Transcript Cynthia_change

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
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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
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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:
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Engage
Empathize
Educate
Enlist
Engagement
• A connection which continues throughout the encounter
– Person to person
– Professionally, as partners
Tools for Engagement
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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
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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
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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
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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
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“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
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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
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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:
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Cause and solution
Functional meaning
Relational meaning
Symbolic meaning
Tools for Enlistment
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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
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Increased motivation
Increased adherence
Partnership
Increased satisfaction
Improved health
Compression of Mortality
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10
0
Disabled
Morbidity
Healthy
Poor lifestyle management
Huben, Bloch, Oehlert, Fries, 2002
Jagger, Matthews, Matthews, et al., 2007
Effective lifestyle
management
Lifestyle Sets the Stage
Poor lifestyle habits
Mortality &
Morbidity
Reduced
Quality of
Life
Productivity
Loss
Escalating
Healthcare
Costs
The Non-Adherence Problem: Lifestyle
Management
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Source: CDC
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
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
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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’?
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Are they ignorant?
Unmotivated?
Non-caring about their welfare?
Rebellious?
Lazy?
What do You Know You ‘Should’ be
Doing but You’re Not?
Eating more
fruits &
veggies
Managing
weight better
Exercising
30 minutes a
day
Getting 8
hours of
sleep a night
Taking a
medication
Other?
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
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Want or need to change;
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Have been told that you “should”
change; or
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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.
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Explain why this this change should be made
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Give at least three benefits that would result from
making the change.
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Give advice about how to do it;
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Convince the client about how important it is to
change.
Get consensus about the plan.
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Activity: Persuasion
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How did the client feel about the process?
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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:
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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
Patient Activation
Knowledge
ACTIVATION
Skills
Confidence
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?
Direct
Manage
Prescribe
Lead
Tell
Guide
Shepherd
Encourage
Motivate
Accompany
Follow
Let lead
Let be
Allow
Go along
Motivational Interviewing
• “A client-centered, goal-oriented method for enhancing
intrinsic motivation to change by exploring and resolving
ambivalence.”
(Miller, 2006)
Guide
Shepherd
Encourage
Motivate
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:
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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…
A provider’s interactions can evoke counter-change talk
from the patient (Moyers & Martin, 2006)
Higher patient resistance led to increase in
confrontational behaviors in health professionals
(Francis, Rollnick, McCambridge et al., 2005)
Pushing against resistance tends to focus on and
amplify it (Hettema, Steele & Miller, 2005)
Resistance is a predictor of poor outcome
(Miller & Rollnick, 2002)
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)
Evoking Change Talk
Talk about
change:
Desire
Ability
Reasons
Need
Amrhein, Miller, Yahne, Palmer & Fulcher, 2003
Moyers & Martin, 2006
Increased
commitment
strength
Behavior
change,
treatment
adherence
& clinical
outcomes
Best Case Scenario
Desire to change
Ability to change
The best case
scenario is where
the provider is
evoking change
talk from the
patient
Reasons to change
Need to change
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!