American Medical News
By — Posted Feb. 18, 2013
Achieving superior clinical outcomes often depends less on physicians making the right diagnosis and recommending the correct treatment and more on their patients' willingness to take the necessary steps to maintain or improve their health.
Heart disease, cancer, stroke and diabetes together kill more than 1 million Americans each year, according to the Centers for Disease Control and Prevention. And it is patient choices — to give up smoking, shed pounds, exercise and faithfully take prescribed medications — that are essential to making a meaningful dent in that deadly toll.
But despite their best attempts to educate, inform, cajole or bargain with patients, physicians often find themselves tossing up their hands in despair at patients' failure to change their harmful health habits. “It's a source of great frustration,” says Yul Ejnes, MD, a general internist in private practice in Cranston, R.I.
Doctors have long hoped that developing a rapport with patients would help their messages finally sink in and prompt change. Now a growing body of evidence suggests that alternative ways of communicating with patients — ones that involve fewer instructions and more questions — can help physicians motivate at-risk patients to make smarter choices regarding their health.
Even when there are breakthroughs with noncompliant patients, it is not always clear what words the doctor might have said to tip the scale toward change. Dr. Ejnes recalls an overweight, middle-aged patient of his with hypertension and diabetes who refilled his medications but was haphazard about coming in for follow-up visits.
“I had been taking care of him for 10 years and he was kind of sputtering, with his numbers marginally under control,” Dr. Ejnes says. Then, one summer the patient's glycated hemoglobin spiked.
“He came in, and I pretty much laid it on the line: 'This is what's going to happen if you don't do something,' ” Dr. Ejnes says. “He was a smart man, and I suggested he start going to Weight Watchers.”
The patient followed that advice, lost 40 pounds, and gained a great deal of self-confidence as well as better control of his chronic conditions.
“Something in that conversation clicked,” Dr. Ejnes says. “I don't think I told him anything he hadn't heard before, but when you turn up the dial a bit on the probability, it can get through. It's like when you're watching the news and they say the possibility of a hurricane strike is 60% instead of 10%. Well, at some point you say, 'We better bring in the yard furniture.' ”
In that case, the get-healthy-or-else approach seemed to work well, but Dr. Ejnes acknowledges that there are some patients who steadfastly refuse to budge. Some physicians seek new methods, such as motivational interviewing, to communicate with such patients. It starts with recognizing that when it comes to changing behavior, it is the patient, not the doctor, who knows best what the barriers are.
“As physicians, we have some specific knowledge about illnesses, how to make a diagnosis and how to treat illness,” says Paula Lozano, MD, MPH, a pediatrician and assistant medical director in the Dept. of Preventive Care at the Group Health Research Institute in Seattle. “But the patients are the specialists in their lives.” They are the experts on how well advice regarding physical activity, medication or smoking will work in their daily lives, she adds.
Lasting patient change, Dr. Lozano and other proponents of motivational interviewing say, comes not when doctors tell patients what to do but when patients decide for themselves that it is time to try something different.
“Motivational interviewing just gives me a place to start,” says Frank J. Domino, MD, professor in the Dept. of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester. “Typically, when doctors approach patients about habits that are unhealthy, they do it in a parental-type way. My first goal in using motivational interviewing is for you, the patient, to identify what you want to do. This takes that paternalism away.”
The approach, proponents say, also reduces patients' resistance to change by allowing them to voice their ambivalence about it. Physicians who empathize with patients' hesitation then can establish themselves as allies in searching for achievable steps.
“The first piece is getting patients to talk about why they want to change and then trying to get them to rate their confidence, and the importance they see in changing,” Dr. Domino says. “Then you ask them to try to identify one thing they could change that is simple to move them up the continuum.”
The motivational interviewing concept is spreading within medicine, with many medical schools covering it during “On Doctoring” courses during the first two years. And research shows that the method, first developed in the 1980s by psychologists to counsel patients with substance abuse problems, has promise for application in treating other medical conditions. A March 17, 2010, Cochrane Collaboration systematic review of 14 studies involving more than 10,000 smokers found that patients who were exposed to motivational interviewing were 27% likelier to quit compared with patients who got usual care or brief advice.
