To improve health outcomes, today’s physicians must be able to communicate effectively with their patients. One approach many experts encourage physicians to use is motivational interviewing (MI), a series of techniques to get at the root of patient concerns and help encourage them to make healthy behavior changes.
These techniques are based on the work of William R. Miller, PhD, who originally came up with the concept to address problem drinking. Miller later teamed up with Stephen Rollnick to write a book on the subject, which is now in its third edition.
The promise of MI, according to interviews with experts, is for physicians to cease wrestling with their patients to adhere to their advice, and begin to feel they are dancing as partners.
“There’s a lot to motivational interviewing, but when it’s done well without taking too much time, it can help a busy healthcare provider ‘come alongside’ the patient,” says William H. Polonsky, Ph.D., CDE, president of the Behavioral Diabetes Institute and associate clinical professor at the University of California-San Diego. “When the physician and patient feel they are on the same side, everything gets a little easier. Patients will be more willing to probably tell their doctors the truth, and maybe more willing to follow recommendations on things like taking medication.”
Benefits to physicians
This transformation does not occur overnight, but it can have a profound effect not only on patients’ health, but on physician satisfaction, says Damara Gutnick, MD, an internist and the medical director of the Montefiore Hudson Valley Collaborative. Introduced to MI while taking part in a chronic disease depression collaborative at Bellevue Hospital, Gutnick began applying MI-based techniques for goal setting and action planning with her patients.
“At this point in my career, I was quite burnt out,” she says, explaining that her population was quite sick, yet patients continued to keep drinking, smoking, or failing to take their medications. “When I learned motivational interviewing, I changed the way I was with my patients, and as a result my patients changed.”
This change was also reflected in Gutnick’s physician report card for diabetes control and other measures. “Mine were all in the green. It was the same patient panel that used to frustrate me and not take their medication, but it all changed when I did,” she says. It also vastly alleviated her feelings of burnout.
“Motivational interviewing gave me the opportunity to connect with patients again, which is what I loved most about medicine,” she says.
‘The listening is the doing’
The concept of OARS offers a snapshot of the skills involved in MI:
O - Open-ended questions
A - Affirmations of the patient’s inner strength
R - Reflective statements
S - Summary statements
Open-ended questions can be anything that requires more than a yes or no response, but there are some that are especially useful in getting to the heart of the matter. Polonsky, a diabetes psychologist for more than 30 years, always asks patients to identify at least one thing that really bothers them about their disease. “I may not be able to solve it, but it changes the tone of the interaction in an important way. You’re going to see your patient differently, and they’re going to see you differently because you’re interested in them as something more than a number, such as their A1c or blood pressure.”
Affirmation and reflection are equally useful, says Gutnick. “If you reflect back and say, ‘You’ve been through a lot. You’re a survivor,’ you’re picking up on the strength of the individual, and that’s an act of doing something,” she says. Even if a clinician can’t directly solve a problem the patient identifies, such as an emotional or psychosocial issue, it’s a valuable interaction. “It’s an act of doing what matters, because you’re meeting the person where they’re at, and you’re acknowledging that they’re struggling. The listening is the doing.”
Summary statements are helpful to use at transition points in the conversation as well as at the end of the visit. Experts recommend phrasing such as, “Here’s what I’ve heard. Tell me if I’ve missed anything.”
John Cullen, MD, a family physician in Valdez, Alaska, has been employing motivational interviewing techniques throughout his 25-year career. “Don’t get too caught up in the terminology,” he suggests. “It’s also important to close the computer in order to be present and empathetic. I would recommend being truthful, yet positive and supportive.”
Capturing the spirit of motivational interviewing
Another useful mnemonic is CAPE, which Gutnick says captures the spirit of the motivational interviewing philosophy.
“If you put a cape on somebody, such as when they’re graduating, it’s a sign of respect,” she says. “If it’s raining, it keeps them warm and dry. Or they become a superhero. You can use CAPE to empower your patients to make changes for themselves,” she says.
Compassion. The entire interaction is driven by the best interest of the patient.
Acceptance and respecting autonomy. Individuals have the right to change or not change, says Gutnick. “If somebody is not ready, you respect that and you don’t push. You might use some skills to try to guide them toward change, but if you’re hearing a lot of resistance and you have four patients waiting, you don’t push that visit,” she says.
Partnership. The physician is not telling the patient what to do. Instead, “You’re helping the patient move toward change, but you’re equals,” Gutnick says.
Evocation. This means pulling ideas for change out of the patient. “As a doctor, I know a lot of reasons why you should quit smoking, but only you know what’s most important to you,” Gutnick says.
This mindset can help neutralize patients’ natural reflex to come up with reasons to not do something when it comes in the form of “doctor’s orders,” Gutnick explains. It’s also important to note that it’s not a dead end if a patient isn’t ready to change. “Pushing is just going to make you more frustrated,” she says. Rather, she recommends physicians ask the patient if it would be okay to revisit the topic at a future visit.
During that next meeting, it may be possible to draw more substance from the patient. For example, a clinician could say, “I know that you might not be interested in quitting smoking, but tell me a bit about what the advantages might be if you did quit,” Gutnick suggests.
The key is identifying what’s important to the individual, which often isn’t a reason that would be brought up by a clinician, Gutnick explains. “The science is that when people start to talk about their reasons for change that are important to them, it increases the chances of them changing.”
Ways to learn technique
There are many ways physicians can familiarize themselves with motivational interviewing skills, including articles, online modules, and workshops. However, Damara and Gutnick, who are both members of the Motivational Interviewing Network of Trainers, advise that these modalities are best used as an introduction, and that ongoing training is a must.
Polonsky says in-person training is necessary to really grasp the concept. “Studies have found that training that’s online and brief doesn’t really stick. As healthcare providers, what we all do is go back to our old habits. Live and ongoing support is most effective.”
And even when one-off trainings truly inspire clinicians, they’re unlikely to implement the skills without a framework that allows them to practice them with feedback, Gutnick says. “Any behavior change is really hard. People might have the desire, but if you don’t have the milieu that allows you to try it, then it’s going to be very hard to implement.”
Caveats and challenges
The biggest obstacle physicians face in learning and practicing motivational interviewing skills is time. Even though this form of communication can be more efficient and productive in the long run, it takes a great deal of practice to do it well.
A frequent mistake that clinicians make, for example, is rushing into creating an action plan with a patient before he or she is truly ready to change, says Polonsky. “You want to capture a patient’s commitment and enthusiasm about saying, ‘I see this as a priority for myself, I feel less ambivalent than before, and I’m raring to go.’”
When patient’s aren’t quite ready to change, it’s the rough equivalent of a man or woman standing at the alter and saying they might take the other person to be their wedded husband or wife rather than they will, says Gutnick. The way to identify an adequate threshold of readiness is to listen for “change talk,” she says.
Change talk indicates that a person has already taken steps toward change, such as buying walking shoes or setting a quit date. However, especially when pressed for time, doctors have a tendency to rush into the nitty-gritty of action planning when patients may still have ambivalent feelings, Polonsky says.
When the physician doesn’t spend enough time getting a true “I will” from patients and rushes into asking patients what actions they’re going to take the next day—How? What time?—patients might begin to give lip service to plans with which they won’t follow through, he explains. “Sometimes we move forward into antagonizing people about taking action before they’re ready to do so,” Polonsky says.
Cullen reiterates that patience is essential. “There is great satisfaction in finding that interventional moment that will allow a patient to change their behavior,” he says. “For some of my patients, it has taken decades.” Other attributes of motivational interviewing include willingness to be silent, to let patients talk, and to be present for them, Cullen says.