Lown Right Care

Reducing Overuse and Underuse

Helping Ambivalent Patients Make Healthy Decisions About COVID-19


Am Fam Physician. 2021 Mar 15;103(6):334.

Published online on January 27, 2021.

Author disclosure: No relevant financial affiliations.

Case Scenario

A 62-year-old patient has type 2 diabetes mellitus, hypertension, and dyslipidemia that are well controlled with medications. The patient lives with a spouse and mother-in-law and is currently unemployed. The patient and spouse babysit their three-year-old granddaughter two days per week. The patient watches cable news and spends at least one hour each day on social media. During the patient's planned care telemedicine visit, the patient states an ambivalence toward wearing a mask and skepticism about the seriousness of coronavirus disease 2019 (COVID-19). The patient also asks the physician what they think about COVID-19. What approach should the physician take when responding to the patient?

Clinical Commentary

There is little evidence that physician advice leads to significant clinical results. For example, a 2013 Cochrane review found that a physician's recommendation to stop smoking improves the cessation rate by 1% to 3% compared with not having the conversation.1 Although this result is statistically significant, it is hard to view this as a great clinical success.

Motivational interviewing was originally developed as an approach to help people who misuse alcohol reduce their alcohol consumption.2 Motivational interviewing has been defined as a “directive, client-centered counselling style for eliciting behavior change by helping clients explore and resolve ambivalence.”3 A 2005 systematic review and meta-analysis found that motivational interviewing outperforms usual care in the treatment of a range of behavior problems and diseases, including reducing body mass index, total cholesterol, systolic blood pressure, and alcohol consumption.4

Motivational interviewing can help treat any medical diagnosis with a behavior component.5 Adherence to a treatment plan, such as taking medications, exercising, eating a healthy diet, getting vaccinated, and wearing a mask during the COVID-19 pandemic, depends on the patient's behavior. A core concept of the motivational interviewing approach is that a patient thinks about goals but feels ambivalent about making the changes necessary to achieve them. The clinician's job is to help the patient make these changes, without triggering rebellion, by eliciting the patient's life and health goals and thoughts about how they might achieve them. The relative importance of the goal in the patient's life should be established on a 10-point scale, with 10 being the highest importance. If the goal receives fewer than seven points, asking the patient, “Why isn't it lower?” will reinforce the importance of the goal by having the patient explain its significance in their life. The next step is reflecting the conversation back to the patient without taking sides by saying, “On the one hand, you would like to live long and feel well, but on the other hand, you are reluctant to give up or add certain behaviors that get in the way of your goals. Do I have it right?” When the clinician does not take sides in the patient's ambivalence, the patient is more likely to defend the importance of making changes.3

The next step is to ask the patient what specific actions they are thinking of taking to achieve their goals, when they will do them and with whom, and what their level of confidence is that they will follow through. If the patient's confidence level scores less than a 7 on a 10-point

Address correspondence to Alan Glaseroff, MD, at aglasero@stanford.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Stead LF, Buitrago D, Preciado N, et al. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2013;(5):CD000165....

2. Miller WR. Motivational interviewing with problem drinkers. Behavioural Psychotherapy. 1983;11(2):147–172.

3. Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. The Guildford Press; 1991.

4. Rubak S, Sandbaek A, Lauritzen T, et al. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55(513):305–312.

5. Reims K, Ernst D. Using motivational interviewing to promote healthy weight. Fam Pract Manag. 2016;23(5):32–38. Accessed January 11, 2021. https://www.aafp.org/fpm/2016/0900/p32.html

6. New models of primary care workforce and financing case example #1: Stanford Coordinated Care. AHRQ publication no. 16(17)-0046-1-EF. Agency for Healthcare Research and Quality. October 2016. Accessed January 12, 2021. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_1.pdf

7. Chu DK, Akl EA, Duda S, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020;395(10242):1973–1987.

8. Czypionka T, Greenhalgh T, Bassler D, et al. Masks and face coverings for the lay public. Ann Intern Med. 2020; M20-6625.

Lown Institute Right Care Alliance is a grassroots coalition of clinicians, patients, and community members organizing to make health care institutions accountable to communities and to put patients, not profits, at the heart of health care.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Lown Right Care published in AFP is available at https://www.aafp.org/afp/rightcare.



Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

More in Pubmed


May 2022

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article