Behaviour Change in Patients with RA - You Can Lead a Horse to Water But …

This morning at the CRA meeting an inspirational talk was delivered by Dr. Michael Vallis. Below is a synopsis of his teachings.

Believe it or not ... behaviour change is unlikely to result from clinician recommendation or education unless the patient is ready to change. A good question to ask your patient (if you have the courage) is, “Why should you listen to me?” You’ll hear three predictable responses to this question:

1. Because you’re the doctor (If you hear this then they aren’t ready for change)

2. Because I know I should (If you hear this then they aren’t ready for change)

3. The patient tells a personally meaningful story (If you hear this then they may be ready to change)

Let’s set the stage. You make a recommendation for a patient to start drug X.  The patient replies by saying, “Oh no, I’ve heard about that drug, it’s dangerous and I’m not taking it.” Now what do you say? Even if you prescribed this medicine, how likely is the patient to actually take it? Have you ever been in this situation?

Medical practice is rooted in scientific rigour. We aspire to the chalice of the randomized controlled trial. Knowledge is deterministic using reductionistic methods. Clinical interactions are based on recommendations and education. The medical treatment paradigm is founded on the traditional competencies of diagnosis, treatment, and outcomes. This culminates in an expert clinician interacting with an uninformed help-seeker. Patients are afraid to tell us the truth. Why? Because you are the expert and they are the uninformed help-seeker!

Most non-adherence is actually intentional. It is important to understand that the strongest predictors for non-adherence include psychological factors such as distress and symptoms, patient-provider discord, and the patient's current health beliefs. Please understand that a patient’s non-adherence isn’t about you being a “bad” doctor. It has much more to do with the patient and their readiness and willingness to accept change. It’s just like weight loss. A patient isn’t going to lose weight just because you tell them. They’re going to lose weight because they want to.

Think about a visit with a patient with RA who you want to start on a new medication. Whose idea is it to start the new medication usually? - The health care professional's. But, who has to do the work? Who has to talk to the insurance company, go to the pharmacy, pay for the medicine, and then take the medicine? - The patient. Think about how enthusiastic a patient may be about this work? - Not very! So you can now understand why your recommendations may not be followed?

Behavioural habits form very easily. This is what makes changing behaviours difficult. Think about going to a conference and going into a big lecture theatre. The first day you pick a seat on the right hand side in the midpoint of the lecture theatre. When you arrive the following day you’ll probably sit in the same seat. Behavioural habits form very quickly. Imagine on the third day you go back to the lecture hall and someone is sitting in the seat you have occupied for the last 2 days. I’ll bet you’ll feel a little perturbed.

The limbic system is the part of your brain that says "I want it all and I want it now." This is our impulsive centre that follows the principle of deriving pleasure, taking the path of least resistance, and has a preference for short-term gain regardless of long-term consequences. The frontal lobes are our check on the limbic the system. The frontal lobes can be used to rationally and consciously make choices. But the limbic system is very powerful and it drives our behaviour. Many healthy behaviours are actually abnormal among humans (less than 3%). Consider that sugar and cocaine have an equal response in the limbic system. Combine this with a built environment that pulls people towards unhealthy behaviours. For example, eating is much more about comfort and social factors than it is about nutrition. It’s easy to see that changing behaviour is difficult. We’re fighting against evolution.

What do we do?

We can start by thinking about changing our model from a diagnosis - treatment - outcomes approach to a describe - predict - choice approach. With this model we can negotiate choice. Change can only happen from a collaborative perspective, so we need to move from a relationship of dominance to a relationship of collaboration - affiliation.

Going back to the example above, the patient says, “Oh no, I’ve heard about that drug, it’s dangerous and I’m not taking it.” The health care professional (HCP) follows by saying, “I don’t care if you take this drug, it is your choice.” The patient replies, “Really?” The HCP says, “Would you be open to a discussion?” Patient says, “Yes”. HCP says, “Let's discuss your disease and its effect on your life to see if it might have a role.” The relationship has changed from one of dominance to a more collaborative one, where the patient is engaged and has a voice.

When communicating, it is best to use principles from motivational interviewing including:

1. Ask questions and minimize statements

2. Take a curious non-judgmental stance

3. Learn to sit with ambivalence

4. Avoid argument

5. Roll with resistance

6. Support with self-efficacy

Starting a conversation by asking a question shows a sign of respect. Then listen to what the patient has to say. The best way to get someone to listen to you is to first listen to them. Summarize what the patient has said by paraphrasing back to let them know that you have listened. Finally, invite the patient to listen to you.

Determining Readiness

You can ask four simple questions to determine if a patient is ready to change:

1. Is this behaviour a problem for you?

2. Does the behaviour cause you any distress?

3. Are you interested in changing your behaviour?

4. Are you ready to do something about changing your behaviour now?

If the answer is yes to most of these questions, then you can move forward with behaviour modification.

If the answer is a mix of yes and no (ambivalent), then you need to expand on the patient's readiness. Discuss personal/meaningful reasons to change, and encourage a willingness to work hard by connecting to principles and delaying gratification.

If the answer is no - you need to understand the reason. Behaviour is not usually irrational. Most behavioural choices are very rational, you just need to understand the patient's point of view.

Behavour modification involves four steps

Once you have determined that a patient is ready for change, then you need to start along the pathway of change. There are four stages of behaviour modification:

1. Goal Setting

2. Shaping

3. Stimulus Control

4. Reinforcement Management

Stimulus control is one of the best strategies we have to modify behaviour. Imagine I said, “Eat all the potato chips you want, when you want, with no restrictions on the amount and I can make you healthier.” I then say, “There are two stipulations. Number 1 - Never eat potato chips in your house and Number 2 - You can only ever have one 75 gram bag with you at any time.” This is an example of stimulus control and it works very well in behaviour modification.

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