For as long as primary care has existed, there have been patients who did not, would not, or (so they thought) could not follow doctors’ advice. Despite hearing physicians’ warnings or even experiencing health consequences, these patients might continue to smoke, eat a poor diet, avoid exercise, skip medications, or otherwise sabotage their own well-being.
But innovative physicians have been honing techniques to reach these most difficult patients.
A catch-all term used to describe patients who don’t follow the recommendations of a physicians is non-adherent. Historically, physicians might lecture such patients repeatedly, but at some point concede that it’s not always possible to make another individual change. But in the era of health reform—in which physicians are increasingly held accountable for measures linked to patient behavior—giving up is not an option.
Enter motivational interviewing. It’s a concept that predates the Affordable Care Act and even the patient-centered medical home (PCMH), but this collaborative communication style offers results that help satisfy both, according to Barbara Clure, MD, a family physician at Interfaith Community Health Center in Bellingham, Washington.
Since adopting the technique about 10 years ago, Clure says she has seen countless patients transform their lives and health in ways she didn’t previously think possible.
Before and after
“I used to be the kind of doctor who would tell people, ‘Hey, you need to quit smoking…blah, blah, blah.’ But they didn’t like to get lectured or hear that, and it wasn’t very fun for me either. It doesn’t generally create any space for change,” Clure says.
But after participating in a research study that included hands-on training in motivational interviewing, Clure began a new path toward empowering patients to set goals they’d actually attain. To illustrate how it works, Clure uses the example of working with a patient struggling with multiple health problems, including diabetes, high blood pressure, and severe arthritis requiring opiate pain medication. He had also undergone heart-valve surgery and remained morbidly obese.
But rather than simply instructing the patient to lose weight, Clure began the conversation in a more open-ended way. It went along the lines of: “You know, your BMI [body mass index] is at a level that’s really dangerous for your health. How do you feel about that?” Clure says.
His response was something like the following: “I know. I’ve been trying to lose weight forever, but I stay a couch potato because my knees hurt, I have a bad heart valve, and I’m afraid to do anything.”
Next, Clure asked her patient if there was any level of activity he’d be comfortable trying on a regular basis, and they agreed he’d take the short walk to get his mail daily, and check back with her in a few weeks. At his follow-up appointment, they set a new goal that he would walk one block a day.
“We kind of did that dance for a year. And after a year, he was able to walk four miles per day—which was huge for him—and lose 60 pounds,” Clure says.
Meanwhile, Clure’s patient also was able to get off his diabetes medications and reduce his pain medications significantly. As the results continued to snowball, he improved his eating habits and ultimately turned his whole life around, Clure says. “He just gained tremendous confidence in realizing he could do this,” she says.
According to Clure, this is just one success story of many that have made her a believer in motivational interviewing. But despite the mounting evidence confirming that the technique works, physicians face barriers of their own in incorporating motivational interviewing into their daily practice.