“Cogito ergo sum”—“I think, therefore I am” was René Descartes’ most famous dictum. But perhaps a more fruitful line of inquiry would have been—“I believe, therefore I do”; a brief summation of what behavioral science has taught us about behavior change. Our beliefs are powerful predictors of how we act. This important insight has been given additional relevance in the work by Street and Haidet in this issue of JGIM, showing how poorly physicians seem to do at predicting the belief structures of their patients, and by implication, how poorly they are able to anticipate their intentions and actions, never mind how best to support them in managing their illness.
In the late 1980s Greenfield and colleagues published several seminal studies that demonstrated the powerful potential effects of a patient activation intervention on chronic disease outcomes. In one of these studies, patients with diabetes who were randomized to an activation intervention prior to a consultation were more active in negotiating decisions with their physicians and subsequently had HbA1c values that were 1.5% lower than those in the control group. These studies are among the most widely cited ones in the larger literature on patient-centered care. Although subsequent studies have not always demonstrated the same powerful effects, researchers have shown considerable interest in fostering patient activation. Several recent studies have continued to generate evidence in favor of fostering patient activation to improve health outcomes, especially among patients with diabetes. Nevertheless, patient activation interventions have yet to be widely implemented in our health care system. Part of the reason why these interventions have not been widely disseminated may be that the mechanism of the activation intervention is unclear. What might lead an activated patient to have better long-term outcomes? A recent observational study found that patients who were more activated had better subsequent adherence to their treatment regimens, leading to better outcomes. But why would an activated patient become more adherent?