The challenge of changing patients’ health behaviors

When Auguste Fortin VI, MD, MPH, FACP, began practicing medicine, he often felt frustrated over his inability to change patients’ unhealthy behaviors such as smoking and not exercising.  

That changed about 15 years ago, after he read the book “Motivational Interviewing: Helping People Change,” by William Miller and Stephen Rollnick. It helped him to see it wasn’t his job to “change” patients, but rather to guide them on a path that helps them see for themselves the importance of engaging in healthy behaviors.

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Now an associate professor in the Yale School of Medicine’s primary care/internal medicine residency program, Fortin will speak at this year’s American College of Physicians Internal Medicine meeting in Washington, D.C. His session, “Motivational Interviewing: On a Scale of 1-10, How Interested Are You?” will take place Saturday, May 7. He spoke with Medical Economics about the value of motivational interviewing.     

ME: Please define the term “motivational interviewing”

Fortin: It’s a technique for interacting with patients that seeks to uncover and strengthen their own internal motivation to change harmful health behaviors. It’s a departure from what lots of us physicians were taught and in fact practice, which has more to do with scolding, warning and cajoling. Motivational interviewing has been shown to be more effective than the techniques and strategies that we usually use.

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ME: Why is it important for internists to know how to use it?

Fortin: If medicine were just about making the correct diagnosis then we wouldn’t need motivational interviewing. But because medicine is actually about getting people better, and because patients own such a huge role in their health, we need to help patients change behaviors that keep them from being healthy, whether it’s taking a medicine we’ve prescribed, or undergoing a test we’ve recommended, or changing a harmful behavior like smoking or using alcohol to excess.

Next: What happens when you encounter resistance from patients?

ME: Are there diseases or conditions for which motivational interviewing is particularly effective?

Fortin: It was developed initially by mental health professionals for use in the substance abuse realm, but has also been shown to be effective for smoking, alcohol use and weight loss. We can use motivational interviewing to gradually move them towards a decision that’s better for their health.

ME: How would you define a good outcome of a motivational interview?

Fortin: For many years, if I had a patient come in who was a smoker and I didn’t get that patient to quit smoking as a result of the visit I felt like I’d failed. But with motivational interviewing we learn that changing a behavior is a process, and if I can move a patient a little closer to the day when they will quit smoking, for example, then I view that as success.

ME: So if a patient who comes to you who smokes a pack a day, and you recognize he’s not going to quit as a result of this appointment, how would you hope he’d be different when he leaves the interview than when he came in?

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Fortin: I would hope that patient would be able to tell me what was important about smoking for him, and whether he had any sense of a future desire to look at this. And I’d hope he’d leave knowing it would be OK to reopen this conversation at a future visit.

The goal is to get the patient to what we call change talk. Those are phrases that speak to the patient’s desire to change or ability to change or reasons to change. When the doctor does all the change talk, then the patient-regardless of how they actually feel-tends to dig their heels in and hold even more tightly to a position that in their heart they know is wrong but it’s natural to become defensive when you feel attacked or threatened as well-intentioned doctors often do with their patients.

ME: You probably encounter resistance from some patients who say, “you’re the doctor, you fix it.” How do you overcome that?

Fortin: I more often encounter resistance in terms of people holding on to the behaviors. So let’s take smoking for example. I might ask, ‘have you considered making a change to your smoking?’ The patient says, ‘No, it’s the only thing that helps me relax, and my grandfather’s been smoking a pack a day and he’s 90 years old.’

Next: Why motivational interviewing is 'satisfying'

When encountering that resistance, the strategy is to roll with it, rather than trying to provide them with data showing that their point of view is quote unquote wrong in the medical sense. I might say, ‘So you’ll probably continue to smoke for the rest of your life?’ What often happens then is the patient responds with change talk. The patient will say ‘well no, not for the rest of my life, because I know it’s not good for me.’ So that’s a few phrases of change talk that just came out of the patient’s mouth because I rolled with the resistance rather than try to confront their resistance, which would only make them more resistant.

ME: What are some takeaways from your session?

Fortin: I think that using motivational interviewing is satisfying. It allows us to let go of our rescue fantasies, that we can make a person quit smoking or stop using drugs. Often we think it’s our job to do that. But our job is to coach and to help the patient uncover the reasons why they might want to make a change and then to help strengthen those reasons by being a supporter and cheerleader.