Sarah Monahan is a wearer of many hats—and that’s an understatement. On LinkedIn, she describes herself as an adaptable problem solver, a dot-connector, and an out-of-the-box thinker with a big, crazy brain. But Monahan is also a registered nurse, a tour guide to business expansion, president of her own practice consulting firm, and a mental health associate working on behavior skills training and psychosocial rehabilitation with kids struggling in the foster care system. While her employment history reveals a lot about her work ethic and long-term commitments, the John Quincy Adam’s quote with which she concludes this summary is perhaps even more telling: “If your actions inspire others to dream more, learn more, do more and become more, you are a leader.” This nuanced understanding of what it means to lead manifests in Monahan’s own efforts to foster change within the medical community. As founder and president of DeLacey Solutions, Monahan works with physicians transitioning to Direct Primary Care and Concierge Medicine to help build sustainable practices that center patients and wellness—a project many doctors are unprepared to tackle on their own.
“Doctors who exit the hospital system to start under Direct Primary Care realize pretty quickly that they’re not trained to listen, ask hard questions, or give patients that red carpet experience that’s key to membership models.” Monahan and her team work hard to fill those knowledge gaps. “We don’t just meet with the doctor; we engage the entire team: the medical receptionist, the physician’s assistant, the nurse, and anyone else who works in the office. We help them understand how to talk to patients in a way that is customer service oriented, how to meet people where they’re at, and how to to break through problem behaviors. In the end, doctors should be able to approach patient health as a partnership, instead of acting like they always already have all the answers.”
Teaching Patient-Centered Practice
Monahan’s behavioral health background allowed her to enter the DPC space equipped with the tools to change its culture. From 2014 to 2015, Monahan worked at The Change Companies, a publishing, consulting, and training company invested in finding out more about the science of change--from why motivational interviewing works to how people can play a supportive role in someone else’s transformation. “I was hired specifically to figure out how this information applied to healthcare. I attended conferences and seminars held by groups like the American Academy of Private Physicians. I also met with doctors one-on-one in their offices to try to find out what kind of challenges they were facing, how people were responding to new models, and what they thought might bring in more patients.” Through these conversations, Monahan came to the conclusion that, although doctors wanted to engage in these alternative models of care, they still hadn’t made the crucial changes necessary to be able to actually provide care differently. “It’s not just a mentality shift for the patients. It’s also a mentality shift for doctors and their staff. I ended up spending a lot of time helping facilitate that shift. They had to wrap their minds around the idea that DPC is a completely different kind of medicine.”
Keeping up with private practice models means not only learning new techniques, but also unlearning old habits. Monahan thinks the latter task often poses the biggest challenge for doctors, particularly when it comes to giving timely advice. “When you’re talking to a patient about their long-term health, you’re frequently going to be telling them things they have already learned, either from their family history or from the media. Take smoking for example. Your doctor is going to say that you need to quit smoking because it’s bad for your lungs, you’re going to get cancer, it puts you at risk for heart disease, it’s expensive, etc. Then they’re going to list the benefits of quitting: you’re going to have a fuller life, you’ll be healthier, you’ll be able to breath better, you won’t have a cough, etc. They essentially just list the pros and cons, thinking that it will help the patients make the right decision.” On a surface level, this may seems like a practical strategy, but deeper research reveals that it isn’t.
“There’s a dynamic called the ‘righting reflex’ in which the listener, when being provided a set of arguments, naturally starts listing all the counterarguments in their mind. For example, when a doctor is talking to a patient about how she is going to get healthier, breath easier, and smell better if she stops smoking, the patient automatically thinks, ‘Yeah, but it is the only way I can stay calm and I’m going to be hungrier and all my friends smoke and if I have to be around them without smoking I’m going to be anxious.’ The patients are listing all opposing reasons in their heads, even though they’re not saying them out loud. Unfortunately, research shows that people follow what they tell themselves, not what an expert tells them. So when doctors make certain arguments, they’re indirectly reinforcing the behavior they’re trying to eliminate.” Helping doctors to change the way they interact with patients in these instances is both the hardest and most important aspect of Monahan’s work. “Doctors have to learn to ask patients what they want, how they might go about accomplishing their goals, and what they would need to be successful in the long-term. Patients need to be listing the pros and cons themselves.” Monahan suggests that doctors do a decisional balance exercise with patients to help foster a more realistic and open conversation about the their capacity and commitment to making change. “Instead of just emphasizing the arguments against a problem behavior or in favor of a healthy habit, doctors need to recognize that there are pros for changing and pros for staying the same, just like there are cons for changing and cons for staying the same. By asking patients to list out all four categories, they get a more expansive understanding of their wellness goals and what they’re ready and able to do about them.”
