I once had a patient do what I said. I said, “Quit smoking.” And he did.
OK, maybe this has happened more than once.
But wouldn't it be nice if it happened more often? If our patients would just follow our advice to quit smoking, exercise, eat better, and take their darn medicine, they would so much healthier and our jobs would be so much easier.
Once there was a mythical time, before the age of consumerism, when patients did what their doctors said. They didn't ask questions, and they took their medicine. Of course, back then physicians smoked along with their patients and didn't advise two-thirds of their patients to exercise and lose weight.
We are trained to be the experts – the oracles with the answers. Yet we've been told our responsibility doesn't end there. It isn't enough to have the answers. We also need to know how to deliver the message. So now we deliver written instructions at a sixth-grade reading level, hand out clinical summaries, and give longer verbal instructions. But despite our good intentions, people still keep getting fatter, smoking, drinking to excess, and not taking the medications we advised them to take.
Enter motivational interviewing. This proven approach to getting folks to change behavior has been around for more than 30 years, but only in the last few years has it gained traction in primary care. FPM introduced the topic in 2011,1 and we bring it up again in this issue with an article by Kathleen Reims, MD, FAAFP, and Denise Ernst, PhD, called “Using Motivational Interviewing to Promote Healthy Weight.”
Around seven years ago I read a wonderful book called Motivational Interviewing in Health Care: Helping Patients Change Behavior.2 I was so enthralled that I told my partners about it, declaring that this should be required reading for every primary care physician. The approach resonated with me, and yet seven years later I still often fail to fully utilize it when I should. Why?
Well, it does take more time. It's not that I don't attempt to spend quality time with my patients, but there are just so many things that need to be accomplished in a visit these days. But time likely isn't the major barrier. Many aspects of motivational interviewing can be included in a visit with only a small increase in time. I believe a larger barrier is my own sense of identity as a physician. Motivational interviewing consists of interesting sounding techniques like OARS, SMART goals, Ask-Tell-Ask, change talk, and scaling questions, but more importantly, it requires an entirely different perspective on the nature of the physician's role. As a practitioner of motivational interviewing, your goal isn't to heal, but to help. It isn't to solve your patients' problems, but to help them solve their own problems. This is a tough mental shift from the more comfortable expert-teacher role. It goes against our natural tendency to just want to fix things.
When I think about the challenges of implementing motivational interviewing in our daily workflow, I imagine Bones, that can-do family physician of “Star Trek” fame, saying to Captain Kirk, “Damn it, Jim. I'm a doctor, not a self-help guru.”
I'd really like to be a healer in the broadest sense and help my patients overcome unhealthy lifestyle choices, so I'm not about to give up on motivational interviewing. I guess I'll just keep practicing and trying harder to incorporate a motivational interviewing perspective into my patient encounters. Maybe eventually I can become both a healer and a self-help guru.