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Am Fam Physician. 2021;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 scale, the action plan is more likely to fail; therefore, the clinician should help the patient refine and simplify the plan until the patient is confident of success. A series of small steps that are likely to succeed can lead to significant changes over time, even if the first action plan seems modest to the clinician.

The final step is asking for permission to follow-up with the patient to see how it went by saying, “You are planning to walk with your spouse for 15 minutes on Tuesday. May we contact you to see how it went?” Recording goals and action plans in the electronic health record can aid in follow-up. The patient determines the cadence of follow-up by granting permission to the clinician. Follow-up should occur soon after the action plan because the action plan is not an end in itself but a small step on the road to the patient's goal. Follow-up can be accomplished through in-person encounters, telephone calls, and video visits and can be performed by any team member the patient knows and trusts.6

Identify and mobilize the patient's intrinsic values and goals to stimulate behavior change, rather than trying to impose the clinician's views onto the patient.
Elicit, clarify, and resolve the patient's ambivalence and allow them to perceive associated benefits and costs.
Resistance and denial are often a signal to modify motivational strategies.
Eliciting and reinforcing the patient's belief in their ability to carry out and succeed in achieving a specific goal is essential.
The therapeutic relationship is a partnership with respect for patient autonomy.

Patient Perspective

Patients go to their physicians for help, not to be lectured. An uncomfortable experience may cause patients to reject advice or even avoid the physician's office altogether.

It is also true that people faced with difficult lifestyle changes may desire change for the sake of others more than for themselves. Risk-taking behavior, such as refusing to wear a mask, is the other side of the same issue: people do not perceive something to be risky if those around them are doing it, and if they do perceive it to be risky, they keep it to themselves. It takes courage to make a public statement such as wearing a mask in certain communities because of the emotionally and politically charged symbolism of masks in present times. A sensitive discussion between the patient and physician would help negotiate this uncertain terrain and develop a rationale for behavior change that the patient could also feel comfortable presenting to others.

The motivational interviewing approach recommends hearing people out and probing the reasons for their beliefs. The COVID-19 pandemic poses a unique challenge in this regard. When individuals summon the self-discipline to effect a change that will improve their health, it is generally met with approval by those around them. However, by wearing a mask during the pandemic, a change of action could mean taking a stand that would subject a person to ridicule, disparagement, or even rejection by the community.

Although it is not advisable to directly challenge or belittle strongly held beliefs, evidence needs to be part of the conversation. Regarding mask wearing, conflicting messages have originated from a wide range of sources since thinking has evolved and become a matter of public debate. Eliciting the patient's values and understanding through specific questions would be a good starting point for an interview. What is the patient's view on the effectiveness of masks in protecting the wearer and others? To what extent does the patient care about the health of their spouse, mother-in-law, and granddaughter? How important is the patient's health to themselves? Does the patient know of anyone who has become seriously ill because of COVID-19? What does the patient think the reaction of friends would be if the patient wore a mask?

A skeptical patient may place more credence in medical opinion when it is supported by the physician's observations and motivated by the physician's concern for the safety of the patient and the patient's family. The ease of any proposed change is also a consideration—although wearing a mask does not seem that difficult, providing a “starter” supply of comfortable masks for the patient and the family will make it that much easier. There may also be clear advantages to wearing a mask that would fit with the patient's values. Does the patient like to take their granddaughter to places that require a mask? Could the patient have fun wearing a mask by getting a mask with a favorite sports team's logo or the granddaughter's favorite cartoon characters?

Resolution of Case

The clinician's job was to listen to this patient's concerns and identify goals. The patient felt respected and listened to; therefore, the patient felt safe to reveal resentment of the public health restrictions and stated that they knew no one who had tested positive for or developed symptoms of COVID-19. The patient also stated that they feared for their family's health more than their own. When asked how important it was to protect their family from a serious illness, the patient rated the importance as 7 out of 10. After the physician asked for the patient's permission to share information, and then discussed the evidence that wearing masks reduces the risk of virus transmission,7,8 the patient proposed an action plan: “I will wear a mask the next time I shop at the hardware store because it's usually crowded.” When a medical assistant phoned the patient to check in a few weeks later, the patient reported that they now wear a mask to all activities outside the home where they come in close contact with others.

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.

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