Motivational Interviewing gives family physicians a potent tool that allows them to partner with obese patients needing to lose weight.
Jill Grimes, MD, FAAFP, a physician at the University of Texas University Health Services in Austin, and Frank Domino, MD, professor and pre-doctoral education director, Department of Family Medicine and Community Health at the University of Massachusetts Medical School, Worchester, discussed how to use motivational interviewing during an office visit at Wednesday morning's "Obesity Management: Motivational Interviewing for Weight Loss and Exercise" CME session. They also offered advice on healthy eating and how to bill properly for obesity counseling.
Jill Grimes, MD, FAAFP
Jill Grimes, MD, FAAFP
Frank Domino, MD
Frank Domino, MD
Because motivational interviewing is empathetic and non-confrontational, it can lead to patient-specific goals and solutions the physician might not regularly consider. Grimes shared an example from her own life involving her hairdresser.
"When she's overweight, she stores her weight in her belly," Grimes said. "She says she needs to lose about two inches so she doesn't burn her hand doing her job with a flat iron. We talked about latching on to that. That's why we want the patients to come up with their own ideas."
The four basic steps of motivational interviewing start with establishing a rapport and eliciting "change talk"—getting patients to hear their own discussion of their ambivalence and then express their reasons for change through open questions, affirmations, reflections, and summarization. Discussion then moves to discrepancy rulers, such as using a 10-point scale to determine how important it is for a patient to lose weight, discussing how confident a patient is about his or her ability to lose weight, or employing "what do you like/dislike" questions.
The physician then offers advice and options based on the patient's ideas. When the physician is the one directing the patient to lose weight, studies show, the 12-month success rate is less than 10 percent. But if the patient feels more in charge of making the change, that rate jumps to about 50 percent.
The final step requires working with the patient to create an action plan and scheduling a near-future follow-up that involves a patient-selected goal such as weight loss and exercise. Domino recommended seeing the patient every month for two-to-three months until the patient has created positive momentum.
Grimes and Domino also reviewed some of the latest weight-loss strategies. Both promoted mindful eating and helping patients develop better awareness regarding what they eat. Grimes talked about using the 24-hour dietary recall every office visit, where patients detail what they've eaten and drank the previous 24 hours.
Fruits and vegetables are best for consuming the fiber critical for weight loss. Grimes recommended counting fruit and vegetable servings from the dietary recall as a way to emphasize healthy eating. She recommends a goal of 10 fist-size servings of fruits and vegetables each day, making sure to differentiate potatoes, rice, and pasta are starches that don't fit into this category.
With evidence showing losing weight and increasing exercise improves type 2 diabetes and cardiovascular outcomes, Domino said, it's time to change thinking about billing for weight loss. He said that he books patients for 30 minutes, bills a Level IV (99214) for them, lists obesity as the lead diagnosis, and includes all co-morbidities.
"Every insurer, including our Medicaid plan, never once refused to pay," he said. "So I urge you all: Don't be afraid. Fill this as a 99214, be effective, and take your focus and time—not on manipulating medicines—but on helping patients help themselves get better."
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Motivational Interviewing Gives Patients the Power to Lose Weight