Patient-Centered Communication:

Core Skills for Motivation and Change

Learning Objectives

• Recognize that communication is an essential component of the practitioner’s role and has lasting effects over time

• Discuss the philosophy and proven principles of motivational interviewing that primary care physicians can implement to empower patients to achieve their health goals

• Demonstrate motivational interviewing as a technique for improving overall adherence to therapies

• Apply motivational interviewing techniques in typical practice settings with patients who have diabetes or other chronic illnesses and related comorbidities

First Premise:Communication matters

• Communication is the physician’s responsibility– Is an essential component of the role– Cannot be delegated– Has lasting effects over time

First Premise:Communication matters

• Health outcomes– Diagnostic accuracy– Adherence

• Social outcomes– Patient satisfaction– Physician satisfaction– Decreased malpractice risk

Communication improves health outcomes

• Symptom resolution• Psychological stress• Health and functional status• Blood pressure control• Pain control• Patient anxiety

Communication improves diagnostic accuracy

• Quality of clinical data

• Quantity of clinical data

Communication improves adherence

• An important predictor of adherence is the interpersonal skill of the physician

Communication improves patient satisfaction

• Physician understands patient• Physician elicits patient’s health concerns• Patient is comfortable with asking questions• Patient perceives sufficient time is spent with the

physician

Communication improves physician satisfaction

• The quality of the physician-patient relationship is the most important predictor of global career satisfaction for physician.

Second Premise:Communication is a Procedure

• Used most commonly– We conduct over 100,000 interviews in our career

• Communication is a procedure that can be learned• Mastering communication requires practice and

experience

Tasks for successful communication

• One Approach to communication:

• Engage• Empathize• Educate• Enlist

Engagement

• A connection which continues throughout the encounter– Person to person– Professionally, as partners

Tools for Engagement

• Introduce yourself• Greet your patient• Welcome your patient• Maintain eye contact

Tools for Engagement

• Use the first few minutes to build rapport• Use a pleasant, consistent tone of voice• Be as curious about the patient as you are about their

medical condition• Use open ended questions• Allow the patient time to tell their story

Tools for Engagement

• Elicit your patient’s agenda– Elicit expectations or goals for the encounter– Get all the complaints– List issues– Prioritize

Outcomes of successful Engagement

• More accurate diagnosis• Increased likelihood of adherence to treatment• Establishment of a partnership between the patient

and the physician

Empathy

• Patient experiences– Being seen– Being heard– Being accepted

• “Perfect understanding”

Tools for Empathy

• Acknowledge:– Facial and body expression– Physical presentation– Notable physical characteristics

• See fully clothed new patients• Eliminate physical barriers

Tools for Empathy

• Listen to the patient’s story– Patient’s feelings– Patient’s values– Patient’s thoughts and ideas

• Reflect your understanding– Reflective listening– List issues

Tools for Empathy

• Judge the behavior, not the person• Normalize when possible• Use appropriate self-disclosure• Focus on the patient’s feelings (empathy) rather than

your own reactions (sympathy)

Outcomes of Successful Empathy

• Improved adherence• Increased level of connection and mutual satisfaction• Reduced physician frustration• Reduced patient anxiety

Education

• Goals:– Greater knowledge and understanding– Increased capacity and skills– Decreased anxiety

Tools for Education

• Assess current knowledge– “What do you think is going on?”– “Why do you think this has happened?”– “What do you understand about your condition?”– “What worries you most?”

