Medscape Business of Medicine
Neil Chesanow
June 26, 2014
An Approach to Improving Compliance That Works
A growing number of doctors have been using a special technique that gets superior compliance from patients. Here are some of the enviable results:
In a study on medication compliance in 50 people with severe asthma, those who received this technique refilled their prescriptions for inhaled corticosteroids 21% more often in a year, compared with those who received usual care.[1]
In a study of 217 obese women with type 2 diabetes, those who received this technique lost significantly more weight than those who didn’t.[2] They also showed significant reductions in their A1c levels at 6 months.
In a study of more than 2500 teenagers who smoked, those who received it showed significantly higher abstinence rates than those who didn’t after 2 years.[3]
What is this special something?
It’s a way of talking with patients that’s designed to elicit their barriers to compliance and assist them in overcoming those barriers. Studies show that doctors using this method of interaction can often work wonders. They can get people with chronic conditions who consistently don’t take their medications as their doctors prescribe — or follow their doctors’ advice on losing weight, reducing alcohol consumption, stopping smoking, or quitting other unhealthy habits — to begin to take constructive action on their own behalf.
Called “motivational interviewing,” the method was first introduced in 1983 by a psychologist whose goal was to change behavior in people who were alcoholics and drug addicts.[4] The idea was to get them — by showing empathy, being nonjudgmental, and posing simple but strategic questions — to reveal why they resisted behavior change and what would motivate them to change so that they could begin to address their barriers.
This method of talking produced such positive outcomes that over the years, it has been adapted to treating patients with a variety of chronic conditions, from cardiovascular disease to respiratory illness, diabetes, and cancer. The method is currently taught by hospitals, such as Massachusetts General; medical schools, including Johns Hopkins and Duke; nursing schools, such as the University of Colorado’s; and even insurers, such as Blue Cross Blue Shield of Michigan.
Until recently, motivational interviewing required more frequent and longer patient visits than primary care physicians could usually offer, and the original method, designed for addiction specialists, is complex and challenging to learn, with lengthy training that’s impractical for many busy primary doctors.
Over the past few years, however, experts in teaching the method have designed a version that’s realistic for primary doctors to use with noncompliant patients.
Behavioral psychologist Kim Lavoie, PhD, Associate Professor at the University of Quebec at Montreal and Codirector of the Montreal Behavioral Medicine Centre in Montreal, Canada, has trained more than 7000 physicians and other providers in a pared-down version of motivational interviewing that she and other trainers, both here and abroad, have renamed “motivational communication.”
This simplified version, for doctors who are short on time for both formal training and interaction with patients, sticks to basics that are easy to grasp. It can get positive results in as little as 5 minutes, Lavoie maintains. Even in an African nation such as Namibia, where 40% of the population is HIV positive and 30%-40% abuses alcohol, a single session can show positive results.[5] Here’s how it works.
Partnering With the Patient
The key to the method is to partner with the patient. This involves asking the patient’s permission to discuss compliance issues, rather than simply offering advice that often goes in one ear and out the other. For example, “Would you like to know why I think you’re having trouble losing weight?”
Patients who are given the opportunity to grant permission have a greater emotional stake in what is then said, Lavoie asserts. Everything else about the method is built on this partnership.
Once permission is granted, you still don’t give advice. Instead, you ask the patient careful questions that studies show can get the patient to reflect on and verbalize his or her barriers to change, Lavoie says. The idea is to encourage talking by the patient and hold off on advice-giving until later in the visit — even if later is only minutes later.
Many doctors fear that if patients are allowed to talk without interruption, they’ll go on and on, making visits overly long and throwing the doctors off schedule. Research, however, doesn’t bear this out. For example, one study found that when uninterrupted, patients concluded their opening statements in less than 30 seconds in primary care and in about 90 seconds in consultant settings.[6]
“Rather than say, ‘I think it’s time to try a new medication’ — what we call ‘prescribing change,’ saying, ‘Do this, do that’ — this is really a motivational alternative to that,” Lavoie explains. “Instead of saying, ‘Here’s my opinion,’ you’d say, ‘May I give you my opinion? Would you like to know what I think about this situation?’ So it’s really avoiding telling patients what to do and encouraging them to generate their own solutions for their problems that are challenges.”
Won’t this interchange extend 15-minute visits by 10 minutes or longer, knocking you off schedule? The answer is no, Lavoie insists.
“The number of words you say is not actually different from before,” she says, “but the message, tone, and atmosphere of the collaboration are very different.
“Rather than just saying, ‘This is what we’re doing; here’s your results; here’s your prescriptions; see you later,’ you instead say, ‘We’re here to talk about your blood pressure. Your results show that you have hypertension. I’d like to discuss treatment options with you. Would that be okay?’
