Given the enormous discrepancy between what is known about the prevention of cardiovascular disease and the low rates of implementation of risk factor modification for cardiovascular disease, we must continue to ask why. The answer, no doubt, is complicated and involves a multitude of factors, including access to medications and the impact of poverty, when other priorities make it impossible for optimal health care to be an end in itself. One additional factor, and the one I would now like to explore with the ProCor community, is the way in which we counsel and motivate patients to change.
When I started to practice, the predominant method of imparting information to patients followed paternalistic models; the doctor had all the answers, and he or she imparted information in a top-down model that was prescriptive and left no space for a patient's input, ambivalence, or questions. In this model, Dr. Jones told Mrs. Smith, "You're overweight. It's a serious problem to your health. You may die soon of a heart attack or stroke, and I'd like you to lose 20 pounds in the next six months." The expected response from Mrs. Smith was to smile acquiescingly, go home, and continue eating super-sized sacks of chips or fried plantains. Since this time, we have learned that the paternalistic model of care, which still is widely prevalent in medical practices throughout the world, simply does not work.
One replacement for this model is called motivational interviewing. The premise behind motivational interviewing is that true change in a patient's behavior must come from self motivation rather than from externally imposed controls. Motivational interviewing is non-dictatorial, non-confrontational, and it appreciates the patient's perspective, including the patient's ambivalence as the starting point to initiate change. The spirit of motivational interviewing recognizes the collaborative nature of the doctor-patient relationship, in which the doctor may provide expert medical advice, but the patient provides expert personal input based on his or her own values, priorities, and ambivalence. For example, when it comes to smoking cessation, a paternalistic physician would inform the patient, "You must change or...", "You must stop smoking or...." The patient in turn, either to himself or directly to the doctor, then might say "But I love smoking, it helps soothe my nerves. I don't really think I can change." After this, there may be a seesaw effect of "You can change," "No I can't," "Yes you can," "No I can't."
In motivational interviewing, the physician would first ask the patient, "Tell me about your smoking. Tell me what it is that you like about smoking. Tell me about your previous experience with wanting to quit smoking, and tell me what happened once you tried to initiate a program of change." Listening to the patient's responses requires open attention to, and respect for, the patient's concerns. In this way, the patient is much more likely to feel "I have a partner in this endeavor," rather than to have his or her own inherent resistance kindled. In the case of smoking, the doctor might say, "I understand how soothing cigarettes may be to your nerves." The physician may then go on to find something about cigarettes with which the patient is not happy--the patient may be unhappy with the cost of cigarettes, or know that another relative who smoked developed lung cancer. If the physician appreciates the patient's ambivalence, the patient may then be more willing to explore the reasons why he or she would like to change. There then follows a natural back-and-forth dialogue between physician and patient, in which the patient's goals, concerns, and fears are elaborated and the physician provides the support, advice and information to help overcome them. Language used is not prescriptive. Instead of "you should...", the language used is supportive, empathic, and essentially neutral, such as, "What else has helped to soothe your nerves?" or "Many patients have benefited from a smoking cessation group."
In reality, the means to achieve an end vary greatly, and there is no one prescriptive solution. In some cases, a patient may need to elicit the help of a spouse who smokes in the house, may need to join a support group, may need medications for nicotine withdrawal, or may in fact need simply to think further about the possible benefits of smoking cessation. The physician may conclude with a statement, "I appreciate that you're not ready to quit now, but I am happy to help you when you need me." This may not be a satisfying end point for those of us who'd like to stamp out disease with a single blow, but nurturing the seed for change is sometimes the most effective strategy that we can follow.
The stages for change in any behavioral modification program have been identified as pre-contemplation, contemplation, preparation, action, and maintenance. Motivational interviewing is a key way to find out what stage the patient is really at, rather than the stage that we would like the patient to be at. By asking open-ended questions and listening consciously to the responses, by confirming and affirming our understanding of patients' goals or perspectives, we give them a base on which to discover self-motivation. It is only thus that the patient will have the tools to make behavioral change a long-term reality.
Date Posted: 8 November 2004