Answer the mysteries of health

• What has happened to me? (Diagnosis)• Why has it happened? (Etiology)• What’s going to happen to me? (Prognosis)

Outcomes of successful Education

• Increased understanding• Decreased confusion• Decreased anxiety• Improved adherence• Greater patient and physician satisfaction

Enlistment

• An invitation from the physician to the patient to collaborate in the decision-making surrounding the problem and the treatment plan

Factors that affect adherence

• Patient’s perception of the seriousness of the condition

• Patient’s perception of the efficacy of the treatment• Duration of both the treatment and the illness• Complexity and expense of the regimen• Relationship with the physician

Tools for Enlistment

• Assume the patient has an internal belief system regarding his condition that includes the following:– Cause and solution– Functional meaning– Relational meaning– Symbolic meaning

Tools for Enlistment

• Keep regimen simple• Tailor treatment to individual’s habits and routine• Get feedback from the patient• Write out the treatment plan• Identify and remove obstacles

Outcomes of successful Enlistment

• Increased motivation• Increased adherence• Partnership• Increased satisfaction• Improved health

Compression of Mortality

Huben, Bloch, Oehlert, Fries, 2002Jagger, Matthews, Matthews, et al., 2007

0102030405060708090

100

Poor lifestyle management Effective lifestylemanagement

Disabled

Morbidity

Healthy

Lifestyle Sets the Stage

The Non-Adherence Problem: Lifestyle Management

• 21% of US adults smoke cigarettes• 33% of US men and 35% of US women are obese• 51% of US adults do not exercise regularly• 75% of US adults do not eat 5 fruits/vegetables a day• 19 million new STD infections occur each year in the

US• 15% of the US population report binge drinking

Source: CDC

The Non-Adherence Problem: Medication

• Only 50% of patients take medication as prescribed. (World Health Organization)

• Non-adherence affects Americans of all ages, both genders and across socioeconomic levels

• Lack of medication adherence estimated at $177 billion annually – Unnecessary disease

progression;– Disease complications;– Reduced functional abilities;– Lower quality of life;– Premature death– (National Council on Patient

Information and Education, August 2007)

Lifestyle Management is simultaneously

the key… and

the barrier

The ‘Non-compliant’ Patient

• What does it mean when we say that people are ‘non-compliant’? – Are they ignorant? – Unmotivated?– Non-caring about their welfare?– Rebellious?– Lazy?

What do You Know You ‘Should’ be Doing but You’re Not?

How do you feel about being called ‘non-compliant’?

Why Don’t People Change?

Motivation …

a central puzzle in behavior change.

Four Popular Notions:The problem with them is ...

• They don’t see; in denial

• They don’t know

• They don’t know how

• They don’t care

What Does It Take?Four Common Solutions

Give them:

• Insight - if you can just make people see, then they will change

• Knowledge - if people just know enough, then they will change

• Skills - if you can just teach people how to change, then they will do it

• Hell - if you can just make people feel bad or afraid enough, they will change

Persuasion Approach

• Think of something that you

Want or need to change;

Have been told that you “should”

change; or

Have been trying to change...

But you haven’t done it yet

• I need a volunteer who is independent

and strong-willed…

Activity: Persuasion

My role in this model is to be the expert.

My objective is to assess and prescribe.

• Explain why this this change should be made

• Give at least three benefits that would result from

making the change.

• Give advice about how to do it;• Convince the client about how important it is to change.• Get consensus about the plan.

Activity: Persuasion

• How did the client feel about the process?

• Did any movement towards change occur?

Better Questions

• What does motivate people?

• Why do people change?

• What can we do to help?

Why People Change

Over the last two decades, researchers have explained this by exploring:• Priorities and values (Values Theory)• Perceived benefits and consequences (Health Belief

Model) • Self-efficacy (Social Cognitive Theory)• Ambivalence (Motivational Interviewing)• Stages of change (Transtheoretical Model)• Activation (Patient Activation Model)• Planning (Implementation Intentions Model)

All rights reserved. No portion of this presentation may be duplicated or used in any way without permission.

Patient Activation

48

Activation is related to many health

behaviors and outcomes.

A Different Approach

• Same volunteer

• Same topic

A Different Approach

My role is to understand and collaborate.My objective is to elicit ‘change talk’ and build motivation

for change.• Listen, probe, understand and reflect back understanding.• Ask thought-provoking questions that elicit desire, ability,

reasons, and need to change.• Find out what works and what doesn’t for this individual.• Give a short summary and elicit plan of action if

appropriate.

A Different Approach

• How did the client feel about the process?• Did any movement towards change occur?

