Behaviour change with Dr. Peter Selby

Today in studio, we have Dr. Peter Selby, professor of family and community medicine, psychiatry, and public health at the University of Toronto. He's also Chief of Medicine in Psychiatry at CAMH. Today, we delve into behaviour change and the context necessary for making those changes with primary care providers.

Transcript

Dr. Rezmovitz: 0:00

Small Changes, Big Impact: A DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. Today in studio, we have Dr. Peter Selby, professor of family and community medicine, psychiatry and public health at the University of Toronto. He's also Chief of Medicine in Psychiatry at CAMH. Today we delve into behaviour change and the context necessary for making those changes with primary care providers. I really hope you enjoy the show.

Dr. Selby: 0:36

Yeah. Maybe you should call it a penny for your thoughts. My pleasure.

Dr. Rezmovitz: 0:40

I think there's going to be a lot of laughing today.

Dr. Selby: 0:44

I think so too.

Dr. Rezmovitz: 0:45

Um, okay, so we've had a lovely opportunity to, um, really banter back and forth for the last couple of minutes. And so, um, let's, let's just dive in.

Dr. Selby: 0:56

All right.

Dr. Rezmovitz: 0:57

Tell me, um, tell me a time that you noticed, um, something that needed to change. Something that happened to you, either in clinical or a, uh, educational setting that you thought,"You know what? We need to make a change."

Dr. Selby: 1:12

Well, there have been a few things during your career and I think if you're open to it and you don't get yourself ossified in your identity, uh, right off the bat, you will find opportunities that'll come up and you'll pay attention to them. So for me, there were quite a few, but realize they fallen to addiction issues, which were completely neglected in society, affecting what we were seeing in, in primary care. And so the first one that got me into doing addiction medicine was actually a patient who had both sickle cell and had a pain disorder and an addiction disorder, and we couldn't figure it out. And so I had to figure that out. And so took the training to, to figure that out. But even after doing that addiction and thinking that opioids, and those are the big problems in society, I saw something that really blew me away and it was in front of us and in front of my nose all the time, which was actually the addiction to tobacco and how it was devastating day to day patients in every discipline of medicine, including family medicine. So those are the things that I felt we needed to change because all we did was either stigmatize the patient or say you should or say what's wrong with you, don't you know it's going to cause you to die. It's causing all these problems, but not understanding why people were not able to change. And so that got me to study what determines change.

Dr. Rezmovitz: 2:33

Okay. Well obviously it begs the question, what determines change?

Dr. Selby: 2:39

Well, now that you ask, I think it's a, it's an interesting phenomenon and I think it looks like change occurs within the context in which the change is supposed to occur. And you can think about it that for change to occur in a, and I, you know, I think the work of Susan Mickey is really great to help understand the dimensions of this. Uh, one is that there has to be the capacity, general capacity to change as well: it has to be capable of changing. Uh, for specifically for that behaviour change that you want to have happen. There has to be obviously the opportunity for that change to occur because people get caught up in an environment which may or may not allow or promote. So there are opportunities and constraints that the environment bring. And then there's obviously the personal motivations that speaks to patients' values, their, their psychological makeup and their, and their abilities and their previous experience with change that determines that. So that's one when you can put it within the context of that individual, but then it's also dyadic in many ways because we as care providers also can be part of that, that change. We are the, we can be the facilitators of that change or the instigators of that change. So it's, it's, it's quite dynamic. So there are, you know, dynamic factors within, uh, within that person's sort of self as well as their, their meso environment. And then there's us who has a role as a provider in that.

Dr. Rezmovitz: 4:02

Yeah. Um, I liked the cut of your jib as they say. I like what you're talking about, um, about making sure that, you know, it sounds like motivational interviewing or the basis of it, you know, capability, um, making sure that the opportunity exists. Um, do you have a specific example, um, from your, um, experience, uh, with a patient per se that, um, you had an opportunity to, um, put all of that model that you've just explained in, into practice?

