Zen and the Art of Patient Activation

Somewhere in a health system in Florida there is a woman with type 2 diabetes who has had her A1c drawn every year for six years running. She has never had a urine albumin test.

Her own guideline says she should have had six of them. The test is cheap, it is fast, and it is the one thing standing between her and a diagnosis of chronic kidney disease early enough to matter. Nobody ordered it. She did not refuse it. She is not sitting at her kitchen table weighing one brand against another. She simply did not finish a path that medicine laid out for her years ago, in writing, with numbers attached.

I think about her a great deal, because almost every dollar our industry spends is spent somewhere else.

The classical view of a patient

In Zen and the Art of Motorcycle Maintenance, Robert Pirsig built a whole book on the difference between two ways of seeing a motorcycle. The romantic sees the shape of the thing, the ride, the chrome, what owning it means. The classical sees the underlying form: the parts, the tolerances, the order in which things have to happen for the machine to even run at all.

Healthcare marketing is almost entirely romantic, and I say that as one of its practitioners. We are exceptionally good at what a brand means. We are good at positioning, at message architecture, at the emotional register of a product launch. And we may be the finest in the world at making a mechanism of action feel like hope. We spend hundreds of millions of dollars a year in that register, and we spend it against the hardest population to move: the patients already in front of a physician, already diagnosed, already choosing, where our drug and two others are all defensible answers.

The classical view of a patient looks nothing like that. It is a sequence. A risk factor documented. A screening test ordered. Then completed. An abnormal result confirmed by a repeat test at three months. A stage assigned. A therapy started. A therapy documented as having failed to move the number it was supposed to move.

Every one of those is a discrete clinical event with a date on it. Every one of them is already defined, in specific terms, by a guideline your brand already sits inside. Chronic kidney disease begins at an eGFR under 60, or a urine albumin-to-creatinine ratio at or above 30, persisting past three months. Nephrologists wrote the definition, health systems adopted it, quality programs encode it, and it sits in the workflow whether or not your brand ever shows up.

Start at the end and walk backward

Here is an exercise I would ask any brand team to run.

You will end up with something that looks less like a funnel and more like a checklist, and the checklist will not be yours. You will have simply transcribed a guideline that already existed.

Then look at your real-world data and find out how many patients complete each step, and you will find the same gaps in care everywhere. Some steps never got taken. Every one of these patients is carrying steps their own care plan says they should have and never received. Call it guideline debt. (Hard pitch: And this is exactly what Essence is the expert in: identifying gaps in care and activating patients to complete them.)

What activation actually is

This is where the word zen earns its place, and I mean it in the older sense of not fighting the machine.

The pathway already exists. A woman with type 2 diabetes and no albumin result on file is, by her own health system’s quality logic, already overdue. The order set exists. The lab exists. The visit type exists. The portal she has never logged into exists. Every part of the machine that would carry her from where she is to a diagnosis is built, staffed, and running. What is missing is smaller than any of it. She has not been asked, at a moment when she could act, to take the next step.

So that is the whole of the work. Finding the patients standing at a defined step who have not taken it and giving them a reason to take it.

What strikes me about that is how little it asks of anyone. There is no argument to win. There is no preference to shift, no competitor to displace, no clinician to re-educate, no behavior to invent. The patient is not resisting. Her physician is not resisting. Her health system has already written down, in its own quality logic, that this step should happen. Everyone involved agrees on what comes next and has agreed for years. The sequence simply stopped, quietly, at a step with a name and a date.

Anywhere medicine has written down what should happen and in what order, there is a version of this, a step with a threshold attached and a population that has not cleared it. Vaccination series that stop at dose one. Screening intervals that quietly lapse. Patients on a therapy for a year that stopped working in month three. Each of those is a defined step and a countable population, sitting underneath a goal somebody is already accountable for.

The exercise itself is not complicated. An outcome, walked backward, with the indicator written down at every step, and then a count of how many patients are standing at each one. I have run it enough times to say that the counts are usually worth the afternoon it takes.