While medical research has made remarkable strides in understanding
the underlying biological mechanisms of the disorder, it is
the patient who is responsible for daily self-care and decision
making. Our focus has been on the cognitive aspects of self-care,
including problem identification, sensemaking, planning, and
decision making. These macrocognitive functions are necessary
for patient adherence, but they are not well addressed by
most current programs.
An example can be seen in diabetes management.
Medical science understands the physiological mechanisms of
diabetes, pharmaceutical companies produce effective medications,
and product designers have produced state-of-the-art equipment.
Despite all this, about 2/3rds of all type 2 diabetics fail
to control their blood glucose levels. Many practitioners
are clueless as to why so many of their patients with diabetes
Our research has found that much of the failure
is not because patients lack discipline, or will power, or
knowledge of physiology. They don’t need more lectures
about how the pancreas works. We found that most patients
simply don’t understand what they must do to regulate
their glucose levels.
The medical model contributes to the problem
by taking control away from patients. Health care providers
have patients collect and bring in test results, but they
don’t use the finding of cognitive science and naturalistic
decision making research to guide patients in interpreting
results, discovering and correcting anomalies, and planning/replanning
future choices. Patients are not learning to make their own
discoveries about how they are driving blood glucose levels
up and down through diet, exercise, stress, and medication,
and how these variables interrelate. We use a dynamic control
model to convey these critical skills.
Health care organizations also must continually monitor
their operations to reflect changes in patients served,
medical advances, legal and fiscal constraints, and professional
availability. Here, the focus must be on continual
attention to the whole health care system. Organizations
must detect changes early, make sense of their potential
impact, plan for anticipated changes, and make timely
and astute decisions. While we can address specific challenges,
our real interest is in building the competence for ongoing
adaptive capacity in organizations.