The Clinician’s Role in Change

As physicians, we’re uniquely positioned to guide our patients through the process of health-related change.  We understand the impact of health behaviors and the potential benefits of change.  We are trusted advisors and educators, with access to intimate details of our patients’ lives.  By combining our knowledge of human behavior with our interviewing skills and compassion, we can help our patients achieve personally meaningful goals.

We can be most effective in promoting change when we honor our patients’ autonomy and evoke their reasons and plans for change.  Only they know what’s most important to them, and what the costs and benefits of change will be.  Only they can make the decision to change. Without this patient-centered partnership, we risk alienating patients and increasing their resistance to change.

This video shows how a well-intentioned behavior change conversation can go awry – frustrating, ineffective, unrewarding, and rapport busting. Have you experienced either side of a conversation like this before? This physician’s intention was to help – why doesn’t it work? This is a short clip from a longer video (available on YouTube) – you’ll see a better version of this interaction later in this module.

Historically, most doctors, like this one, simply explained why they recommended a change and expected patients to make it, which wasn’t terribly effective. Neither was advice giving or scolding. While knowledge is a prerequisite for change, it usually isn’t sufficient – most of us are naturally inclined to resist unsolicited advice or coercion and have trouble changing unless the reasons for change are our own.

An alternative to this frustrating interaction is motivational interviewing (MI), which was developed in the 1980s by clinical psychologists Drs. William Miller and Stephen Rollnick. They describe MI as “a collaborative person-centered form of guiding, to elicit and strengthen motivation for change.” Although it was originally used to treat addiction, MI has been adapted to many different health problems that are common in the primary care setting.

Research shows that compared to ‘treatment as usual’, patients exposed to MI are more likely to change.

• Improve medication adherence
• Participate in follow-up visits
• Adhere to glucose monitoring and improve glycemic control
• Increase intake of fruits and vegetables
• Increase exercise
• Reduce stress, sodium intake, alcohol and drug use, needle sharing, unprotected sex
• Quit smoking

In this workshop, we will explore the ‘spirit’ that underlies effective and ethical MI and practice key communication techniques and strategies.

Resources & references

A Dialogue with MI Co-Founder William Miller, Columbia U School of Social Work, 25 minutes and interesting! YouTube

Summary of controlled clinical trials involving MI. https://motivationalinterviewing.org/sites/default/files/mi_controlled_trials_2020_nov.pdf

Key Communication Skills & Strategies

Physicians often use a directive communication style, leading with their own expertise, advice, and power. If there’s an emergency or a clear best treatment, this may be appropriate, but telling someone what to do doesn’t usually lead to change.  Motivational interviewing, on the other hand, is guiding rather than directive. The clinician knows the benefits of change in preventing and treating illness. But instead of telling the patient what to do, they use strategic questions and reflections to guide the patient in finding their own ideas and motivation for change.

These communication techniques are already part of your toolbox, but in behavior change conversations they are used in a specific way.

• Open-ended questions are used to explore concerns, goals and ideas for change
• Affirmations are used to highlight strengths & build self-efficacy
• Reflections are used to respond to sustain talk, evoke change talk and highlight ambivalence
• Summary is used to demonstrate active listening, highlight ambivalence, and make connections

This excellent 10-minute video from the Yale/Coursera Addiction course reviews key principles of motivational interviewing and demonstrates how OARS skills are used to support these principles. These same skills and principles are applicable to any behavior change you might discuss in your PCP.

Open ended questions

In a typical interview, you’ve used OEQs to gather information and explore patient’s attribution and perspectives. Here, they are also used to explore goals and values, elicit change talk, assess stage of change, and bring out ideas for change.  Here are some examples:

• To ask permission: Could we talk for a few minutes about your (behavior)?
• To explore goals and values: What are your goals for your health? Family? Work? Finances?
• To explore goals and values: What would you like your life to be like 5 years from now?
• To develop discrepancy: How does continuation of (behavior) fit in with these values?
• To assess stage of change: How likely are you to change your (behavior) in the next 6 months?
• What has worked for you in the past?
• What would you be willing to try?
• What do you intend to do?