Getting doctors to embrace this radically different style of interaction presents a unique set of difficulties. Monahan doesn’t think the resistance to it is conscious. Instead, she suggests that it stems from years of habits learned in medical school and under insurance-based systems. “Insurance has played a huge role in keeping doctors pressed for time. They have had to pick out the top needs that can be coded, and then had to solve those problems as fast as possible to maximize the number of patients they could treat. When doctors listen to a patient describe symptoms, it still triggers this automatic flow-chart in their head. Based on the symptoms listed, they come up with diagnostic questions that can point them towards a correct answer. Based off the answers, they have more questions that can point them to a diagnosis, a prognosis, and a treatment. They use the diagnostic process to problem solve; that’s very, very much what medicine has become. It isn’t easy telling someone who knows that process—lives it and breathes it—that they have to start listening to what patients want without immediately trying to solve all their problems.” In that sense, the DPC model and other private practice models require doctors to assume a different role than they're used to. “They have to focus on relationship-building. They have to tackle the patient’s health as a partnership. This model compels doctors to be more social, and, in some respects, to act like a counselor. This can be very uncomfortable for a lot of people, but that doesn’t mean they can’t succeed.”
Monahan and her team play an integral part in facilitating that success and making a patient-centered practice possible for their clients. To achieve long-lasting change, doctors can’t be the only ones making an effort. “I think it’s important for the doctors to keep the rest of their staff involved, especially if they’ve converted over from conventional medicine and have taken two or three people with them. Typically, those other team members—like the receptionist, nurse, or medical assistant—weren’t brought into the conversation about making the switch to DPC. They may have come along happily, but they still haven’t had the same time to mentally prepare or fully understand how the new model might alter what is expected of them.” Implementing new standards for customer service means ensuring that everyone is informed and empowered, so Monahan tries to use strategies that target the culture of the entire practice. “In the past, I’ve created training programs for doctors and their staff that explain the goals, methods, and reasons behind becoming patient-centered. I ask questions like: ‘What does it feel like to walk into your office? Can the patient sense that they are being valued? Is the receptionist making eye contact? Do they know your name? Do they remember you from your last visit?’” From the patient’s perspective, the quality of these small interactions makes a huge difference. “You can’t boast patient-centered care if the person walks through the door and receptionist isn’t making eye contact or is still speaking curtly. Many of the supportive staff members have gotten very used to the system of being rushed, trying to get the forms filled out, making sure all the signatures are there, and keeping the patients away from the doctor until the doctor is ready. The doctor can be as nice and caring and welcoming as ever, but if all these negative moments happen before the patient actually enters the room, they might have already decided that nothing is different and will likely be more resistant to the model."
Reorienting Towards Wellness
Cultivating positive patient experiences is about more than just following customer service best practices. Monahan emphasizes the interconnectedness of comfort in the doctor’s office and achieving long-term wellness goals. In her eyes, getting patients in the door before they get sick is essential to moving toward a preventative care model and away from the last minute, drastic fix. To make that happen, doctors have to encourage patients to invest in their future health—regardless of what that word means to them. Monahan has abandoned the idea that wellness has a static definition, and she thinks health practitioners should too.
“I think wellness is being able to do the things that you want to do in your daily life, both now and in the future. If that means you want to be able to walk up and down the stairs without being winded, then that’s what wellness is for you. Wellness might mean something completely for the super athletic type who wants to wake up in the morning and run twenty miles. Essentially, it means being able to do what you want to do without the emotional, physical, mental, and spiritual limitations that you’re saddled with when we’re unwell. Part of achieving wellness requires that you figure out what you need to do to get yourself feeling good in the day-to-day. That might mean losing weight, improving nutrition, quitting smoking, or getting a handle on chronic health issues. You also have to think long-term and really understand that, in order to maintain your level of wellness, your behaviors are going to have to change to keep issues from arising in the future. It’s much harder to have an issue develop and get back to where you were than it is to maintain your current level of wellness.”
As Monahan points out, it’s often much easier for people to see some validity in the tenets of wellness than it is to actually practice them in daily life. “It’s hard because we’re instant gratifiers, and we’re good at living in the moment. It’s easier to think about our happiness in the next twenty minutes than it is to think about our health in the next twenty years. An integral part of wellness, however, is really thinking about what we want for ourselves in the future.” Monahan believes Direct Primary Care doctors have a unique capacity to help patients who aren’t sure how to get started. “There’s a number of ways that doctors can approach a conversation about wellness. They could start by asking patients for their number one health goals. Some people may say something like, ‘My dad died of heart disease at fifty-eight and I’m forty. I really don’t want to have only eighteen more years left to live.’ That one is surprisingly common—I’ve heard it more than once from patients. I think it’s most effective in those cases for a doctor to ask what the patient would be willing to do based on that knowledge. If a doctor just steps in and say, ‘Okay, well you’re on your way to heart disease, so you need to do x, y, and z,' the patient has already stopped listening once he hears that he is on his way to heart disease. He's already panicking.”
The question "Would you be willing?" invites patients to collaborate with doctors to create a wellness strategy. If people feel like they have ownership over the long-term plan, it often feels more feasible in the short-term. “When a patient says ‘yes’ to questions like, ‘Would you be willing to incorporate some exercise into your daily routine?’ or ‘Would be willing to try to cut sugar out of your diet?’ or even, ‘Would you be willing to let me give you some advice?’, they’re giving themselves internal permission to actually listen to what the doctor says next. Even if it’s not their idea, they can involve themselves by agreeing to it, and in that sense, they’re investing in their own wellness too.”