The value of motivational interviewing
While we may not be able to convince the government or insurers of the value of intrinsic motivation for physician reimbursement, we can apply these principles to patient care to get better results and make our office visits more efficient. One way to harness the power of intrinsic motivation is through a technique called motivational interviewing.
Motivational interviewing can inspire change in any patient—even those who initially seem to show no interest in changing. The hallmarks of the technique include helping the patient to find their own reasons for change by eliciting their ideas and feelings using open-ended questions, and reinforcing these motivators with reflective listening and empathy. If the patient begins to demonstrate a willingness to change, the next step is to help the patient think through their own solutions and then create an action plan.
Inspired by a video I watched, I practiced motivational interviewing with one of my patients with elevated liver enzymes who admitted to drinking more alcohol than she should. I had lectured her previously on safe levels of alcohol consumption, the need to cut back on drinking, and even discussed medication options to help her. “I know, I know,” she would tell me, rolling her eyes, and despite my lectures, her liver tests and other markers of hepatic dysfunction continued to bump up at each visit.
I decided to give motivational interviewing a try. “Would anything in your life get better if you cut back on drinking?” I asked her.
“Well, my husband would be happier and would probably stop nagging me so much,” she answered. She suddenly seemed thoughtful. “That certainly would be a good reason to quit.”
That was an interesting response to me. I had been lecturing her about how much her health would improve if she quit drinking, which never made her bat an eyelash. Instead, what really motivated her was the idea of getting her husband off her back.
Following motivational interviewing, I used the technique of reflective listening and validation, nodding empathetically and responding, “Sounds like things would be much more pleasant around your house if you cut back on drinking.”
“You got that right!” she answered.
This was the first positive response I had ever seen from my usually recalcitrant patient. When I saw that she was showing evidence of contemplating change, rather than suggesting medication or AA like I would have done before I learned about motivational interviewing, I used the technique of having her come up with her own possible solutions. “What would be a first step you could take to cut back on drinking?” I asked.
“I could go back to drinking tea at breakfast instead of vodka,” she answered without hesitation. This answer stunned me. While I suspected that my patient had a drinking problem, I never imagined the severity, and here she was, opening up to me just by this simple open-ended question.
We discussed her plan for a bit longer and wrapped up the visit. I was doubtful that my patient would take any real action, but a month or two later she was back in the office for repeat labs, looking healthier than I had seen her in some time. She had cut back on drinking, but what she really wanted to talk about was her new exercise plan. “I’ve been taking water aerobics at the Y three days a week,” she told me. “I have much more energy.”
While motivational interviewing may not work every time, I was amazed at how well it had paid off in this case. Techniques like this and other tools from psychology can help physicians get better results from patients, but unfortunately, physicians don’t always get much training in how to apply psychology in the exam room.
The good news is that there are conferences, CMEs, and online learning modules to study techniques like motivational interviewing, including this online resource, online toolkit, eBook, and intensive training course.
Rebekah Bernard, MD, is a family physician in Ft. Myers, Fla., and the author of How to Be a Rock Star Doctor: The Complete Guide to Taking Back Control of Your Life and Your Profession. She can be reached at her self-titled site, Rebekah Bernard, MD.