Reflection

In a typical interview, you’ve used simple reflections to confirm what you’ve heard (sounds like…). As you saw in the video, reflection can be used in several other ways in a behavior change conversation.  It may be a neutral response to patient statements arguing against change (remember this sustain talk is expected for ambivalent, contemplative patient.) Reflections respond in a way that doesn’t feel like an argument.

Because these reflections are statements rather than questions, your voice should go down at the end. This is key – if your voice goes up as if you are questioning, it completely changes the meaning and can increase rather than lessening resistance.  Compare these two clips – hear the difference?

Reflection can also be used to respond to change talk, encouraging your patient to build on what they’ve already said. While simple reflections repeat or rephrase what your patient has said (sounds like…), complex reflections can deepen the conversation and move it forward.

Complex reflections may:

Double sided reflections

This skill is used to mirror your patient’s ambivalence about change back to them, highlighting the gap between their goals and values and their current behavior, which is also called discrepancy.  Recognizing this gap can help people move towards change.

An effective double-sided reflection ends in the direction that supports change. Your patient’s response will likely follow up on the last thing that you said so this structure can promote change talk.  Double sided reflections should always use the conjunction “AND” (or “at the same time”) rather than “but”. AND holds both sides of the reflection to be true, as they really are for ambivalent patients. BUT can change the feeling completely, making the patient feel like you’re skeptical rather than collaborative.  Compare this example to the one above – hear the difference?

Phrases you can try out in reflections:

• It sounds like…
• What I’m hearing is…
• So you’re saying that…
• You’re feeling like…
• For you, it’s a matter of….
• From your point of view,…
• You are…
• I would imagine you…
• Must be…
• Through your eyes,…
• Your belief is that…
• Your concern is that…
• It seems to you that…
• You’re not terribly excited about…
• You’re not much concerned about…
• The thing that bothers you is…
• The important thing as you see it is…

Summary in behavior change conversations

As in other interviews, summary demonstrates active listening and allows the patient to reflect on what you’ve discussed, correct misunderstandings, or add new information. In behavior change conversations, summary can also be used to reflect underlying meaning and feelings, highlight ambivalence, and help your patient make connections between things that they’ve discussed.

• A collecting summary brings together several related things that the patient has talked about.

“So your strengths as a parent include a lot of patience, true enjoyment of playing with your kids, and setting clear boundaries”

• A linking summary may help the patient see connections between something they’ve said and an earlier conversation.

“Earlier you said you wanted to think about cutting back on alcohol and you’re also noticing difficulty with sleep.”

• A transitional summary marks and announces a shift, often at the end of the visit.

An example

You saw this video of Ron Jackson and Joe Merrill in the Substance Use chapter.  Now watch through the lens of motivating change – Ron uses open-ended questions, reflections and summary to guide Joe in identifying his own reasons and plans for change, as well as a couple more techniques that you’ll see in the next chapter.

Assessing Readiness to Change

Though the Stages of Change model is based on the people who smoke, clinicians have found it applies in many other situations.  Most people do not change any behavior quickly and decisively; they move through a process of change, often toggling back and forth between stages or spending years in one stage before moving quickly through to the next. Relapse is common and returns the person to one of the earlier stages of change.

Cycle of Changed modified from Prochaska & DiClemente, 1992

Different strategies to promote healthy behavior are appropriate at each of these stages – understanding someone’s readiness to change will allow you to meet each person where they are.

Precontemplation

Pre-contemplative patients are not yet considering change and may voice resistance if it’s suggested. Although we may assume they just don’t understand the reasons to change, studies show this usually isn’t the case. While knowledge is necessary, it’s often not enough – competing priorities, lack of resources, culturally inappropriate care, past failures and structural oppression can all act as potent barriers to healthy behavior.

In the pre-contemplation stage, your goal is to open the door to change by building a therapeutic relationship, exploring and honoring your patient’s priorities and values, and – with permission – providing information. It may be tempting to try to “fix the problem” by cheerleading for change, but this unsolicited advice can break down rapport and build resistance.