Engaging patients in agenda-setting takes only a few moments, she maintains.
A Different Kind of Doctor-Patient Interaction
“As a second step, you’ll probably want to provide some patient information,” Lavoie says. “Motivational communication prescribes a certain way of doing this that is more likely to be well received.”
“The first step,” she says, “is always asking permission before giving information; ensuring that patients have understood what you said; and asking them whether there’s something about a given treatment, say, that they would like to hear more about.”
For example, you might say, after recommending a medication, “There may be side effects, but they’re usually not too bad. Would you like to know about them?”
This may strike some doctors as a bit galling. “Patient pay to see me,” they may think, not unreasonably. “Do I really need to ask their permission to tell them what I think? Isn’t that why they’re here: to learn what I think?”
This, as it turns out, is one of the most complicated questions in medicine. After 40,000 studies on compliance, a definitive answer remains elusive.[7]
Yes, patients come to learn what you have to say. But many patients simultaneously feel ambivalent about what they hear. You may say, for example, “You really need to go on a diet.” What patients may hear is, “Oh my God, the doctor wants me to fundamentally change my lifestyle, which I like — forever.”
In the end, it comes down to this: Do you want to be right, or do you want to be effective? Research shows that asking permission can be remarkably effective.
It may be effective, but it only gets you in the door. Ambivalence and resistance are normal parts of the change process, Lavoie notes. If you want to get noncompliant patients to be compliant, these barriers must be addressed.
Simple Questions to Get Patients Talking
“If there’s resistance to the information that’s discussed, then you want to explore the patient’s ambivalence about or resistance to change,” Lavoie says.
How do you explore this ambivalence? One way is to ask open-ended questions that can help the patient, in attempting to answer them, realize the gap between his current state of health and where he would like it to be. If patients can come to this realization on their own, without you simply telling them, it may actually sink in, Lavoie says. They often become more motivated and open to change.
There are many open-ended questions you might ask, but they shouldn’t have yes/no or simple answers. The goal is to get patients to think about and verbalize what it would take for them to change unhealthy habits, Lavoie says. For example:
• What’s good about your behavior? What’s not so good?
• How would your life be different if you weren’t doing X?
• What would you need to change to achieve your goals?
Behavior change is tough. Expressing empathy is important. When patients feel understood and not judged, they are more apt to open up, Lavoie says. The more they reveal, the better able you then are to offer them information and support.
Here are examples of empathetic statements:
• I know how hard this is.
• I understand what you’re saying.
• That must have been hard for you.
Patients who are noncompliant are typically ambivalent about changing chronically unhealthy behavior, Lavoie notes. By recognizing and discussing patients’ ambivalence in a nonjudgmental way, you help them to acknowledge the problem. Owning up to the fact that one indeed has a problem is a necessary precondition for exploring the problem and working it through.
Questions that draw patients’ attention to their ambivalence include:
• Has your behavior ever caused problems for you or anyone else?
• What was life like before you started having problems with X?
• If you keep doing what you’re doing, how do you see things turning out?
Using Scales to Get Patients to Talk
To move patients from clarifying their barriers to compliance to revealing what they would need to do to overcome their barriers, the concept of a 10-point scale can be useful, Lavoie says.
“‘Mr. Jones, I just want to get a sense of where you’re at with the smoking,'” she offers by way of example. “‘On a scale of 0-10, how important would you say it is for you to consider stopping now?’
“Let’s say that Mr. Jones gives you a 7, which is kind of important,” Lavoie observes. Following the method, “you would say, ‘Tell me why you picked a 7 and not a lower number?’ That’s going to get Mr. Jones talking about why it’s important to him to quit. What does he see as a benefit?”
“For behavior change to happen — not just with your patients, with anyone — people need what I call the ‘what’s-in-it-for-me?’ factor,” Lavoie says. “Even when changes are good for you, they often involve sacrifice — smokers want to smoke, overweight people probably like to eat — and you need to feel that in making this change, you’re going to see a personally relevant benefit.”
What if Mr. Jones picks 2, meaning that he’s not very motivated to quit?
“Then you would say, ‘Mr. Jones, right now quitting smoking doesn’t sound very important,” Lavoie replies. “What would have to happen for your 2 to go to a 6 or 7?'”
“He’s still going to tell you his reasons,” Lavoie says. “For example, ‘I guess I’d have to be sick.’ And then you would acknowledge that.”
Arguing with a patient is a no-no. Ambivalence and resistance are normal parts of the change process, Lavoie says. The method stresses doctor-patient collaboration, not confrontation. Instead of trying to control the conversation, explore the patient’s concerns. Ask permission to offer a different perspective.
