This morning at the CRA meeting, Dr. Monique Camerlain and Dr. Kim Lavoie gave a symposium on motivational communication.
Compassionate communication increases satisfaction for both patients and physicians, and improves treatment outcomes and adherence. Consider the following statistics (Dr. Roy Kessels) about a patient visit:
50-75% of what we say is forgotten within 6 minutes of leaving the office.
50% of retained information is incorrectly remembered.
80% of patient needs and expectations are not met during a clinic visit.
Only 7% of our communication is verbal, 38% is influenced by tone of voice and 55% is our body language.
Our challenge is to achieve a balance between the hypothetico-deductive model and the art of compassionate communication.
Chronic diseases are main causes of global morbidity and mortality. One hundred years ago we were dying of infection and the majority of doctor visits were a one time event. We are now in the age of chronic disease management. However, consider that less than 1/3 of medications being prescribed for chronic disease are not being consumed. Adherence is the extent to which a person's behaviour corresponds with agreed upon recommendations by a health care professional. However, our health care system has made the assumption that education will lead to behaviour change. Unfortunately, knowledge does not always lead to action.
"It's not that patients don't know what to do, it's that they don't do what they know." (Marvin Baig)
Without realizing it, the more we give advice, especially when it is perceived as telling someone what to do, the more we risk having a counterproductive effect in what we are trying to do. Beware of the advice trap. When a patient asks for advice, they may not be asking for advice but rather validation. Advice giving approaches do not consider the patient's level of motivation for change. In order to change, patients need to feel that change is both beneficial and possible. If you don't have both of these, then you likely will not see change.
The goal of motivational communication is to elicit "change talk" where patients say things in favour of change with the goal of resolving a patient's ambivalence about change. Motivational communication is not a way of tricking people into doing what you want, it is not just a technique, it is not a panacea, it is not for everyone, and it is not easy.
Why are people resistant to change? Because they are ambivalent. Ambivalence reflects equally powerful desires FOR and AGAINST change. Ambivalence is normal and is often mistaken for resistance. Motivational communication tries to help overcome ambivalence.
To Engage Your Patients:
Ask them what are their goals, what do they want to achieve, and why is this important?
Ask them how they expect you to help or contribute to their success?
Offer hope by explaining your role, how you can help, and how you have helped others.
In order to elicit change-talk you must first learn how to ask questions. Remember, every question has a purpose and some responses are entirely predictable. For example, "How are you doing?" with the predictable answer, "Fine." Or the question, "So, you're taking your medication as prescribed?" with the predictable answer, "Yes." These are called closed questions and you must beware the closed question trap.
Closed question: Are you taking your medication as prescribed?
Open question: Tell me about what you are taking for arthritis and how often you take it?
When you detect resistance to change, the goal is not behaviour change but rather avoiding a power struggle. Imagine you have a patient with active arthritis who is resistant to starting an injectable therapy. Often our response in this situation is to provide solutions (i.e. We have someone who can help you with that). However, this response may lead to a power struggle. Rather, when you encounter a barrier, a different approach encompasses reflection. Below are examples of reflective approaches.
"So you see the benefits, but the needles are turning you off."
"On the one hand, you want to do something that will help your arthritis but on the other hand you aren't confident you could manage the injections."
"You would never consider trying a treatment as long as it had to be injected."
Tips on Giving Information
Information is offered, not imposed - Ask permission (Would it be ok if we discussed this?)
Share facts, not opinions, so patients can make an informed decision
Keep it simple - Share no more than 3 pieces of information at a time
Ask for feedback
Concerns About Asking Questions
Many physicians have concerns about the time it takes to ask open ended questions. The data tells us that the average patient response time to an open ended question is 30-90 seconds. However, physicians tend to interrupt after 15-20 seconds.