To assess the stage of change, clinicians may ask if someone is considering a change within the next six months. If the answer is ‘no’, the person is pre-contemplative.  Verbal responses or nonverbal cues can also suggest pre-contemplation, as shown in the video below.

Contemplation

Contemplative patients are considering change, usually within the next 6 months. The hallmark of this stage is ambivalence – there are reasons your patient wants to change but they still have reasons to maintain the status quo. Here, your goal is to build intrinsic motivation by eliciting their reasons and ideas for change. This change talk may come out spontaneously or it may be pulled out with the communication techniques described in the next few chapters.

Here’s the same patient with a more contemplative response.

Here, you heard a mix of change talk – statements supporting change – and sustain talk– reasons to maintain the status quo. Sustain talk is normal and absolutely expected at this contemplation stage. If there weren’t reasons to sustain, the patient would already have made the change!

Preparation

In the preparation stage, patients are actively planning to make a change. They are motivated but don’t yet know how to make it happen. Our goal is to support them in developing a specific and realistic plan that honors their individual barriers and resources. Listen to our patient in the preparation phase.

Action

In the action phase, patients have started making the planned changes. This stage requires a considerable amount of time and energy because each action still requires conscious choice or executive control, and the risk of relapse is high. The more times and in more contexts the new behavior is repeated, the more routine it becomes and the less conscious control it requires.

In this stage of change, you can offer affirmations of efficacy, ask about positive impacts of the change (more change talk!), and use open-ended questions to explore barriers and needed resources.

Maintenance

In the maintenance phase, patients are working to prevent relapse and to consolidate the changes they made in the action phase. Solidifying this new habit usually takes about 6 months, but it varies depending on the behavior.

In this stage, physicians should anticipate and explore lapses, and differentiate them from relapse. Even a well-established behavior might lapse when the context changes unexpectedly. These lapses provide information that helps solidify change and build resilience. Eliciting information about how they have overcome other unusual circumstances, affirming commitment and flexibility, and brainstorming options for responding to new challenges helps to solidify the new habit.

For example, our patient may be regularly going to the gym but not anticipate a change in hours over a holiday leading to a missed day. Exploring the lapse with you, he might decide to have a backup physical activity that is more flexible, suggest to his family that they walk together after the main holiday meal, or might strategize a way to get to the gym even when company is over. He might decide holiday weekends will not be exercise days at all!

Supporting our patients’ autonomy, wisdom and resilience gives them the tools to sustain change over the long run.

Relapse

Relapse is common.  Our society tends to blame individuals when behavior doesn’t line up with values, but as physicians we know that will power and morality have very little to do with establishing habit. Anticipating the possibility with your patient up front can prevent shame and avoidance if it happens.

Patients must know that we will provide care for them with or without a specific behavior change. If we have laid the groundwork well, both we and they know that the change was not for the physician, and the patient need not be ashamed. Many patients may find themselves “recycling” through the stages of change several times before the change becomes truly established. Normalizing this for patients is helpful.

• “Change involves ups and downs. I’m here for both.”
• “I‘m on your side. I look forward to checking in next month whether this idea works or not.“

Relapse returns a patient to one of the early stages of change: pre-contemplation, contemplation or preparation, as they decide how to respond. But whether a patient decides to try again or not, they can benefit from exploring the journey they’ve taken. When things were going well what did they like about the new behavior? What did they learn about themselves? Acknowledging and reinforcing the successes they did have helps shift the focus away from failure.

The physician must take care to recognize the transition to relapse and use skills appropriate to the new stage. Helping the patient reflect back on their original reasons for change, re-establish goals, and troubleshoot barriers can be helpful.

Eliciting Change Talk

Motivational interviewing helps people to talk themselves into a change that they have identified as important. Change talk builds self-efficacy and makes any change more likely to stick. It may be spontaneous or be prompted by a question; either way, follow up with OARS to try to draw out more.

The mnemonic ‘DARN CAT’ can help you elicit and recognize change talk. DARN statements suggest your patient is contemplative. CAT statements, which are usually spontaneous, suggest readiness to make a plan.

