When Peter B. Barnett, ACP Member, walked into the hospital room of a patient with emphysema, both his resident and the patient thought they knew the drill. Dr. Barnett, an assistant professor of internal medicine at the University of New Mexico, would lecture the patient on how he had to quit smoking or face dire health consequences.
Instead, Dr. Barnett sat down and asked the patient what he thought about his smoking and his disease. In response, the patient listed off all the reasons that he should quit smoking and accurately described the link between cigarettes and emphysema.
When Dr. Barnett and his resident left the patient's room, after a friendly discussion of the patient's barriers to quitting, the resident expressed his surprise at the exchange. “He said, ‘You didn't tell him anything, but he knows it all,’” reported Dr. Barnett.
Residents are not the only physicians who underestimate their patients' level of understanding, he added. “I think clinicians often—and I hate to stereotype my colleagues—make the assumption that patients are clueless.”
As a motivational interviewing trainer, Dr. Barnett teaches his colleagues how to gain a more accurate understanding of their patients and thereby improve their medical care. Motivational interviewing is a counseling technique developed by William R. Miller, PhD, and Stephen Rollnick, PhD. When Dr. Miller first described the concept in 1983 as a treatment for alcohol abuse, he didn't anticipate its adoption in health care, but it seems to be a good fit, he said.
Today, physicians and other health care providers are using motivational interviewing techniques to help patients quit smoking, lose weight and adhere to medication and lifestyle regimens, in addition to treating substance abuse.
“It's interesting that the problems [of substance abuse treatment and medicine] are similar. With chronic diseases, in particular, you're talking about the need to make some lifestyle changes that are substantial,” said Dr. Miller, “and that people often have difficulty making the commitment to do.”
Stop lecturing, start listening
Motivational interviewing may be naturally suited to physicians' goals for their patients, but it can be a dramatic change from their usual style, noted Richard Saitz, FACP. “There is a tendency for us physicians just to say, ‘Look, you need to exercise, eat right and take this medication or else you're going to die.’”
That typical lecture approach is exactly the opposite of motivational interviewing, explained Richard G. Pinckney, ACP Member, who has taught motivational interviewing to residents. “The focus many times is on listening rather than giving information,” he said.
If the physician listens carefully, he will often find that the patient already knew the information he was planning to impart, or that the patient's problem is actually entirely different from the one expected.
For example, when Dr. Saitz sees that one of his hypertensive patients has high blood pressure, he asks the patient, “Your blood pressure is up today. Why do you think that is?” If the patient answers that she has missed some pills, Dr. Saitz might say, “Many people miss pills. Can you tell me a little more about that?”
Uncovering the causes of the patient's nonadherence can take a little time, Dr. Saitz acknowledged, but it enables him to more effectively resolve the underlying issue.
“You would never know why the patient isn't taking their medication if you didn't allow them to tell you what was important to them. I'd rather do that than waste my time explaining the pathophysiology to a patient whose problem is that they don't have a pillbox,” he said.
In issues of lifestyle change, most patients already know what they are doing wrong and why they should change their behavior, said Dr. Barnett. For example, he said, “I've never met a heroin addict who didn't think that heroin was bad for you.”
It is the task of the interviewer to help patients convert that knowledge into a commitment to change, said the motivational interviewing experts. “You're trying to convince people to do things they don't want to do. They may intellectually understand but they basically would like not to have to change,” said Robert C. Smith, FACP, who wrote a book on patient-centered interviewing.
Motivational interviewing trainers teach physicians to use empathetic and reflective listening to encourage patients to talk about the behavior at issue. Although reflective listening is, at its simplest, repeating back what someone has said to show that you have heard and understood, it takes practice to master, said Dr. Saitz. “It sounds really, really simple but it's hard to do in practice and have it sound and actually be natural and genuine.”
In their own words
Once the patient is talking, her own words often provide the evidence that change is needed. “Listen so that you can develop some discrepancy for the patient between their values and their actions,” advised Dr. Saitz. Dr. Smith gives the example of a smoker who says it would take a heart attack or stroke to make him quit, but realizes, once he hears those words, that it doesn't make any sense to wait for such a drastic consequence.
“Patients literally talk themselves into making the behavior changes they need in the interests of their health,” noted Dr. Miller.
One key is for physicians to refrain from unwanted advice-giving, which inspires resistance in patients, he added. “If motivational interviewing taught us anything, it was to sort of shut up and listen to the other person,” said Dr. Barnett.
The lessons that individual practitioners of motivational interviewing have picked up are also supported by statistical evidence. More than 170 clinical trials of the technique have been conducted, said Dr. Miller. “I think there are now more clinical trials of motivational interviewing in health care applications than there are in addiction,” he added.
Dr. Miller said that the last meta-analysis he conducted of 72 trials found that motivational interviewing had an effect size of about 0.5 or 0.6—considered by researchers to be a medium-sized effect—for producing behavior change in short-term follow-up. Another review, published in the British Journal of General Practice in 2005, found that motivational interviewing outperformed traditional advice-giving in 80% of studies, and had the most significant effect on body mass index, cholesterol, blood pressure and blood alcohol concentration.
Despite growing interest among researchers in the topic, motivational interviewing has yet to become the standard in medicine. Dr. Barnett blames time and financial pressures for physicians' failure to use motivational interviewing. “Medicare and the insurance companies don't reimburse for this,” he said. “In the crush of necessity to see patients, it gets lost.”
But motivational interviewing experts are spreading the word, especially through the training of medical students and residents. There are instructional lectures and books available, but Dr. Saitz believes the most effective training takes place in workshops, with role-playing or patient interaction.
Drs. Miller and Rollnick have taught motivational interviewing to a large number of people—most of whom work in nonmedical fields, such as social work and corrections—and those certified trainers are listed at motivationalinterview.org. Motivational interviewing training can be low-tech and inexpensive, noted Dr. Barnett. “You don't need a computer simulator. You don't even need any expensive expertise.”
Erik Rufa, ACP Member, learned about motivational interviewing as a resident during an educational session led by Dr. Pinckney. “I had been doing a lot of the things already. It's just taking it to the next level,” he said. “I didn't realize that there could be such a powerful technique to help people change.”