Motivational interviewing is an effective strategy for encouraging health behavior change and improving outcomes for people with alcoholism, substance abuse, and several chronic medical conditions.1,2 Despite its effectiveness, translating the use of motivational interviewing into primary care visits has proven difficult because of the increased time it takes to get at the “whys” behind patients' behaviors.
Two key elements for successful health behavior change are that the patient must have 1) the desire to change and 2) the confidence that they can change. Only then can you help the patient establish a workable process for change.
Using a modification of motivational interviewing principles to promote health behavior change has significantly increased my effectiveness at helping my patients set goals they want to accomplish and they succeed in completing. This process is about helping patients build the skill of setting a goal they can — and want to — accomplish and keep. Many health conditions are amenable to motivational goal setting, but this article will focus on four areas where this can be done in a reasonable amount of time in the office setting. Those areas are 1) nutrition, 2) activity, 3) emotional well-being, and 4) smoking reduction.
When setting goals with patients, be careful not to set too many goals at once and to tailor the goals to what is most important for them regarding health behavior change. For example, if a patient has diabetes and wants to lose weight and control their blood sugar, setting one nutrition goal and one activity goal is reasonable.
Motivational interviewing is an effective strategy for encouraging health behavior change, but incorporating it into office visits has proven difficult because of the time required.
The “IQSC” four-step modification of motivational interviewing principles can help patients quickly set health goals involving behavioral change.
This process is designed to be “no fail” and to build patient confidence to change.
THE FOUR STEPS
The four steps to setting patient-centered goals are described below and labeled IQSC:
Identify what the patient wants to change,
Quantify what they are doing now,
Get the patient to set a goal they guarantee they are going to keep, no matter how small the goal may be,
Confirm the goal is theirs, not yours. Many patients will say they are going to do something in order to please their doctor, not because they intend to do it; therefore, make sure the goal is focused on what they want to do, not what they think you want them to do.
Here's how each step in the IQSC process looks in practice.
Identify: To identify what habit the patient wants to change, I like to use open-ended questions as much as possible because I learn more about what is important to them. For a nutrition-related goal, ask, “What is one nutritional habit you could change and are willing to change?” The most common examples in my practice are “I eat fast food too often,” or “I drink too much soda.” For activity, ask, “What is a physical activity you enjoy doing and would like to do more?” Examples include walking, swimming, gardening, dancing, playing hockey, or weightlifting. For emotional well-being, ask, “What is an activity you enjoy doing to feel better or relieve stress?” I enjoy this question because I am always surprised at the answers. Some examples I have heard are “I am a professional opera singer, and I would like to do more of it,” or “I have a collection of birds I enjoy taking care of.” (This person had 47 birds!) For smoking reduction, ask, “Do you want to cut down on your smoking?” Note that the focus is on smoking reduction and not smoking cessation, as abstinence-only programs do not tend to work long term.
Quantify: For the quantification question, ask, “On average, how often do you do that?” For example, a patient might say they eat at fast-food restaurants five times per week. I have had patients say they drink as many as 12 cans of soda per day. Quantification of current behavior is key to the next step.
Set: To help the patient set a goal, ask, “When I see you next month, what can you absolutely guarantee me you will decrease [or increase] that to?” If they are increasing a habit, the goal will be minimal (e.g., walk at the park at least three times per week), but if they are decreasing a habit, the goal will be maximal (e.g., no more than three cans of soda per day). The goal needs to be simple, obvious, and easily doable. Because you are asking the patient to guarantee they will accomplish this goal, you will need to help them assess any barriers (e.g., lack of meal planning, which leads them to stop at fast-food restaurants). Their confidence level must be at 10. If they are not completely confident that they can accomplish the goal, do not to set the goal. This is designed to be a no-fail system to build confidence.
Confirm: The last step is the confirmation question to make sure the goal is the patient's, not what they think you want them to do. For the confirmation question, ask the patient if they want to make the goal easier. For example, if a patient currently goes to fast-food restaurants five times per week and wants to set a goal of three times per week or less, ask them, “Do you want to make it four times a week or less?” It is not until they push back and say, “No, I want to make it three times per week or less” that you can set the goal together.
Two body-language signals indicate that you and the patient are on the right path. First, when setting the goal, the patient spontaneously smiles. I believe patients do this for two reasons: 1) they no longer fear displeasing their doctor and 2) they feel confident — and feel good about feeling confident. The second body language signal is during the push back. When you ask the confirmation question and they say “no,” they often vigorously shake their head.
WHAT SUCCESS LOOKS LIKE
The success that occurs from this form of health behavior change is gradual, more like a plane entering the runway and taking off. For example, a few years ago, I asked a patient what nutritional habit she wanted to change. She said, “I drink too much soda.”
When I asked how much soda she drinks, she said 12 cans per day. “By next month, when I see you, what can you guarantee me you will be down to?” I asked.
She said, “Six cans a day,” and smiled.
“Do you want to make it seven?” I asked.
“No,” she said and shook her head.
Anticipating that she would miss the carbonated beverages, she decided to replace six of the cans of soda per day with zero-calorie, carbonated, flavored water. By three months, she realized she liked the flavored water as much as soda and stopped drinking soda entirely. This was the only nutritional advice I gave her. She lost five pounds the first year, 12 pounds by the end of year two, and a cumulative 20 pounds by the end of year three.
PRACTICAL QUESTIONS FOR PHYSICIANS
Before implementing this approach, physicians may have the following questions.
How much time does it take? These steps do not take a long time to accomplish in the office. It takes less than two to three minutes to set a goal. The follow-up is even easier. I simply ask, “How are you doing with your goal?” Most patients are excited to share what they have been doing and how it has worked. Because they have taken ownership of the goal, when they accomplish it, they are proud of themselves and eager to talk about it.
What do you do if the patient does not accomplish the goal? Remember this is supposed to be a no-fail system that is about skill building. About 95% of the patients I set goals with accomplish their goals or exceed them. The 5% that do not accomplish their goals usually have an external reason for that. For example, one patient was going to go to the gym three times per week until her mother became ill and she had to use the time to take care of her. If patients do not reach their goal for any reason, I say, “We did not set the right goal. Let's reset it.”
Too often, patients beat themselves up for failures and then give up, so it's important to resolve ambivalence. In other words, normalize the tension between wanting to change and not wanting to change. When you resolve that ambivalence, guilt disappears and confidence improves. So, once a patient sets a goal, I make sure they have the necessary health education around that goal and then I tell them, “Enjoy your vices.” I don't want their progress to get derailed by guilt. Using the example of the patient who wants to reduce their fast-food consumption from five to three times per week, I would say, “Enjoy your fast food those three times.”
Should I do this with every patient? Not everyone needs to change their health behavior. If their habits are good, you can quickly help them set a maintenance goal by saying, “Just continue doing what you are doing.” For example, if a patient says, “I run three miles three times a week, and I lift weights three times a week,” simply encourage them to continue what they are doing. For chart documentation, state the goal they are going to accomplish and say confidence level 10 and barriers zero.
MAKING CHANGE DOABLE
Despite the time limits, health behavior change can be accomplished in primary care office visits. Motivational interviewing principles can help to resolve ambivalence and promote patients' desire to change and confidence to succeed at completing their goals. Primary care physicians can elicit from patients a practical way to achieve their health goals using the four steps identified in this article.