The Secret to Patient Compliance: An Application of The Four Tendencies Framework

This report is a summary of a webinar presentation by Gretchen Rubin, author ofThe New York Times畅销书《四种倾向》、《比以前更好》、《幸福计划》和《在家更快乐》。

Gaining an understanding of how other people think and operate can allow healthcare professionals to communicate more effectively, and, ultimately, enable patients to make good healthcare decisions.The Four Tendenciesis a personality framework developed byThe New York Timesbestselling authorGretchen Rubin将人分为四种不同的类型:支持型、质疑型、义务型和反叛型。一个人的倾向会影响他行为的各个方面，所以理解这个框架可以帮助人们实现目标，满足期限，更有效地参与，等等。

This report covers the following:

1. 四种倾向的概览。
2. An understanding of how these tendencies can affect behavior in a healthcare setting, particularly patient compliance.
3. 与不同倾向的病人和同事一起工作的实用技巧。

The Four Tendencies

One of the challenges healthcare professionals face every day is determining how to get people, including themselves, to comply with health guidance or recommendations. The Four Tendencies framework can make this task easier by revealing how each person responds to expectations. By asking this question, healthcare practitioners can gain exciting insights into how patients respond to expectations to in order to help them achieve their goals.

Everyone faces two types of expectations: outer expectations, such as a work deadline or a request from a friend; and inner expectations, such as the desire to keep a New Year’s resolution or start a meditation habit. How someone responds to the combination of outer and inner expectations determines his personality profile. When we know how others respond to expectations, we have a better understanding of how to help them be more effective.

Each of the Four Tendencies deal with expectations differently:

• AnUpholderreadily meets outer expectations but struggles to meet inner expectations. Upholders keep their New Year’s resolution without much difficulty. They want to know what people expect from them, but their expectations for themselves are just as important.
• AnObliger满足外界的期望，但努力满足内心的期望。这类人知道如果他锻炼就会更快乐，但却不能让自己定期锻炼。他在学校时可能是运动员，当他加入球队时，他从不缺席训练。
• AQuestionerinvestigates all expectations–both outer and inner. Questioners want to do what they think makes sense and resist anything they deem to be arbitrary or inefficient. They always want to do know why they should do something, so they make everything an inner expectation. If it meets their inner standard, they will follow through. If it fails their inner standard, they will resist.
• ARebel抗拒所有的期望，无论是外在的还是内在的。他们以自己的方式，在自己的时间做自己想做的事。反叛者不喜欢别人告诉他们该做什么，甚至不喜欢告诉自己该做什么。例如，Rebel不会在周六报名参加动感单车课程，因为他不知道自己在周六上午10点想做什么。

The Four Tendencies and Patient Compliance

One of the challenges in healthcare is that patient behavior is the biggest factor in determining length and quality of life.Roughly 40 percent of how long and how well people live is determined by personal behaviors. In comparison, traditional healthcare delivery has very little impact–around 10 percent. Because the Four Tendencies framework can indicate patient motivations and behaviors, it can be an effective tool to encourage healthy behaviors.

As the healthcare industry shifts towards population health and value-based care strategies, practitioners are thinking more about preventative health than they ever have before. Once healthcare professionals have a basic understanding of the Four Tendencies, they can begin thinking about how it affects healthcare patient compliance and discover unique ways of communicating with patients.

Can we reduce healthcare costs as a result of more people adopting healthier lifestyles? Can we prevent a patient from ending up as a diabetic? This framework is extremely applicable as we think about population health strategies.

Patient Motivations and the Four Tendencies

Upholders都是自我指导的，所以在大多数情况下，他们会忠实地听从建议服药、锻炼、改善饮食，以及在其他方面依从。

• 他们可能会经历“收紧”，规则不断收紧，直到他们不堪重负(所以医疗专业人员不应夸大健康预期)。
• 他们接受规则和时间表。
• They can come across as rigid, cold, or judgmental because they don’t understand why other people are struggling.

Obligers需要监督、截止日期和监控。医疗专业人员应确保关键的问责制度到位。

• Obligers may fall into Obliger-Rebellion if overwhelmed, which can cause them to resist health-related advice, such as changing diet and exercise.
• Obligers can often do for others what they can’t do for themselves.

Questionersput a high value on reason, research, information, and efficiency, and will meet health expectations only if convinced of the justification.

• 他们只有在尊重“权威”的专业知识的情况下才会听从他/她。
• 他们通常喜欢定制，所以他们可能不遵守规定的指示。
• They tend to enjoy monitoring their actions, which can be useful in healthcare.
• They can drain and overwhelm others with their need for data and information.
• They get caught in “analysis paralysis”–the desire for more and more information prevents them from making decisions.

Rebels喜欢做任何他们想做的事情，然而，如果有人要求或告诉他们做某事，他们很可能会拒绝。他们可以受到反抗精神或对自己身份的诉求的鼓舞。

• 他们对监督、提醒或指示反应不好。
• They resist routines.
• 他们经常抗拒自身条件的要求。
• They can often be manipulated to act out of resistance.

Four Scenarios Applying the Four Tendencies Framework in Healthcare

This framework is an excellent tool for thinking through different ways to interact with patients based on their tendencies. Looking at some specific healthcare scenarios, different ways of communicating may be more effective in achieving better results for specific patients.

