To Each Her Own—A Call for Individualized Medicine

Behavioral Medicine is about the interaction of everyday behavior with medical treatment. One study, for example, found that more introverted persons tend to have longer hospital stays—they enjoy the relative quiet and inactivity. So why hurry up the healing process—slow down and enjoy the stay! In contrast, more extraverted patients tend to be itching to get out and return to their action. If you are a hospital administrator, then you likely would want to call your team together and brainstorm appropriate ways to nudge more introverted patients towards discharge.

Using behavioral information to shape medical treatments would necessitate administering a personality assessment before planning such treatments, plus acquiring a knowledge of the research on behavioral medicine. I have long urged that healthwrong size care providers maintain information from a behavioral personality assessment for review before committing to a treatment plan for an individual patient. Where a trait supports traditional treatment—no problem. Where a trait works against traditional treatment modalities—create an alternate, or supplemental, plan that works like a crutch in support of healing. The treatment must fit the patient, just as the clothing, bicycle, helmet, and so forth, must fit the person.

My wife’s recent surgery illustrates this trait-treatment interaction. The traditional treatment modality for her procedure entailed two days of surgery followed by three days of in-patient rest, physical therapy, and observation. Then discharge.

That treatment approach assumes that the patient is able to ignore significant post-surgical pain levels (seven to ten on a ten point scale) and proceed with physical therapy (i.e., getting out of bed and back down again, wearing a brace and sitting in a chair, walking the halls, stepping up stairs, and the like). Jane exhibits a low level of the Big Five trait called Need for Stability. This means that she is minimally reactive to stressors—a trait that supports working through pain. The surgeon was pleased with her progress.

In contrast, he related to us that some patients who have experienced significantly less invasive and traumatic surgeries, and with somewhat lower pain levels, have taken several days before they were even willing to try getting out of bed, much less walking the halls and stair-stepping. The reason is that they worried that their hurting body was just not up to the physical demands, that they would suffer physical harm if they tried much movement, that they might fall apart, as it were. Such patients likely have higher levels of the Need for Stability trait—they are emotionally reactive. Persons with higher levels of Need for Stability tend to augment the negative, while persons with lower levels tend to minimize the negative. The former is helpful in alerting the doctor that something’s wrong, while the latter is helpful in facing painful therapy.

pain continuum

That’s Individual Differences 101. Persons low in Need for Stability find it more natural to work through intense pain to begin the hospital’s traditional approach to physical therapy. Patients low in Need for Stability do not take to the traditional approach, one which is designed for a highly-motivated, tough-as-nails personality accustomed to ignoring pain. This is not a problem with the patient, but rather a problem with the one-size-fits-all approach of the surgical/therapy team. There was nothing wrong with the other patient’s reactivity—being alert to the body’s signals can be a lifesaver. We had a calm friend in Europe who had uterine cancer but minimized the discomfort for months, thinking it a mild form of influenza. She died shortly after it was diagnosed. If she had been an augmenter, she would likely have lived.

So, what could the surgeon’s treatment team have done to facilitate treatment? Well, reactive people like to emote and get support from others. Emoting is their strength. Knowing what a hospital stay is typically like (I’ve stayed in the hospital room 24 hours a day for each of my wife’s back surgeries), I know that patients have precious few moments for meaningful conversation—lots of darting in and out. How about a patient support group—an area where they could wheel several of their more reactive and outgoing patients to talk among one another about their aches and fears, their hopes for a positive outcome, and what they must do to aid the healing process? Misery loves company, and talking it out tends to relieve the stress and build up confidence.

In a similar manner, two friends had bariatric surgery—stomach by-pass. Both friends initally lost 100 pounds. One gained it all back, while the other kept it off. The follow-up treatment required eating only ¾ cup of food per meal—well-balanced food, that is. One was a perfectionist (we call that being high in C1: Perfectionism in the WorkPlace Big Five Profile). The other was the opposite of a perfectionist (low in C1)—more casual in adhering to quality standards. The perfectionist followed the nutritional guidelines to a “t”—minimal sweets, low carbohydrates, ample protein, plenty of green leafies. The other abandoned the nutritional guidelines as soon as the 100 pounds disappeared. She devoted her life to mayonaise, cream, and sugar, with the result that she regained all the lost weight. The perfectionist to this day adheres to her nutritional regimen—she stays full, is rarely if ever hungry, has occasional sweets and alcohol—and the weight has stayed off.

The success of the traditional treatment plan for such bariatric surgery depends on patients being temperamentally suited to following a regimen, and C1: Perfectionism supplies that temperament. In this case the treatment team needed to plan a support mechanism to assist the non-perfectionist—some kind of crutch was needed. This could have been accomplished by instituting an externally imposed regimen that minimized her self-defeating impulsivity, such as a refrigerator-stocking plan, a peer-counseling partner with weekly support get-togethers, an online support group, a six-days-on/one-day-off approach, a catered meal service, and so forth.

Recidivism could be reduced appreciably if treatment planners would take individual differences into account. Of course, trait levels are not the only influence on the success of traditional treatment outcomes. Family context, support systems, finances, work demands, basic intelligence, physical stamina—all, and more, play a part. The positive feature of addressing trait levels is that they are relatively easy to understand—if a person is a loner, leave them alone, but if they are sociable, it’s party time!maimonides

I think perhaps there’s a book in this. I’ve not seen a behavioral medicine guide for health care providers and home nurses (including family!). Maimonides wrote The Guide for the Perplexed. Perhaps I can do a Guide for the Complex Patient. If you know of one, please make me aware. Time’s too short to do what someone else has already provided.

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  1. Baird Brightman
    June 18, 2015 at 10:33 am

    This book may be worth exploring Pierce:
    http://www.amazon.com/Personality-Guided-Therapy-Behavioral-Medicine-Psychology/dp/1591470439
    I think it would be very worthwhile for you to develop a Healthcare Report based on your excellent personality assessment that gives a patient and their medical provider guidelines for optimizing the treatment from a behavioral perspective. I look forward to seeing what you do with this topic.
    Baird

    Baird Brightman PhD @ Worklife Strategies (www.wklf.com)

  2. piercehoward
    June 18, 2015 at 11:29 am

    Thanks, Baird! I have ordered the book (it is part of a series, actually) and will prepare a special report based on contents. Cheers!

  3. Clark Phipps
    June 18, 2015 at 1:50 pm

    Pierce, I always enjoy reading your blog, and I think this is a very appropriate series of questions to ask. Thank you for having an open mind and surfacing new ideas to the rest of us!

    Clark

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