Doctor’s Don’t Scold

Wednesday, May 1, 2013 // Uncategorized

I can remember three patients who each lost over one hundred pounds.  I asked each one how they had done it and they each answered because they were tired of being obese and wanted to change.  I asked if there was something that I could’ve said that would have helped them come to this conclusion sooner.  they all said, “No”.  We always look for what will motivate change in our patients.  This is from the Wall Street Journal.

To Motivate Patients to Change, Doctors Stop Scolding


Health-care providers are helping patients kick bad habits and start new regimens by turning the tables on the traditional doctor-patient relationship.

They are using a technique called motivational interviewing, which was developed and used effectively in the 1980s in substance-abuse and addiction counseling. It has since been adapted for chronic-disease management, medication adherence, smoking cessation and weight-loss counseling by health systems and companies including Aetna AET +1.41%and Weight Watchers International Inc. WTW +0.50%

Doctors are using a new untraditional strategy to help patients achieve health goals like quitting smoking or starting diet and exercise programs. Laura Landro and Healthwise founder and chief executive Donald Kemper explain. Photo: Getty Images.

Instead of telling patients what to do and scolding them when they don’t do it, clinicians ask the individual what changes he or she is willing and able to make, and then promote patients’ desire, confidence and commitment to following through.

Doctors who lecture or give scary warnings can cause patients to become defensive and disengage, says Stephen Rollnick, a professor of health-care communication at Cardiff University, in Wales, and a founder of the nonprofit Motivational Interviewing Network of Trainers, whose members provide training, coaching and consultation in 35 countries. “When people are struggling, they don’t like to be told what to do, and they dislike being labeled and blamed,” Dr. Rollnick says. Motivational interviewing “can bring patients back on board and empower them to consider difficult changes.”

In workshops and courses, doctors, nurses and health coaches are trained to collaborate with patients on treatment decisions, offering choices rather than prescriptions and avoiding terms like “must,” “should” and “have to.” They might ask patients why they think they aren’t losing weight or taking their medications properly, and they elicit goals from patients, such as being able to dance comfortably at a wedding.

While one aim is to resolve the ambivalence of patients who aren’t ready to cooperate, clinicians also learn a technique known as “roll with resistance,” which encourages small initial steps toward a goal the patient sets, such as cutting down on sweets or cigarettes a little at a time. Some programs incorporate the motivational interview into interactive online tutorials for patients at home.

[image] Brenda StarksMona White had back surgery in 2010 and began to gain back weight she had lost after a 2009 lap band procedure. “The desire to change has to come from within and you get a much better result if a person is involved in setting goals for their own recovery,” she says.

Motivational interviewing can help patients control blood pressure and diabetes, lose weight, start exercising and quit smoking, recent studies have found. A large federally funded study with sponsors including the American Academy of Pediatrics is looking at the effectiveness of motivational interviewing by pediatricians who are helping parents of obese children make progress toward a healthier diet and weight loss.

“Many doctors struggle finding the right balance between supporting patient choice and autonomy, and meeting their obligations to make informed recommendations,” says Ken Resnicow, a University of Michigan health-behavior and education researcher who is leading the pediatric study. He owns Academic Assistance, a for-profit provider of motivational health-care training based in Ann Arbor. Generally, Dr. Resnicow says, these techniques are most effective with patients “who have low energy for change and a high level of resistance.”

A major goal is to help patients resolve their own lack of commitment—such as the person who wants to quit smoking but enjoys it too much to give it up, says Chet Fox, a professor of family medicine at the University at Buffalo in New York, who works with the American Academy of Family Physicians on motivational interviewing courses.

Rather than push a person beyond what they think they can do, the technique aims to get patients to set their own minimum goals. It makes it clear they can exceed the goals at any time and encourages them to stay motivated and committed. Often, he says, it helps patients set their own more ambitious goals.

One of Dr. Fox’s patients, Mona White, had back surgery in 2010 and began to gain back the weight she had lost after a 2009 lap band procedure. The weight gain was endangering her health and made a needed knee replacement out of the question. Ms. White, getting over a breakup and feeling depressed, turned to cookies, ice cream and a peanut butter, sugar and coconut candy called Chick-O-Sticks.

A recovered addict now working as a client advocate in a mental-health court, Ms. White says her own experience with drugs and alcohol taught her “the desire to change has to come from within, and you get a much better result if a person is involved in setting goals for their own recovery.”

Try, Try Again

  • Nearly 69% of adult smokers in 2010 wanted to quit. More than 50% tried. Only 6.2% succeeded.
  • Over a six-year period, 43% of the patients in a weight-management program dropped out before achieving sustainable weight loss.
  • Overall, about 20% to 50% of patients don’t follow through on prescribed treatment and medication.

Sources: Centers for Disease Control and Prevention; Canadian Journal of Surgery; Archives of Internal Medicine

Dr. Fox suggested an easy first step to get her into the weight-loss mind set: Cut back the number of Chick-O-Sticks by one box per week. “Dr. Fox would always be encouraging, saying we are going to get the weight back off, you know what you need to do and you’ve done it before,” Ms. White says. She was motivated to do better, cutting down to three boxes from five. She has continued limiting sweets and portion sizes and says she is starting to see results.

Weight Watchers began training meeting leaders in motivational interviewing in 2005. Chief Scientific Officer Karen Miller-Kovach says leaders all have successfully lost weight, but “it doesn’t mean the choices they made will work for everyone, and this helps them with the empathy to coach others and identify solutions that are going to work for them.”

Insurers and health systems find the technique helps manage large populations with chronic illness. Aetna worked with Dr. Resnicow to train nurses who work as telephone coaches in the technique. Before its wide adoption in 2010, “we could identify where an individual was on the continuum to take action but couldn’t really motivate them or help them motivate themselves,” says Susan Kosman, chief nursing officer. More members are agreeing to participate in disease-management programs and dropouts have fallen 55%, she says.

HealthPartners, a large nonprofit health system and insurer based in Minneapolis, asks members who have an employer-sponsored wellness program to fill out a survey assessing health risks. Those at risk for diabetes or other chronic illness are contacted by a nurse or health coach, and they work together to create an improvement plan.

The plan may include a motivational-interviewing program called Conversations, developed by Healthwise, a nonprofit that designs patient-education materials. With the soothing voice of a virtual coach named Shelley, the program asks patients about weight, sleep and positive thinking. Employers may offer incentives such as a $200 reduction in a patient’s deductible. It “gives people a little push to get over the hump and get engaged,” says Nico Pronk, HealthPartners vice president of health management.

Doctors and even health coaches often have limited time, but Shelley “has all the time in the world,” says Donald Kemper, Healthwise founder and chief executive. The program helps provide patients with “empathy, clarity on the changes they want, acceptance of the limits they set and support for doing what they think they can accomplish successfully,” Mr. Kemper says.

Write to Laura Landro at [email protected]

A version of this article appeared April 30, 2013, on page D1 in the U.S. edition of The Wall Street Journal, with the headline: To Motivate Patients to Change, Doctors Stop Scolding.


Copyright 2012 Dow Jones & Company, Inc. All Rights Reserved


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