“Instead of asking, ‘What are you lacking?’ you’re really asking, ‘What do you need to succeed, and how can I help you?'” Lavoie says. “The patient might say, ‘Well, I’d need my partner to quit smoking too.’ Or, ‘I’d need help with side effects.’ Or, ‘I’d need to be reassured that I won’t gain weight.’
“And then you’d address that, “Lavoie says. “For example, you might say, ‘There are things we can do to prevent or minimize weight gain. Would you like to hear about them?’ The patient will say yes. Then you’d say, ‘Okay, there’s this and this and this. Not a problem.’ And the patient says, ‘Wow, I didn’t know that.'”
Simply by asking patients’ permission, she says, they are more willing to listen.
Planting the Seeds for Change
A visit concludes with the doctor summarizing the solutions that the patient has verbalized, and then asking the patient what he or she thinks is possible to accomplish by the next visit.
“You get patients to weigh in on what they think is acceptable now, what they have tried, what’s worked in the past, or what’s worked for their friends,” Lavoie says. “You really want to get them talking. The more they generate solutions, the more their solutions are going to be realistic for them, and the more likely they are to do them. Then you say, ‘Great. What do you think is feasible between now and when I see you again in 6 months?’ The patient may say, ‘Well, maybe I could try this and this.’ And you say, ‘Wonderful! Good job!’ And you’re done.”
“You’re just planting the seeds for change at this point,” Lavoie says. “That can certainly be accomplished in 5 minutes. Mr. Jones then leaves your office thinking, ‘What would have to happen for me to stop smoking? Do I really want to get sick before I decide to quit?'”
You can get the ball rolling in as little as 5 minutes because most change happens incrementally over time, Lavoie says. It’s a process. When you see Mr. Jones next, even if it’s months away, you can then build on the groundwork for change that you helped him lay previously, continuing to help him chip away at his resistance, visit by visit, until his barriers to compliance are overcome.
Developing Your Skills
Motivational communication includes a variety of concepts and tools, and the number of different situations with noncompliant patients in which to use them is vast. To get good at this, some training is recommended. Most training is divided into 2 parts: concepts and skills, and role-playing doctor/patient scenarios.
Regardless of your preference, there’s a training format for it. There are live workshops offered by medical centers, as well as by individual trainers — who are often psychologists, nurses, or social workers, as well as some physicians — who may go on multi-city training tours. Hospitals, medical and nursing schools, insurers, and a plethora of “institutes” offer online courses, often for continuing medical education credit. You can read a textbook, view training videos (many free), attend a Webinar, download a podcast, read journal articles galore, and use flash cards to remind you of key concepts and tools in your office.
Seminars and workshops may extend over a period of weeks or months, but briefer, more comprehensive sessions are available as well. Even a few hours of training can produce positive results in patients, Lavoie contends. She says that many doctors begin with live training to get an introduction to the basics and then switch to online courses, because they are more convenient, to hone their skills.
“Some motivational communication is better than none,” she says, “and more is better than less. The nuts and bolts of what you’re saying isn’t different. That’s why it shouldn’t take longer. What’s different is how you deliver the message.”
References
- Lavoie K, Moullec G, Blais L, et al. The efficacy of brief motivational interviewing to improve medication adherence in poorly controlled nonadherent asthmatics: results from a randomized controlled pilot study. Program and abstracts of the Chest 2011 Annual Meeting; October 22-26, 2011; Honolulu, Hawaii. Abstract 4.
- West DS, DiLillo V, Bursac Z, Gore SA, Greene PG. Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care. 2007;30:1081-1087.
- Hollis JF, Polen MR, Whitlock EP, et al. Teen reach: outcomes from a randomized, controlled trial of a tobacco reduction program for teens seen in primary medical care. Pediatrics. 2005;115:981-989.
- Resnicow K, Dilorio C, Soet JE, Ernst D, Borrelli B, Hecht J. Motivational interviewing in health promotion: it sounds like something is changing. Health Psychol. 2002;21:444-451.
- Clinical Training Institute. Taking skills to Namibia and Tanzania. http://www.motivationalinterviewing.info/about.html Accessed May 2, 2014.
- Rabinowitz I, Luzzati R, Tamir A, Reis S. Length of patient’s monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care. BMJ. 2004;328:501-502.
- Honigberg R, Gorden M, Wisniewski AC. Supporting patient medication adherence: ensuring coordination, quality and outcomes. URAC. 2011. http://adhereforhealth.org/wp-content/uploads/pdf/URAC-MedAdherence_WP.pdf Accessed May 6, 2014.