 2007). Likewise, research has shown that smoking cessation can spread from friend-to-friend, between spouses, siblings, and even between co-workers at small firms (Christakis & Fowler, 2008). The same study found that increased geographical distance did not reduce the person-to-person spread of smoking cessation; the connection is what mattered. Finally, a randomized controlled trial has indicated that public health interventions that specifically target and utilize friendship networks can improve population health (Kim et al., 2015).

Based on these studies, this proposed patient interview intervention could lead to improvements in health outcomes already tied to social relationships. As our examples suggest, it would be a simple matter for a physician to ask a patient to not only consider eating healthier, but also to advise a close friend, spouse, sibling, or co-worker to improve their diet as well. Even if a patient admits to having difficulty changing her or his unhealthy behavior, that patient may yet find it easier to advise a close contact to reduce or not initiate the unhealthy behavior, without necessarily compromising the clinician’s encouragement that the patient do the same. Finally, this strategy would not be limited to advising only ill patients to counsel close contacts. Our examples illustrate that well patients can also be invited to share their wellness behaviors and strategies with close others.

Aside from the potential spread of person-to-person health benefits, there may also be benefits for vulnerable populations that may be experiencing tenuous or frayed social relationships. Inviting patients to counsel others on improving their health behaviors may have an ancillary effect of restoring or rebuilding trust and social ties between family members, friends, neighbors, and community members at large. Improvements in neighborhood or community efficacy may become a by-product of multiple and widespread efforts by physicians to have patients counsel their close contacts to improve or maintain health behaviors. All of these become possible opportunities with simply a brief sentence or two spoken by the clinician to the patient during the closing of the patient encounter.

This proposal has some important limitations to consider. First, some clinicians may already feel overburdened by the demands of a patient visit to add yet another task. Second, patients may feel burdened by the clinician’s request. Third, clinicians may feel that achieving behavioral change among patients requires a special set of skills, even among already highly trained clinicians, much less untrained patients themselves. Finally, a clinician asking a patient to encourage a close contact to adopt a healthier behavior might raise the ethical issue of “divided loyalty,” potentially leading a patient to feel as if the clinician is prioritizing the close contact’s health over that of the patient and unnecessarily compromising the clinician-patient relationship. These are all important limitations that may arise.

However, as stated earlier, our first example above would add 15 to 20 seconds to the patient encounter. As an invitation from her clinician, the patient can decide on her own time if and when she chooses to advise someone else, or even not at all. The intervention, as described, is simple and would not require any specialized training. As the clinician is inviting the well patient to share the patient’s own wellness behavior and experiential wisdom with another person, the intervention lessens the possibility of divided loyalty. The patient instead may actually feel empowered by the opportunity to share her wellness behavior with someone else. Finally, from the perspective of building a culture of health, a well patient who encourages just one close contact, if only even one time, creates at the minimum one instance of narrative change towards a culture of health. While this one instance may not be consequential in the end, it is certainly a small step of progress towards building a culture of health, over the alternative of not applying this intervention at all. As with our first example, our second example also avoids many of the important limitations raised.

In the short term, this proposal’s goals are primarily three-fold.

  1. Invite clinicians to begin implementing this intervention in actual clinical practice and/or discuss with colleagues its possible implementation. Such a change in the interview would add perhaps 30 seconds to a minute in additional time at the end of the patient interview yet potentially lead to additional benefits in regards to patient health, community health, and strengthening the physician-patient relationship.

  2. Invite medical schools and other clinician programs currently training students to incorporate this small change into their clinical communications curriculum.

  3. Invite textbook authors of clinician communications and training protocols to incorporate a few sentences or one short paragraph encouraging physicians to implement this intervention. Clinical communications textbooks routinely used by medical schools already instruct physicians that when discussing a future treatment plan with patients, to confirm that patients have adequate social support and help patients attain such support if necessary (Fortin IV et al., 2012). This brief intervention simply asks that patients become such a source of support for others. This addition would essentially append a very brief "community-centered" intervention to the current “patient-centered” interview, but only after the clinician has already determined it would not damage the immediate clinician-patient relationship.

In closing, in line with efforts to promote health equity and advance community health, especially for vulnerable populations, clinicians and clinician-training programs should incorporate a brief request for patients to advise one or more close contacts to adopt a healthy behavior. It is a brief and relatively costless intervention that could yield lasting improvements to reducing health disparities, building a culture of health, and improving population health.

Works Cited

Christakis, N. A., & Fowler, J. H. (2007). The Spread of Obesity in a Large Social Network over 32 Years. New England Journal of Medicine, 357(4), 370-379.

Christakis, N. A., & Fowler, J. H. (2008). The Collective Dynamics of Smoking in a Large Social Network. New England Journal of Medicine, 358(21), 2249-2258.

Fortin VI, A. H., Dwamena, F. C., Frankel, R. M., & Smith, R. C. (2012). Smith's Patient-Centered Interviewing: An Evidence-Based Method, Third Edition. New York: The McGraw-Hill Companies.

Kim, D. A., Hwong, A. R., Stafford, D., Hughes, D. A., O'Malley, A. J., Fowler, J. H., & Christakis, N. A. (2015). Social network targeting to maximise population behaviour change: a cluster randomised controlled trial. The Lancet, 386(9989), 145-153.