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August 2, 2019

Why 'finger-wagging' at patients doesn't work (and what doctors should do instead)

Daily Briefing

    In an effort to better connect with patients and improve outcomes, some clinicians are taking a new clinical approach to giving advice that encourages "exploring, guiding, and choosing, rather than directing," physician Perri Klass writes for the New York Times.

    Motivational Interviewing 101: Help patients take an active role in their care

    The problem with 'finger-wagging'

    Doctors for many years have given their patients direct, evidence-backed advice, but it's rare that such open feedback motivates patients to change their behavior, Klass writes.

    In her own experience as a patient, Klass writes that "doctors have suggested better eating habits, more exercise, improved sleep hygiene, not carrying such a heavy shoulder bag, even exercises to improve my posture." But, according to Klass, her behavior never really changed.

    Ken Resnicow, a professor at the University of Michigan School of Public Health, said research shows that most patients have similar experiences.  Put succinctly: "Finger-wagging doesn't work."

    The reason, according to Resnicow, is that "both parents and children respond aversely" when physicians "use what we call the language of control: you must, you should, you have to."

    A better alternative

    In response to these problems, some clinicians are shifting to an approach called "motivational interviewing" to encourage their patients to adopt healthier behaviors, Klass writes.  

    Motivational interviewing "trains doctors to discuss the changes that might help people be healthier, while emphasizing respect for the patient's volition and autonomy," Klass writes. The goal is to get patients to work on improving their behaviors on their own.

    For clinicians, the process is broken down into a series of steps.

    The first step is to "ask permission" from the patient or the patient's parents to discuss a certain topic, according to Richard Wasserman, a professor of pediatrics at the Larner College of Medicine at the University of Vermont. For instance, in the case of an overweight child, doctors could ask the patient's parent, "Would it be OK if we talked about Jennifer's weight?"

    If the parent says yes, doctors may then ask the child to explain what is preventing them from making changes, "and then think about possible small changes and realistic goals," Klass writes.

    The goal is to practice reflective listening, or "responding to what the patient explains, restating what you've heard," according to Klass. Providers can use reflection to help patients think more deeply about their values and goals. In this step, Wasserman explains the provide is "creat[ing] the circumstances to allow people—and for pediatricians that's usually parents—to reflect on the discrepancy between what their values are and what they're doing."

    Then the patient and the provider can create "change plans" for the patient to work on at home, Klass writes. "We work with patients till they feel they want to do it on their own terms," Resnicow said.

    The impact of motivational interviewing

    Melissa Faith, a child clinical psychologist at Johns Hopkins All Children's Hospital, who has trained clinicians in motivational interviewing, said the skill isn't easy to learn, and in some cases could require an organizational shift to get providers to learn and adopt the approach.

    But once providers are accustomed to the method, motivational interviewing can be a positive change for clinicians and patients, according to Faith. "The providers tend to feel they are making a difference in patients' lives," she said.

    Wasserman, for instance, found the approach liberating because it helped him realize "it wasn't my job as a physician to change anybody's behavior."

    Further, when physicians practice motivational interviewing, their patients are less likely to miss appointments and more likely to change their behaviors, Klass writes. "You actually improve clinic flow," Faith said. "People are not crowding the schedule with things they could have made changes at home to prevent."

    Patients also typically rate providers who practice motivational interviewing as more emphatic and as better listeners, according to Faith.

    "The more the physician talks, the worse she does, the more the parent talks, the better she's doing," Wasserman said. "Empathy is the core of motivational interviewing, to recognize what it might be like in the parent's situation and allow the parent to express it" (Klass, New York Times, 5/6).

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