Pros and cons

This communication technique highlights the ambivalence of people who are contemplating change.  Asking about the pros of the current behavior acknowledges the difficulty of change up front and makes your patient feel heard.  Sample questions for exploring pros:

• What are the good things about…?
• What are some of the things you enjoy about…?
• What do you like about…?
• What are the good things about…?

After the first response, you could ask again about pros, repeating until there is nothing more to add.

When asking about the cons of the current situation, use words like “enjoy less” or “not so good” rather than “bad”. People at the pre-contemplative stage are often not thinking about negative consequences, so it may be easier for them to agree to ‘less good’. Sample questions to elicit cons:

• What are some of the not-so-good things about…?
• What concerns do you have about …?
• What worries you about …?
• What are some of the things you enjoy less about…?
• What problems have you had so far?
• What do you think will happen if you don’t quit…?

If your patient has mentioned a specific change that they’re considering, you can also explore the cons and finally the pros of the healthier behavior. This order is important: you want to end on the good that could come of change so your patient can build upon that. To wrap up the pros and cons, use a double-sided reflection or summary, again ending in the direction of change.

A simple way to explore pros and cons is with these two questions:

1. First: What are the good things, and the not-so-good things about…
2. Then: When you think about changing what would be hard, and what would be best?

Readiness Rulers

This technique assesses readiness to change, which is a product of a belief that the change is important, and confidence that one can succeed. Rulers can also elicit change talk and uncover barriers that you can address. 

Compare the 5-minute video below to the snippet you saw in the introduction. In the first video, the physician used a more directive style, the conversation became confrontational and it ended without progress toward change. In the second example, the physician uses a more collaborative style and calls on motivational interviewing techniques – you can see this conversation guiding the parent toward change. This is what you are aiming for!

Clinicians also elicit change talk in the action and maintenance phases, to support self-efficacy as the patient builds and consolidates new habits. This 4-minute video from the FIU School of Medicine shows a PCP and patient collaborating around behavior change in diabetes. This patient has already made some significant changes, and the visit ends with a plan to build on those next time.

Providing Information Respectfully

Unsolicited advice often leads to resistance and impairs rapport. But patients do need accurate information to guide their choices about change.  How can we provide information in a way that doesn’t feel like unsolicited advice?

Ask–tell–ask is a flexible framework for providing information in a way that honors the patient’s autonomy and individual context. Ask-tell-ask is not an excuse to lecture or to give advice, rather a respectful way to offer key information that the patient might be missing.

Tip: Practice using this technique whenever offering information to patients, even if it isn’t in a behavior change conversation! “Is there anything else I should know before we talk about my impressions?” “What do you know about antibiotics for bronchitis?” <give information> “What questions do you have about that?” “How will that work for you?”

“Yeah, but…”

Motivational Interviewing skills are designed to evoke motivation, commitment, and planning from the patient, often expressed in the form of change talk. When we overestimate a patient’s readiness for change or begin to give too much advice, we may notice an increase in sustain talk. By pushing too hard, we’ve put the patient in the position of arguing against change. In MI, this is also called resistance.

If you hear “yeah, but…”, you may be pushing too hard. Rolling with resistance means pivoting to open-ended questions (try pros and cons of the current behavior), neutral reflections (“this just doesn’t feel possible right now”) or affirmations (“you‘ve made a lot of important changes before, I believe you‘ll know when the right time is.”)

Making a Plan

In the preparation stage, the goal is to work with your patient to create a plan that is specific enough to succeed. Action plans work best when patients identify their own goals, resources, support systems and coping strategies.

A common mistake clinicians make is to end the conversation when a patient agrees, in concept, to a change. “Yeah, I really should start exercising.” Without a specific plan that addresses a patient’s unique context, change is unlikely to occur.

“Don’t leave CHANGE on the table. Make a plan!”

SMART goals

One approach to planning is contained in a mnemonic borrowed from the business world. The SMART goal approach helps patients develop specific goals that are measurable and meaningful. When goals are too vague it can be hard to know where to get started and how to track your progress.

Some ways to start the conversation around goal setting could include asking “What are some steps you would like to take?” “What is one step you could take this week?” “What is a step you think you could take now?” “If you were going to do this, how would you start?”

