I spend so much of my time nagging patients to take better care of themselves that they probably think my specialty is bitchingologist. When I’m on a roll listing the litany of health horrors that will befall those who fail to do as I tell them I am scarier than Stephen King and harder to argue with than King Kong. The tide would not come in if I told it to stay out and exercise.
Or so I thought. There is growing evidence this old approach to getting patients to live healthier lifestyles (exercise more, eat less, etc.) is usually failing to change what most patients do, and on a national basis is being drowned by a rising tide of patient inertia and obesity. Few of the patients who physicians urge to exercise at least five times per week actually do so. Fewer still are eating the recommended five servings of fruits and vegetable per day. Physician nagging — what we thought was the penicillin of our persuasion armamentarium — turns out to work like eye of newt.
Few but newts would care about that but for this little problem: By some estimates, 40 percent of a patient’s health status determined by his or her lifestyle, much more than is determined by their medical care. If physicians are largely ineffective convincing patients to stop living unhealthy lifestyles, it means they are largely ineffective treating the most important “disease” most of us have.
This ugly paradox — that despite how good our health care system is at treating many things we are lousy at treating what primarily ails America and Americans — has led many in health care to begin dumping the fundamental nag and scare model for convincing patients to change. One alternative that shows promise is called motivational interviewing, a profoundly different approach that requires new roles for patients and their caregivers in change discussions.
Motivational interviewing is a structured discussion designed to help motivate the patient to change. It contains specific components, including “the change talk,” in which the patient identifies their own desire and need for change, reasons for wanting change, their ability to change, and finally, their personal commitment to change. It seeks to identify the patient’s ambivalence about change, which is defined as the discrepancy between how important they feel the change is and how confident they are in their ability to be successful making changes.
With that ambivalence identified, the interviewer then works with the patient on identification of steps the patient feels they can take that would reduce their ambivalence to change, and thereby lower their personal threshold to action. Finally, the patient and health care provider summarize the results of the discussion and come up with a plan, including specific follow up in the near future to see how the patient is doing implementing the change plan.
This makes what I have been doing with the nag, nag, nag approach look like the application of leeches by comparison. Motivational interviewing is patient-centered, designed to find what would motivate the patient to change taking steps they identify, for reasons that are theirs. It has structure, intent, and a growing body of evidence from studies of the approach that it actually works. My old way, while motivated by my concern for the patient, was largely about my trying to motivate the patient with fear to do the things I suggested, for reasons I identified, using steps I recommended. That approach needs to be replaced by motivational interviewing and other techniques based on actual science of motivating human behavior change in lifestyle.
If motivational interviewing is to have a real effect, however, it cannot simply be a way for health care providers to talk with patients. Such a limited application would be insufficient to the task of changing the downward trajectory of the health of more than 200 million overweight, relatively sedentary Americans. We all need to change from being a nation of naggers to a nation of motivational interviewers, to adopt this technique for the conversations inside our own heads about motivating ourselves, and inside our own homes to motivate those we love.
What might help you start using it today?
Erik Steele, a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.
No comments? Must because Dr. Steele hit the nail on the head with you as he did with me. :)
SScrew that!
Hey Erik, have you seen the prices on good food out here ? I guess it does not matter when you work for a non profit and make about $400.000 / year. I am also pretty sure it is easy for you to take a walk in the middle of the day – there is a HUGE reality perception gap between the incredibly privileged and insanely highly compensated MD’s and the rest of the US population.
Look to Europe – more equality in working and living conditions as well compensation = healthier populations.
I am sorry Erik but when you make 400K and your CNA’s are making $9.00/hour just trying to hang in there caring just as much for patients as you are it’s hard to see how you can advice on solving lifestyle issues. And no, I am do not work in the healthcare industry but it does not take a “Doctor” to diagnose these ails..
WP
Those who literally have no time to exercise likely don’t need to, for the res of us, there’s only excuses. Eating better will save you money in the long run. Healthy people cost less, are able to work more with less sick time and don’t have nearly the same negative impact on the healthcare system.
But, stick to the I have no time, can’t afford it excuses, you need only convince yourself.
While wparish’s comments are harsh and judgemental, he’s not wrong to say what he says. I’m lucky enough to make a decent salary (not even 1/8th the stated income of $400k/ mentioned above, but, decent enough), and I can tell you, there’s no comparison. People who work entry-level jobs are the hardest-working, least-appreciated people out there. I get reasonably decent pay, and am respected where I work. But entry-level workers? Oy…they work so hard, for so little, and to get almost nowhere.