All rights reserved. No portion of this presentation may be duplicated or used in any way without permission.

Behavior Change Science

• People need more than well-intentioned advice or scare tactics to get them to change.

Which Coaching Style is Best for Addressing Treatment Adherence & Lifestyle Change?

DirectManage Prescribe

LeadTell

FollowLet leadLet beAllow

Go along

GuideShepherdEncourageMotivate

Accompany

Motivational Interviewing

• “A client-centered, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” (Miller, 2006)

GuideShepherdEncourageMotivate

Accompany

Snapshot of MI Literature Review

• Emerged in addictions field in the 1980s (Miller & Rollnick)

• Over 300 clinical trials

• Primary care • HIV • Diabetes

• Public health • Smoking • Adherence

• Health Promotion

• Diet • Obesity

• Dyslipidemia • Hypertension

• Exercise

Snapshot of MI Literature Review

• www.motivationalinterview.org• Research supports MI as being:

– Equivalent to more intensive treatment– Efficacious at low dose (2-3 sessions)– Effective as pre-treatment adjunct– Most effective approach for less motivated, less ready people– Applicable in wide range of situations for diverse populations– Successful in improving patient activation, self-efficacy, health

status, and clinical values

First, Do No Harm…

Worst Case Scenario

The least desirable situation is for the provider to argue

for the change while the patient argues against it

By simply reducing resistance, we

increase the odds of a good clinical outcome

(Amrhein et al., 2003)

Talk about change:Desire Ability

ReasonsNeed

Increased commitment

strength

Behavior change,

treatment adherence& clinicaloutcomes

Amrhein, Miller, Yahne, Palmer & Fulcher, 2003

Moyers & Martin, 2006

Evoking Change Talk

Best Case Scenario

MI Technique: Rolling with Resistance by Using Reflective Listening/Empathy

• Objectives: To establish rapport and avoid resistance by demonstrating your understanding of the patient’s situation. To avoid pushing against and magnifying the resistance.

• Example: “It’s not easy making all these changes. You’re thinking that you might not want to take the medication anymore. ”

• Follow-up after giving patient a chance to respond: “On the other hand, you said that you know that these numbers [A1Cs and blood glucose levels] put you at risk.”

MI Technique: Elicit-Provide-Elicit (E-P-E) Technique

• Objective: To find out what the patient already knows, fill in the gaps or correct misconceptions, and explore how this will fit into the patient’s life. This is a time-saving strategy that both validates patient knowledge and allows time to address barriers.

Example: • Elicit: “Mrs. Roberts, what do you know already about

what helps to manage diabetes?” … • Provide: “That’s great. You know a lot about diet and

exercise. I’d like to tell you about the role that medication can play.” …

• Elicit: “What do you think makes sense for you right now? What are you willing to do?”

MI Technique: Menu of Options

• Objective: To avoid the ‘Yeah-but’ dance that typically happens when advice is given. To provide the patient with tips and techniques that have helped other but to put them into the driver’s seat to ‘own’ the solution.

• Example: “So Mr. Gonzales, you do want to get these blood sugars under control but you just keep forgetting to take your medication. Would you be interested in hearing about some tips that have helped other patients?”After patient gives consent, the provider presents 3-4 brief ideas. Then says: “Of these options or another that you can think of, which one(s) do you think might be helpful for you?”

Summary Slide

• Communication is an essential component of the practitioner’s role and has lasting effects over time.

• According to the research in behavior change science:– The worst case scenario is one in which the practitioner is

arguing for the change while the patient argues against it;– The best case scenario is one in which the practitioner evokes

change talk from the patient and builds commitment strength for the change plan.

• Providers can learn these skills and apply them in brief encounters with their patients in order to:– Improve the quality of their work life;– Improve clinical outcomes.

Faculty Development Team

Tom Bent, MD Susan Butterworth, PhD, MS

Alan Glaseroff, MD

Coming Attractions

• Workshop This Afternoon!– Be sure to attend the workshop with Drs.

Butterworth and Glaseroff to learn more!