Once the conversation is started you can help the patient tailor their goals using the SMART approach. These are the key steps to developing a patient driven plan.

Specific: What does the patient want to do? What EXACTLY is their goal? Eating healthier sounds like a good idea. What does that mean to you? Any specific thoughts on changes you could make to your diet? What would you need to carry out that change?

Measurable: How will you and your patient measure progress? How will your patient know when they have reached their goal? Walking more sounds like a great idea. You mentioned walking three days per week. How long will you walk for to start? That sounds like a goal you can track.

Achievable: Is this goal realistic? Is it in your patient’s power to accomplish this goal? What barriers or obstacles does your patient anticipate? What is their back up plan? What type of support do they have or do they need? You mentioned cutting out sugar all together from your diet? Do you think that is something you can reasonably do? Are there certain foods that you may be able to decrease to help you cut down on your sugar intake?

Relevant: Will achieving this goal affect your patient’s health? Will they get the desired results? Can they realistically achieve their goal? You mentioned wanting to be able to keep up with your children on the playground. It sounds like increasing your exercise would help you reach that goal.

Timely: When would be a good time to start this plan? When do they hope to achieve their goal? When would it be helpful to come back or check in? It sounds like you want to quit smoking next week after you finish your last pack of cigarettes. Would it be helpful for us to set a visit for a few weeks from them to check on how things are going and to help troubleshoot any challenges you encounter?

The following video shows an example of setting a SMART goal around pre-diabetes management:

When developing a plan, the more specific, the better. Ask the patient to think specifically about how they will make the change happen. It is much better to spend some time troubleshooting one visit to the gym that actually happens than to make a lofty abstract goal. Actually visualizing the process functions as practice, and helps identify hurdles. Short term follow up can provide reinforcement and break the task into smaller parts.

In this case, we might ask “when in your schedule do you see adding exercise?” “What can you imagine getting in the way?” “What support do you need?” “Who/where could you get that support?” “When will you go for the first time?“ “What time on Monday?“ “What if that doesn‘t work?“ “As you imagine yourself waking to your alarm at 6 in the morning, what has to happen to get out the door?” “What has to happen the night before so that you can get up at 6?” “What equipment will you need?”

“How can I support you in this change?” “Would it help to send me a message after you go, or to have my nurse check in with you next week?”

The action phase is supported by anticipatory planning that builds in new cues, piggy backs on established habits, plans around friction points, and recognizes intrinsic reward.

One-Time Actions and Systemic Supports

The easiest time to make a change is right after deciding to do so. And it’s easiest to make a change when structural supports favor the new action. Information is also most useful when it applies to an immediate choice, for example, to receive a vaccine or sign up for a program. Put together, these factors suggest prioritizing systemic supports as part of the plan whenever possible.

For example, we can lower the barrier to performing an action after making a decision by having on-site services. For example, we can offer immunizations in the exam room, offer lab/x-ray onsite, deliver discharge medications to a patient in the ER, have a flexible schedule that allows us to place an IUD or perform a PAP at the time the decision is made. Referrals are completed more often if the appointment is made for the patient eliminating the need for frustrating phone tag. A warm-handoff reduces the barrier of following up with someone the patient doesn’t know.

Insurance companies reduce ER visits by providing 90-day pill supplies. As prescribers, we can also make sure to provide 90 day prescriptions when possible, with adequate refills.

Pregnancies are reduced when a year of birth control is dispensed at a time, or long-acting reversible contraception is placed. Adherence is better for pills that are taken once a day than four times a day and can be taken without regard to meals.

This is another reminder for humility in assumptions about the structural supports or barriers in a patient’s life. Tasks that may have tremendous structural support for one person (whose assistant makes appointments for them), may have tremendous structural barriers for another (no reliable transportation, high copays and 30 day supplies of medications).

Putting it all Together

We have covered many different skills in this module. Determining the patient’s stage of change will help guide which communication tools may be most helpful.

