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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. But innovative physicians have been honing techniques to reach these most difficult patients.
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.
The time conundrum
A reality of medical practice today, of course, is that physicians’ face-to-face time with patients is limited, notes Craig M. Wax, DO, a family physician in New Jersey and member of the Medical Economics advisory board.
As a result, physicians may assume they don’t have time to really engage their patients through motivational interviewing. “I think the biggest misconception is that you can’t make a positive impact on a patient in a relatively short time,” Wax says.
One of the ways Wax seeks to help his patients, he says, is by being a good role model: exercising vigorously every day, following a plant-based diet, and not smoking or drinking.
“So when I encourage someone to lose weight, I can tell them that I was a fat kid,” he says. “Or if somebody comes to me in pain, I can say, ‘Well, I’ve fractured my spine in the past and have pain every day. But I manage it with exercise, healthy lifestyle, and a positive outlook, and I am here to help you.’”
When it comes to working with patients on setting their personal goals, it may take a bit more discussion time at the start, Clure says, but the investment pays off through improved outcomes in the long run. “When you really try to engage people, they come up with really creative solutions,” she says. “And they are a lot more effective because they know what works for them and what doesn’t, and they know what they’d be interested in trying or not. It’s more efficient to ask people what’s going to work for them rather than put your own spin on what you think will work for them.”
How to handle mismatched priorities
But before many patients will be open to change, physicians must first address their top priorities, even if they’re not the most important issues medically, says Wax.
“The first thing is you have to listen to the patient,” he says. “You have to understand what the patient’s goals are, what your goals are as a physician, and try to get ‘something for everybody.’”
Wax cites a recent visit with a patient who had hypertension, high cholesterol, and smoked two packs a day, but arrived at the office because he had an ingrown toenail. “Of course I wanted to address his hypertension, hyperlipidemia, smoking habits, and lack of preventive care over the last five years; but he just wanted to deal with his toenail,” Wax says. “And if I didn’t deal with his toenail first, none of the other stuff would be on the table.”
Practice makes perfect
The best way for clinicians to learn their way around these stumbling blocks, according to Wax, is through practice.
“You can consult with other speakers on positive thinking and interviewing techniques, but no one holds all the truth. Practicing with patients and their families and learning what works with each individual patient is ultimately the answer,” he says.
For Clure, attending training sessions that included role-playing made all the difference. While reading about the techniques and watching presentations about them gave her a good start, she explains, it was trying it out with educators that really led her to understand the concepts and use them well.
“Now these skills are pretty much just part of my practice,” Clure says. “I don’t really think about it any more.”