Visits can be more productive when patients set the agenda
First in a three-part series: Motivational interviewing is one technique for engaging patients and developing strategies that work
From the March ACP Internist, copyright © 2008 by the American College of Physicians.
By Bonnie Darves
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A 52-year-old male with diabetes and worsening obesity dependably shows up for appointments but appears unmotivated to address the lifestyle factors that have caused his disease. If ignored, his behavior will soon land him in serious health trouble. He takes his prescribed medications sporadically and hasn’t started the exercise program his doctor has been recommending for three years.
Sound familiar? For many internists the scenario is a frustrating reality of everyday practice. However, some are discovering that a more collaborative approach in the exam room may prevent such patients from being written off as lost causes.
“Clinicians often assume those patients are unmotivated to lead a healthier life, when the real issue may be that the patient faces barriers to making changes,” said William Polonsky, PhD, a University of California-San Diego psychologist whose work focuses on patient self-management in diabetes. “The fact that they show up for the visit means they are at least somewhat motivated, but unless the visit includes the patient’s own personal concerns and agenda,” it’s unlikely the clinician will uncover those barriers.
Let the patient guide treatment
Motivational interviewing addresses that disconnect by encouraging physicians to ask open-ended questions and actively listen to what the patient has to say. For example, rather than starting the visit by rattling off test results, the internist might instead ask the patient what he would like to accomplish, and how he feels he is managing his diabetes. If the patient expresses dissatisfaction with the way things are going, the internist would attempt to tease out what the patient finds difficult.
Motivational interviewing encourages physicians to ask open-ended questions and actively listen to what the patient has to say
“If you start with the patient’s agenda, you guarantee they’ll be more engaged in the encounter,” Dr. Polonsky said. The idea behind motivational interviewing is that if the patient and clinician work together to set the agenda and identify health-improvement goals (and potential barriers), the relationship changes for the better.
Bob Mead, MD, a family practitioner and president of Bellin Medical Group in Green Bay, Wisc., is a case in point. “We’re not telling patients what to do anymore, but instead letting them sort of solve their own problems—with our help,” he explained.
For example, Dr. Mead said, when he was “doing things the old way” he would walk into the room, tell Mr. Smith that his blood sugars were off and his blood pressure too high and then propose a course of action. Typically, that meant increasing the antihypertensive medication dose and giving the “exercise rap”—again. Now, he starts by asking the patient how he thinks he is doing and whether he has any goals for his health, and linking those responses to test results. Depending on the patient’s responses, Dr. Mead might venture a third question: “Are there things you are doing for your health that you might do better on?”
“If the patient is still balking about having goals, I prompt him and say, ‘How do you see yourself staying healthy—or getting healthy?’” The idea, he added, “is to pin down the patient to get him to identify a more concrete goal, and how likely he thinks it is that he can achieve it. And that determines where we go from there.”
One of Dr. Mead’s patients, for example, came up with the goal of decreasing his McDonald’s meal consumption from nine times a week (he had to count them, Dr. Mead recalled) to twice weekly. “If you’re a busy clinician, you would not be asking your patients how many times they go to McDonald’s,” Dr. Mead said. “But it worked—and by the next visit the patient had lost 30 pounds. And for me, that becomes a totally different visit. It’s more personal and it really changes the interaction.”
Alan Glaseroff, MD, a Eureka, Calif., family practice physician, cited a similar experience with a diabetic patient. In response to his open-ended question seeking her health-improvement ideas, she said, “Maybe I should be exercising more.” He then asked her why she thought exercising was important, and asked her to propose an exercise plan she felt she could achieve.
“It’s a lot less of telling patients what to do and more of drawing out of them what they want to do but are ambivalent about.”
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“It’s a lot less of telling patients what to do and more of drawing out of them what they want to do but are ambivalent about,” he said. “The point is to let the patient say what she is willing to try.” Three months later, Dr. Glaseroff’s patient had her diabetes under better control and, perhaps more importantly, was feeling much more positive about herself.
“Motivational interviewing is about the spirit you bring to conversations with patients. It’s about being collaborative,” Dr. Polonsky observed, “When used effectively, it changes the relationship from a sense of wrestling with them to dancing with them.”
For the internist used to operating in the didactic “driver’s seat” mode, making that switch can be difficult. But it’s more readily doable than many think, and if those collaborative conversations involve more time initially, they save time ultimately, Dr. Mead suggested. Patients who’ve become more engaged in their own illness management tend to adhere more to treatment and prepare more for the visit.
“We’ve found that patients work on their goals and they achieve better results,” Dr. Mead said. “They’re improving their diabetes without adding fancy technology or without me manipulating their insulin or adding new medicine.”
And when patients come in for a visit, he concluded, “They’re not only better prepared—often they even want to know what their numbers are. In a sense, the ownership [of the visit] has changed a bit, from us to them.”
Three techniques for motivational interviewing
.Simple reflection. This involves carefully listening and then feeding back what the patient has said, to ensure she knows the physician is listening, and acknowledging the patient’s ambivalence (if cited). For example, if a patient says he ought to quit smoking, but considers it too difficult because “All of my friends smoke,” the internist might say, “So you’re interested in quitting smoking, but it just seems too hard right now.” That lets the patient know that the physician isn’t judging or blaming him, but is instead listening closely.
Elicit, provide, elicit. This technique involves asking the patient an open-ended question that seeks to draw out the patient’s thoughts on a particular subject., then asking the patient if the internist may “share some information” about that issue. If the patient says she is concerned about her high hemoglobin A1c level, but isn’t sure why it’s important, the internist might then explain the association between A1c and diabetes progression. The clinician then proceeds to elicit the patient’s response to the information provided. In this manner, a potentially boring lecture is transformed into an engaging, collaborative conversation.
Summary statements. One major use of this technique is at the end of the visit. When a physician provided a summary of what has been discussed, focusing on whatever plan for action has been developed collaboratively, the patient is more likely to have felt heard to and to be enthused about further self-management actions. For example, if the patient has said that his goal is to lose 30 pounds and that he will start walking twice a week for 45 minutes, the internist recaps that information. For example the doctor can say “Just want to be clear on what we’ve discussed today: We talked about your goal of losing 30 pounds, and your action plan to begin taking two 45-minute walks a week. Do I have that right?” A nurse can review goals with the patient at the end of the visit, and later follows up by phone to see how it’s going.
Additional resources
.“Techniques for Effective Patient Self-Management,” a free 30-minute video produced by the California HealthCare Foundation that describes the basic principles of motivational interviewing, and demonstrates its techniques through actual patient encounters. To order, call 510-258-1040 or visit www.chcf.org/topics/chronicdisease/.
Motivational Interviewing in Healthcare, by S. Rollnick, W.R. Miller and C.C. Butler, published by The Guilford Press, New York (2008), which provides an overview of motivational interviewing, and the scientific evidence supporting its benefits.
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