For pre-contemplative patients:

• Pros and cons may help you better understand your patients values
• Reflections can be used to respond to sustain talk
• Ask-tell-ask to provide information that might lead your patient to consider change

For contemplative patients who are already thinking about change, you’re trying to build motivation and confidence.

• Pros and cons and rulers to elicit change talk
• Open ended questions and reflections to amplify change talk
• Reflections to respond to sustain talk – remember this is to be expected!
• Double sided reflections to highlight ambivalence and their reasons for change

For patients in the preparation stage, your goal is a specific plan to increase the likelihood of success.

• Ask-tell-ask to provide information on options
• Menu of options that others have used
• Develop a SMART goal together

Medication Adherence

Sixty percent of American adults take at least one daily medication, and 15% percent take five or more. But for many people, taking medications as prescribed is difficult.  Research shows that one out of every five new prescriptions is never even filled, and of those that are, only half are taken as prescribed.

Medication adherence has important consequences for both individual patients and society. In chronic conditions such as coronary artery disease and heart failure, adherence is associated with improved clinical outcomes, fewer hospital admissions, lower mortality, and lower healthcare costs. An estimated $300 billion/year in direct health care costs is attributable to nonadherence.

In diabetes, adherence to glucose lowering therapy, defined as taking >80% of prescribed doses, is associated with fewer ED visits, hospitalizations, and acute complications of diabetes. Better diabetes control reduces the risk of long term complications like kidney failure and heart disease.

Factors that influence adherence can be related to the patient, the health condition, and the drug regimen.  Common reasons for medication nonadherence are the 3C’s: cost, complexity, and concerns about specific side effects or about taking medications in general.

Diet and exercise

Half of American adults have one or more preventable chronic diseases, many related to poor quality eating patterns and physical inactivity. Recent prospective cohort and randomized controlled trials have demonstrated a clear influence of diet not just on risk markers, but on outcomes. For example, higher fruit and vegetable intake is associated with lower incidence of heart disease and stroke. In long term controlled trials, diets emphasizing fruits and vegetables improved multiple risk factors: blood pressure, lipid levels, insulin resistance, inflammation, adiposity, and endothelial function. Together, these studies provide strong evidence that fruit and vegetable consumption reduces the risk of heart disease and may reduce diabetes.

Cohort studies also show that exercise is associated with lower risk of premature death, coronary artery disease, stroke, hypertension, type 2 diabetes, and depression. The benefit increases with increased exercise, but any amount of activity is better than none.

Diet and exercise also play a key role in the treatment of many chronic diseases, including diabetes, hypertension and cardiovascular disease. In diabetes, excess adipose tissue worsens insulin resistance – diet and exercise can improve control, slow the rate of progression, and limit complications.

Achieving these diet and exercise goals can be difficult, both for individual and systemic reasons. Changing your behavior is hard – but given the evidence for diet and exercise, is clearly worth the effort on the part of the patient and the healthcare team. Access to healthy options is a major systemic barrier. For example, vegetables and fruit are more expensive than less healthy foods, in part because of US government subsidies and policies that favor other crops. Healthy options may be unavailable in lower SES communities (“food deserts”). Many communities also lack access to a safe space to exercise.

Goal: Promote health, with a special focus on people with conditions affected by diet and exercise, like diabetes, hypertension, or heart disease.

Next steps: Physician counseling or referral to a dietitian, a health professional with expertise in both assessment and counseling.

Tobacco

Experts suggest the 5As as an approach to smoking cessation counseling, starting with Ask about tobacco use.

Advise your patient to quit, connecting this advice to their current health concern if possible.

Assess readiness to quit.  Are they ready to set a quit date within the next month? If so, move on to the next A. If not, use motivational interviewing to try to increase their readiness for change.

Assist your patient in making a plan.  Set a date and decide together on additional therapies – you’ll learn more about these later in Foundations.

Arrange follow-up.

For clinicians with less time or expertise, the 5As are modified to Ask, Advise, Refer to Tobacco Quitlines and local smoking cessation programs; or Ask, Advise, Connect to other providers with expertise in smoking cessation, like a clinical pharmacist or behavioral health specialist in the clinic or hospital.