First let me say that I’m not a physician so I’m not disagreeing with anyone. But I do have an opinion based upon my own failure to lose some weight (which I gained after I quit smoking 15 years ago). I think that a motivational speech approach to better health doesn’t take into account the root of the problems people face. Alcoholism, drug addiction, smoking, over eating, destructive behavior in general is driven by more than a lack of will power. Will power and good intentions can be overwhelmed by something which is stronger, an innate but persistent drive to seek pleasure out of whatever your personal feel good habit may be. After smoking for 25 years quitting was incredibly hard to do. It took a long time to achieve success, years. Yet 15 years later I’m still carrying around that extra 60 lbs I gained afterward. I’ve dieted with some success but, sooner or later, the weight comes back. So what is it? I pay attention to my doctor and certainly I believe his dire predictions. Yet there is something stronger in my make up which continues to drive me back for that second pork chop. They say alcoholism is a disease and I wonder if this inner drive to indulge a habit is also a sickness. Regardless, I hope that someday the medical community discovers just what this driving force actually is and helps those who, like me, just don’t seem to be able to do what is best for our body.
I’ve had trouble losing weight for years and during those years I was involved in athletic competitions consistently which meant that I was also working out. It wasn’t until about a year ago a friend of mine suggested going paleo/primal. Now, I will tell you this is not for everyone and it’s indeed a lifestyle change and not a diet but the differences have been awesome. While I still weight roughly the same I’ve lost nearly 3 belt sizes the in the past 4 months and that was before I began working out about a month ago. Perhaps it’s not something you’ll be interested in because it goes against conventional wisdom (Mr. Dr still shakes his head at me) but I love it and see myself doing this for the rest of my life. If you are interested check out Marksdailyapple.com for more details. Good luck to you in the future!
The healers are at The Acadia Hospital.
My doctor used to give me grief for smoking. What finally made me quit was finances-I became unemployed and couldn’t afford to smoke anymore.
Hello Dr Steele, nice article !!! Wife and I miss you and many truly wonderful people from Bangor !!!!
Greetings Doctor and welcome to the party. Motivational Interviewing has been around for many years. It was born in the field of substance abuse and it is indeed exceptionally effective. I encourage you to refer your clients to those of us who can invest the time to meaningfully identify underlying needs and properly assist folks in moving beyond ambivalence.
Treating humans like laboratory rats is hardly the approach that should be taken by people who consider themselves “healers.”
How to conscience taking weight-proportional, 5X a day fruit and vegetable eaters, (organic, even), and ordering CT scans, and the like, at the drop of a plum, given that tremendous amount of radiation?
The “motivational interviews” would be significantly more effective if the patients made similar inquiries of their physicians.
We can do things we are not doing. We can take walks. We can cut down on food intake. We certainly do not need more fear. The entire country is swept up in an epidemic of fear. The Internet provides a host of fearsome news, and, certainly, medical suggestions for what ails a person yield some of the most frightening possibilities. The best reason for people to take as much charge of their bodies is to avoid becoming “interventionees”.
Instead of a “motivational interview,” taking a walk, even down the hall, with a patient, or playing a round of golf with him or her, would be a lot more human, rather than this “medical intervention.”
My mechanic told me not to drive.
Tell your overweight patients not to eat pasta, crackers, chips, bread, and sweets, and not to drink beverages with calories (exception: the occasional glass of wine). It’s easy to follow and they will almost certainly stop gaining weight. When an overeater overeats, it usually involves these items. And if the overweight person is not an overeater, cutting out these fast-carb choices will definitely help.
I’m a clinical psychologist who’s spent the past 25 years trying to make sense of why people so often fail to follow through on their own good intentions. I think we’re barking up the wrong tree when we concentrate on convincing patients to engage in healthy behavior. Most patients are already convinced. The real problem is – and this applies to us as well as our patients – just because a person is truly convinced that he/she should do something doesn’t mean that he/she will actually do it. It’s a fact of human nature that there’s often a huge gap between intention and behavior. As much as we like to believe otherwise, intentions don’t directly drive behavior. So although exposing patients to more information, more education, more persuasion, more nagging may make their intentions stronger, even the strongest intentions may fail to drive behavior.
If we’re going to improve patient follow through, we have to refocus our efforts. We have to stop concentrating on convincing patients to engage in healthy behavior and recognize that the real challenge is to help the already-convinced to start actually behaving in accord with their own good intentions.
Conceptually, there’s at least one way to help patients follow through. That’s by allowing the already-convinced to “register” their good intentions in a way that forces them to act in accord with their own good intentions. This may at first glance sound heavy-handed, but in light of the disconnect between intentions and behavior that’s rooted in human nature, it makes a whole lot more sense than all the convincing we’ve been spinning our wheels doing. Isn’t it time to start thinking outside the box about creative ways that society could make it possible for people who truly intend to make positive behavior changes to be “willingly forced” to actually make them?