Dr. Selby: 4:31

Yeah, about 20 years ago actually I was asked, uh, to deal with this issue around tobacco addiction in patients with mental illness and especially people with schizophrenia. There was, you know, it was emerging evidence back then. These patients who had schizophrenia smoked at high rates, they smoked a lot and they were dying, uh, but 20, 25 years earlier than, than the general population, primarily from smoking related illnesses. So, you know, and starting the evidence, looking at the evidence and just looking at what the evidence suggested that suggested, well, offer them a patch. But you know, I had a patient who smoked five packs of cigarettes a day, that's a hundred cigarettes at a time, and I'm giving them a 21 milligram patch, which was in my mind, like putting a bandaid on somebody's gaping, you know, aneurysm that had burst and hoping that they, it would start stem the bleed. But anyway, that's all I had. So I gave him my sort of bandaid treatment of a single patch and the guy came back a week later and said, doc, it started working and then dropped out of treatment. But interestingly enough, came back a couple of weeks later saying,"Hey doc, you know what I did with the remaining patches? I put two patches on and I smoke less. And can I put on three?" And I said, you know, I was mortified because I expected, I said,"how come you're alive? You should be dead. You're not supposed to smoke on the patch." Because that was a common sort of belief that if you smoked with a patch on, you die. Uh, it, you know, it's fake news. Uh, but, uh, so he asked me about three patches. I did some research, couldn't find a lot, and I said, okay, well I'll monitor you. I'll observe you telling me what happened. Tell me what happened to your smoking. Tell me what it's like when you smoke with a patch on, watch for the symptoms of too much nicotine toxicity and come back and tell me. I had him come back almost every day and you know, he came and you know, we discovered that he went up to three patches. He smoked even less and then he said, my secrets aren't tasting as good anymore and I don't feel I can go long hours without smoking. And then we kept going up and we ended up at four patches and close to fight patches. Actually one day. And he completely stopped smoking. His vitals were fine, he was doing well. And uh, and then he sort of said, you know what, I don't feel like smoking anymore, doc. And then I noticed actually out outcomes. He looked different. He was coming in looking healthier because he was not coming in with dirty clothes. He was not coming with clothes. I had, you know, uh, cigarette burns in them. He had new clothes. And so I asked him, what's happened since you quit? And he says, well, I have money and I have money and I bought some clothes, I bought some new shoes, I'm eating fruits and vegetables. And I said, Hmm, this is really interesting. And that got me motivated to research more to look up studying it and actually studied it in an open label way. Used it and adopted it as a mechanism of dosing nicotine replacement and now studying it in a randomized control trial with placebo to see if this mechanism of uh, titrating your dose, uh, which we do in medicine all the time but hadn't been applied to this condition, um, could work. And that's what we've done. It actually sounds like you're doing a patient centered harm reduction strategy. Yeah. You could call it that. Yeah. Well it's patient centered and I think the issue is, you know, there's one thing to, to read and look at odds ratios and you know, numbers you to treat and what have you. But I'm actually interested in those numbers that didn't respond to the standard treatment because usually the numbers needed to treat, you know, are quite larger than the numbers who actually got benefit. And so I pay attention to that other group and say, well, what do we need to do? Adapt the treatment so it can work for this population? Yeah. That's applying the, um, a different mechanism to someone's context. Um, because not everybody's context is going to be the same. You know, not everyone's going to respond the same way to, um, pictures on cigarettes that, um, that say, you know what, you can get lung cancer from this. You know, that may work for, for 80% of the population. But what about the other 20%? Well, exactly. And what about the people who are buying contraband cigarettes and there's no picture warning for them to see anyway. So, you know, and, and again, you know that different strokes for different folks. And so I think as a physician, especially if you're working in primary care as a family doc, you need to understand your patient's context, their developmental context, that current context and adapt the evidence to meet their needs. Unfortunately, that takes a lot of time. Yeah, time. Time is an interesting thing. And I think that's the other innovation that I'm spending more time on now, both in education and in, in care delivery, is that, you know, if you look at the model of care that we have, which is going a hundred, 200 years or even longer, is it requires synchrony of time and space for that interaction. And early developments on that have been sort of, you know, of addressing the issue of, of geography and space is, is telemedicine and having virtual visits and what have you. Uh, but it still requires synchrony of the provider and that one to one patient. And I think given the complexity, given what's happening to people, uh, in addition, we need to have other models that allow us to address both the issues of, uh, time and S and geography so that, you know, use the power of technology and the internet so that people can get care at times that are convenient to them. Not Nestle when it's convenient to the provider and vice versa. But there are mechanisms for that to happen. And those are the kinds of research studies that I'm doing right now, uh, of using virtual care platforms whereby people can manage chronic disease. And when you say people, do you mean providers or do you mean patients? Both. You, you, you know, I think as a, as an, as, as a scientist, as somebody trying to intervene and create malls, you need to look at the entire ecosystem and that system. And in that system, it's the patient, it's the provider, it's the family members, the other assets in their community. And how do those all interact with each other and what are the dynamics between them and how can you facilitate that. So as much as the patient is the, is the focus, you also need to think about the provider, uh, also being the F the focus of these interventions so that they can, uh, they can actually, uh, provide the scale in a way that is meaningful to both and, and outcome driven. So the IHI, the Institute of health improvement has the triple aim or quadruple aim now and actually takes that into consideration. Yes. So my question then to you is, um, you sound like you're disrupting the current, um, traditional model of care. Have you had any pushback or challenges along the way because of this disruption? Because it's, it doesn't sound like a traditional model of a synchronous care. Um, you know, I think if you create a lot of anxiety and as I say, if you activate people's