An April 2005 systematic review published in the British Journal of General Practice found that 80% of 72 randomized controlled trials demonstrated a clinically relevant effect of motivational interviewing in lowering body mass index, total blood cholesterol and systolic blood pressure. Yet another systematic review, focusing on weight loss and published in the September 2011 Obesity Reviews, analyzed 11 randomized controlled trials. The study found that overweight or obese patients exposed to motivational interviewing lost 3.24 pounds more than did patients who received only typical counseling.
Physicians should consider how they can change their counseling styles to help motivate their patients, says Kim L. Lavoie, PhD, who has trained more than 5,000 physicians and other health professionals in motivational interviewing.
“We're all dying because of chronic disease because of bad behavior. It's not enough to go see the doctor once a year and have him tell you what to do. It's not that people don't know what to do, it's that they don't do what they know,” says Lavoie, co-director of the Montreal Behavioural Medicine Centre in Canada.
Lavoie advises physicians to ask open-ended questions, listen to patients' answers and avoid doing all the talking in the exam room. Instead of arguing with, lecturing or interrupting patients, doctors should summarize what patients are saying about the challenges they face, and encourage them to develop solutions that work for them.
“It's about collaboration, rather than talking down,” she says. “It's not an expert talking down to the subordinate patient, saying, 'Just go home and lose 20 pounds and quit smoking.' It's working with the patient to make them more engaged in their health.”
One big barrier to better health habits is that patients who struggle to manage chronic conditions are likelier to have symptoms associated with depression. These patients often feel discouraged about the efficacy of actions such as adhering to medications, says Gbenga O. Ogedegbe, MD, director of the Center for Healthful Behavior Change at New York University School of Medicine.
“Cognitively, if I'm so depressed, then my ability to positively appraise my situation is dampened,” says Dr. Ogedegbe, professor of population health and medicine at NYU. “If that's dampened, it follows that my confidence, judgment and capability to carry out the desired task is impaired.”
Dr. Ogedegbe is the lead author of a study published Feb. 27, 2012, in Archives of Internal Medicine, now JAMA Internal Medicine, which showed that inducing positive feelings among African-American patients with hypertension made an impact on medication adherence. All 256 patients in the study were given educational materials about hypertension and the importance of adherence. The patients in the intervention group also got bimonthly phone calls. They were asked to identify small things in their lives that made them feel good and to reflect on those positive feelings while going about their daily routines.
Though less than half of all the patients were compliant with their blood pressure medication regimens, the patients who got the feel-good phone calls were 17% likelier to be adherent, the study found. These good-feelings exercises may be especially helpful for patients who don't trust the medical system, Dr. Ogedegbe says.
“If you're thinking about when you got married, when you had your first child, and you're thinking about those proud moments, it invokes a positive affect that then makes one much more open to receiving health messages that would otherwise be threatening,” he says.
Dr. Ogedegbe plans future research and hopes to show that positive-affect interventions help improve patients' blood pressure control as well as drug adherence.
In the broader area of motivational interviewing, there is a lack of clarity in the literature about the “dose” of this kind of counseling needed to make an impact. Some studies have found success with relatively brief physician sessions of 15 minutes over several weeks, while others involve more in-depth visits with health psychologists that last 30 to 90 minutes.
Dr. Domino of the University of Massachusetts agrees that time is of the essence in the exam room. But he argues that focusing the conversation on discovering patients' own motivation for change can go a long way toward better health outcomes.
“The paternalistic badgering we were taught to do — it's foolhardy, and it's a waste of your time,” he says. “I'll often see a patient for a half-hour visit and spend most of that visit dealing with their high blood pressure, diabetes, hyperlipidemia by covering weight loss. If you get them to engage their behavior through one 20- to 30-minute conversation, that will lead to far better health improvements than any combination of meds you'll put them on.”