“I really hope you aren’t going to be one of those doctors who lectures me,” my new patient said at the start of our visit. “My last doctor talked to me like a school teacher to a child, rather than to an adult man with his own business.”
The school teacher analogy struck a chord with me. More and more, doctors are being grading on “performance,” with increasing pressure to demonstrate patient achievement of various goals such as A1c reduction, statin use, and smoking cessation.
Primary care physicians are being held accountable for improving patient health parameters, even though outside of our short interaction with our patients in the exam room we have no control over our patients’ behaviors and choices. In an average ten-minute visit, we are expected to satisfy a checklist of criteria which will be electronically zapped to a third-party payer for review, who will in turn respond with “Dear Provider” letters, charts comparing us to other physicians, and pay cuts for failing to make the grade.
Is it any wonder physicians turn to lecturing our patients?
The problem is that lectures don’t work to motivate patients. Why? Because the use of guilt and threats are horrible motivators. The same goes for doctors. Send us threatening letters, call us “non-preferred providers,” and shove pay-for-performance down our throats. You still won’t get better care out of us. And doctors won’t get better results out of our patients.
The problem is that carrots and sticks – also known as extrinsic motivators - don’t function well with the complexities of the human mind. Extrinsic motivators actually make us less likely to want to do something and even inclined to try to game the system.
What does work is intrinsic motivation: helping patients – and doctors – to discover what will motivates them internally to succeed, and to determine the best steps that they can take to realistically achieve that success. By considering what we find naturally satisfying and rewarding, we can use this insight to direct our behaviors towards our goals.
While we may not be able to convince the government or insurers of the value of intrinsic motivation for physician reimbursement, we can apply these principles to patient care to get better results and make our office visits more efficient. One way to harness the power of intrinsic motivation is through a technique called motivational interviewing.
Motivational interviewing can inspire change in any patient – even those who initially seem to show no interest in changing. The hallmarks of the technique include helping the patient to find their own reasons for change by eliciting their ideas and feelings using open-ended questions, and reinforcing these motivators with reflective listening and empathy. If the patient begins to demonstrate a willingness to change, the next step is to help the patient think through their own solutions and then create an action plan.
Inspired by a video I watched, I practiced motivational interviewing with one of my patients with elevated liver enzymes who admitted to drinking more alcohol than she should. I had lectured her previously on safe levels of alcohol consumption, the need to cut back on drinking, and even discussed medication options to help her. “I know, I know,” she would tell me, rolling her eyes, and despite my lectures, her liver tests and other markers of hepatic dysfunction continued to bump up at each visit.
I decided to give motivational interviewing a try. “Would anything in your life get better if you cut back on drinking?” I asked her.
“Well, my husband would be happier and would probably stop nagging me so much,” she answered. She suddenly seemed thoughtful. “That certainly would be a good reason to quit.”
That was an interesting response to me. I had been lecturing her about how much her health would improve if she quit drinking, which never made her bat an eyelash. Instead, what really motivated her was the idea of getting her husband off her back!
Following motivational interviewing, I used the technique of reflective listening and validation, nodding empathetically and responding, “Sounds like things would be much more pleasant around your house if you cut back on drinking.”
“You got that right!” she answered.
This was the first positive response I had ever seen from my usually recalcitrant patient. When I saw that she was showing evidence of contemplating change, rather than suggesting medication or AA like I would have done before I learned about motivational interviewing, I used the technique of having her come up with her own possible solutions. “What would be a first step you could take to cut back on drinking?” I asked.
“I could go back to drinking tea at breakfast instead of vodka,” she answered without hesitation. This answer stunned me - while I suspected that my patient had a drinking problem, I never imagined the severity, and here she was, opening up to me just by this simple open-ended question.
We discussed her plan for a bit longer and wrapped up the visit. I was doubtful that my patient would take any real action, but a month or two later my patient was back in the office for repeat labs, looking healthier than I had seen her in some time. She had cut back on drinking, but what she really wanted to talk about was her new exercise plan. “I’ve been taking water aerobics at the Y three days a week,” she told me. “I have much more energy.”
While motivational interviewing may not work every time, I was amazed at how well it had paid off in this case. Techniques like this and other tools from psychology can help physicians get better results from patients, but unfortunately, physicians don’t always get much training in how to apply psychology in the exam room. The good news is that there are conferences, CMEs, and online learning modules to study techniques like motivational interviewing, including this online resource, online toolkit, eBook, and intensive training course.