amygdalas, which means you activate theF fright flight of your response, you will get p ushback. And rightly so. Nobody likes to be, you know, made afraid about an uncertain outcome. U h, so part of this is to really spend time engaging people to understand and make the rationale a nd, and, and create that engagement. So that people willingly engage in this as opposed to, you know, coming in like a bull in a China shop and breaking everything up and causing a lot of distress. I don't think that's necessarily healthy right now. We've got a very stressed workforce. So I think the way to come to this is to come with a co-created solution that people want to participate in as a, as opposed to have assure assured almost. So when you say co who, who are the CO's, who should we have, who are the stakeholders that we should have at the table? So I think if you, if you actually pay attention to a integrated knowledge to action sort of cycle for implementation, everybody is a stakeholder right? From the funder to the program manager to the, you know, the implementer, whoever that might be, the team members, the patients, the families, whoever else you to identify all those people, they all have a stake in this supply chain. And so rather than just looking at it and it's a doctor patient in a very myopic way, pay attention to the broader system in which they find themselves. And look at that, that supply chain, because if that is aligned and there is something in it of value to each person in that supply chain, and it doesn't always have to be money, but there has to be value Capitol. Yeah. Or capital that that people can point to and appreciate. Then you start seeing the change happening in a much smoother way. Oh, of course. I mean instead of just focusing on the micro system or not realizing that the, you've been focusing on the micro system, recognize there's a macro system here, a musical system that's right. And then allow the alignment to occur at the micro system and then you'll see the results change at the macro system. Yeah. And, and a little bit of both, right. You're paying attention to this, the scale up effect or the leverage effect of this happening. And I think, you know, that's why we need to pay attention to the evidence that is emerging from QSI because it really speaks to the cycles of improvement as opposed to we get, we got to get it right the first time we do it. Oh, definitely. And so tell me about your success with this program. Well, you know, in my clinic we at chem H I can see a thousand patients. Uh, but I realized that okay, a year. Oh, okay. Oh yeah, I could see them with that. Well actually, you know, well maybe, but let me tell you this, you know, but there are sort of 2 million smokers in Ontario, the 5 million in Canada and I had limited funds from the ministry to actually create a program that could have impact. So I could have just been very myopic and said, you know, I'll create the best center right at Kemet and everybody has to come to Toronto from wherever they are. And the whole, we'll have to get it here. But what I did instead is take a look at the assets we have in a health system, like primary care, like a community addiction agencies like public health and do our programs that they could implement with expert guidance from us using technology. And so instead of me only thing, a thousand patients a year. Currently we are seeing 27,000 patients a year in Ontario. And we've just treated a quarter million patient across the province. That's about 10% of all smokers have been touched, treated by our program. So how do you do that? Well, I think there's a, you know, again, I'll go back to motivational interviewing. I'll go back to behaviour change. And I think part of it is first step is where you engage people where they are at, whether that's the health system and see where they are at, find common ground, find what's of value. Then elicit from them how they might implement this, this innovation. And so what I'm doing is imbalancing and helping them balance fit and fidelity. No, but is it a, um, is it an online program? Well, it's a, it's a computer decision support system that is an online portal that provides any healthcare provider the ability to assess the patient. Uh, we're using evidence based methods and then guides them in real time to the right treatment for that patient. So making something available for the patient, making something available for the provider within the team, creating systems so that it can be delegated to the right team member to do that and then have realtime outputs and outcomes, helps the, that system stay engaged in making an impact on their patients. And so this is for smoking cessation? Yes. Is there any way that we can adapt this kind of, have this computer assisted, um, system decision making system for other behavioural change? Um, uh, aspects. Uh, what's the word I'm looking for here? For other behaviours? Absolutely. In fact, we've, uh, you know, when I look at it, you know, working in smoking cessation has been a catalyst to help many of our primary care settings get engaged in behaviour change in a meaningful and measurable outcome. And because smoking over samples and gets to patients who are more likely to drink, have depression, have social disadvantage, have other chronic diseases, we've used that to actually, uh, add programs like, uh, brief interventions for alcohol on top of it, interventions for depression on top of it. We are now doing one for opioids and we're going to do one for what I lovingly call us my six pack for health promotion, which is smoking, drinking, physical active inactivity, nutrition, stress and sleep. And you take those six behaviours, they account for roughly, they affect about between 50 to 250 chronic diseases and they account for a loss of average of seven years of life lost in Ontario. And if we were able to help patients who often have these clustered behaviours change by paying attention to the biological determines the social determinants and the developmental determinants, uh, that could potentially change the way in which we manage, uh, our patients.

Dr. Rezmovitz: 17:12

Thank you. I want to thank you for coming in today. We're, we're unfortunately out of time, but I just, do you have any last words that you want to tell our listeners, um, that you'd like to leave them with?

Dr. Selby: 17:24

Well, I think it's to be open and pay more attention to observing your patients on what's- and whoever your stakeholders are around you and contextualize the evidence that you read, uh, so that you're not married to one over the other. And that you actually combined the two in how you make your decisions with your patients.

Dr. Rezmovitz: 17:46

Couldn't have said it better myself. Peter, thank you so much for joining us today. I look forward to seeing the results of the paper and the program that, uh, you talked about today. Thank you so much. Thank you, Jeremy. Thanks for having me. Have a great day.

Dr. Selby: 17:59

If you'd like more information, visit www.nicotinedependenceclinic.com. This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullin, Brian Da Silva, and the whole podcast committee. Thanks for tuning in. See you next time.