Scenario 1: How to Get A Rebel Patient to Take His Diabetes Medication?

医疗保健专业人士知道药物有效——有临床研究证明这一点。然而，人们往往很难遵从医生的指示。这通常归结为沟通的方式不能与特定的病人产生共鸣。在叛军的案例中，服用糖尿病药物是医生的命令。他们不喜欢别人告诉他们该做什么，所以这是不可能奏效的。Instead, there are a number of other communication methods that are more effective for Rebels:

Appeal to Their Identity

Rebels have a strong identity. Appealing to their identity can make taking their medication seem like their choice and thus be more effective. For example, a doctor could say to this patient, “You’re a strong, healthy person. You want to travel the world. You’ve got a million things you want to do. This is going to get in your way. Don’t you want to continue that lifestyle?” The doctor should remind them that taking their medication will help give them the life they want.

Information, Consequences, Choice

The sequence of information, consequences, choice can work well with Rebels, especially in terms of healthcare. First, healthcare professionals should give them the information: “You have diabetes.” Next, they should provide the consequences: “If you don’t treat your diabetes, you increase your risk of many serious health problems most of which are entirely preventable if you keep your blood glucose in a healthy range.” Lastly, the professional lets them choose. “Taking this medication will help keep you healthy.” Although it may seem severe to leave the decision to the patient, caregivers should remember that pushing or reminding Rebel patients to do something ignites the spirit of resistance.

Try a Challenge

A challenge can work well with some Rebels. They can be inspired by the spirt of resistance. For example, a care manager might say, “The doctor said he likes what he’s seen, but he’s not sure if you can stick with it for a year. I’ve seen you do amazing things when you put your mind to it, so I don’t know?” If it’s in the form of challenge, it just might work.

情景2:如何让一个有义务的人改善她的饮食习惯?

Knowing someone is an Obliger is a hugely important piece of information to have, because while the Rebel might resist accountability, for the Obliger accountability is essential.

Obligers are very different from Rebels in terms of what accountability looks like. Some of these patients might even be accountable to their future selves. For example, she might say to herself, “Well, Now Gretchen doesn’t feel like doing this, but think about Future Gretchen. A year from now, she’s going to be really upset if she hasn’t stuck with her diet.” Their duty to be a role model for someone else often motivates them follow through on something they think is important. A caregiver might prod, “Sticking with this will show your family that you’ve made health a priority.”

外部问责制对大多数义务人来说是非常有效的。他们可以加入许多技术解决方案、应用程序或团体，帮助提2022卡塔尔世界杯赛程表时间供坚持健康习惯所需的问责制。

Scenario 3: How to Get a Questioner Employee to Participate in a Corporate Wellness Program?

Many corporate wellness programs are designed perfectly for an Obliger. These programs generally provide outer accountability with apps and team-based competitions, but they provide little motivation for Questioners.

Once Questioners have bought into something, they usually execute well. They don’t need accountability the same way that Obligers do. They need reasons and research behind what they’re being asked to do. The best way to get a Questioner to participate in a wellness program is establish credentials of the program and show why it is the most efficient up-to-date solution. They will resist anything that seems arbitrary. For example, many programs encourage the 10,000-steps/day goal, but the Questioner might say, “Why 10,000 steps?”

The Questioner employee needs links, pamphlets, data, etc. that support the reasons behind what they’re being asked to do. And, ideally, the program will be customized for their needs. Once they have the justification and they’ve bought in, they will follow through.

Scenario 4: How to Keep an Upholder On-Track When Expectations Change?

Upholders are very good at executing goals and probably the easiest tendency to keep on track. But, their rigidity may get in the way. Healthcare professionals should not exaggerate expectations as Upholders can easily become stressed or overwhelmed. In the case of a corporate wellness program, Upholders may resist systems they feel are unnecessary measures of accountability. Their ability to fulfill expectations on their own can be great, but can also be rigid. Changes in rules or expectations can demotivate or upset them because of their strict adherence to schedule. Despite these challenges, Upholders tend to be ideal patients in terms of patience compliance.

How to Determine Someone’s Tendency

知道有更有效的方式与四种倾向进行沟通，你怎么知道一个人的倾向是什么?A more in-depth description of each personality profile is available inThe Four Tendencies book,the quiz, or theone-page flash guide. There are also clues to look out for that can reveal someone’s tendency, such as when someone says that something is “arbitrary.” That is a big sign of a Questioner. Any time someone uses words like “self-care.” or “make time for myself,” that person is usually an Obliger.

反叛者经常会提到自发性或做他们想做的事情。如果一个病人说，“我已经看过三个医生了，我不能按他们说的做。我必须以我认为合适的方式过我自己的生活，这是一个叛逆者的标志。支持者的标志通常不是具体的语言，而是他们思考事情的方式。如果他们看起来非常热衷于执行某件事，那可能是一个维护者。

In healthcare, the idea that there’s a magic one-size-fits-all solution is outdated and ineffective. Instead, healthcare is becoming more personalized and targeted, and the Four Tendencies provides a framework for personalization that can lead to better outcomes.

Additional Reading

你想了解更多关于这个话题吗?Here are some articles we suggest:

1. The Top Five Recommendations for Improving the Patient Experience
2. Unleashing Patient’s Power in Improving Health and Care