April 2 Flashcards
lecture title: “motivating patients: evidence for the importance of…”
autonomy support
question asked to guide this lecture
how can doctors motivate patients to adopt health-improving behaviours?
Dr Frederick Ross
2002 international story
Doctor in Winnipeg, very respected GP
he told his patients to quit smoking, or at least commit to trying to quit with his help, or find another doctor
sent letter to all his patients
if they were smokers, told them they must reach out to him for help, or he’d find them another doctor
Dr Frederick Ross quote on why he sent out the letters
“I got fed up with wasting my time treating people with smoking-related diseases. People who continue to smoke are obviously not interested in maintaining their health”
^ but this is a CONTROVERSIAL statement - most smokers try to quit each year, but cigarettes are chemically and psychologically addictive
^ there’s a lack of empathy in this quote
Dr Ross - quote in response to the reaction to the letter
“I am surprised at how positive the reaction has been. the support was overwhelming, even from patients who smoke. since I issued the ultimatum I have had only 3 patients request that their files be transferred to another doctor”
30 people called him asking for help, and only 3 left his practice
he interpreted the 30:3 ratio as a success
but he had 500 patients who smoked, and only heard from 33 of them
the rest probably just ignored the letter (ie. decided to lie about being a smoker at their next check up)
Dr Ross quote on what the patients’ response showed
“the patients’ response shows that most of them really want to quit but NEEDED TO BE PRESSURED TO DO IT”
“I’ve had a lot of demand for the patch and other methods of quitting. a lot of people are telling me how they are trying to quit. THEY SEEM TO WANT MY APPROVAL”
^ he’s highlighting that he was able to motivate people because they FEEL PRESSURED and WANT HIS APPROVAL
^ these are classic forms of EXTRINSIC MOTIVATION
Dr Ross’ patient’s comment
“I think it’s good. It’s SCARING ME and I think he’s a good doctor and I like him so I DON’T HAVE ANY CHOICE but to quit smoking”
^ but a key to success rests in feeling like you have a choice, and pursuing something because it’s personally important and meaningful
^ this quote sounds like the beginning of INTROJECTION (making people feel guilty and shameful)
Dr Geoff Williams background
contrast to Dr Ross
idealistic and young doctor, competent and committed
frustrated because he found that 3/4s of his patients didn’t take the meds, he prescribed, failed to exercise etc
so he pivoted and went to study motivation
Dr Geoff Williams thought that what was a part of his job?
patient motivation
“how I interact with the patient will have a major impact on their motivation”
thought he must relate to them in a way that helps them internally want to do what is needed to achieve their goals
2 key motivational concepts highlighted by Dr Williams
- AUTONOMOUS MOTIVATION
^ “feeling a sense of volition and choice in one’s behaviour”
ie. health is important and meaningful to people, but there’s often some ambivalence and difficulty to meet health goals - idea is that the doctor can help swing patients towards commitment
- AUTONOMY SUPPORT
^ “taking and acknowledging patient’s perspectives, providing choices, and meaningful rationale”
ie. don’t belittle a smoker, acknowledge the difficulty of their addiction
the specifics of autonomy support
- make eye contact
- ask open-ended questions
- listen carefully
- don’t interrupt (give patient a minimum of a minute to talk about what’s going on with them)
- encourage initiation and involvement
- provide a rationale for your suggestions
3 studies by Williams
- smoking cessation
- medication adherence
- diabetes control
all 3 of Williams studies found what pathway of effect?
DOCTOR AUTONOMY SUPPORT
(autonomous or controlled)
>
PATIENT AUTONOMY MOTIVATION
(high or low)
>
ADHERENCE TO MEDICAL REGIMEN
(mediation model all built around how the doctor interacts with the patient)
Dr Williams study 1 - smoking cessation sample and setup
230 patients meeting with personal doctor who’d been trained in National Cancer Associations Brief Motivational Interview re smoking (the 5 A’s)
39 years old, 26 years of smoking
motivation assessed 2 weeks after the 5 A’s
check-ups at 6, 12 and 18 months
self-reports validated with chemical tests
National Cancer Associations Brief Motivational Interviews re Smoking
composed of the 5 A’s
- Ask (3 qs)
- Advise
- ASSESS
- Assist
- Arrange (follow up)
brief intervention where you do directive listening in order to assess if a patient is READY TO MAKE A CHANGE, and based off this assessment, you intervene in one way or another
recent meta analysis of motivational interviewing for smoking found…
significant positive effect
especially when delivered by an MD
the 5 A’s in depth
- ASK:
^ identify and document tobacco use status for every patient at every visit
- ADVISE:
^ in a clear, strong, personalized manner, urge every tobacco user to quit
- ASSESS:
^ is the tobacco user willing to make a quit attempt at this time? only 20% say they’re ready
- ASSIST:
^ for patients who are willing to make a quit attempt, use counselling and pharmacotherapy to help them quit
- ARRANGE:
^ schedule follow-up contact preferably within the first week after the quit date
Dr Williams smoking study - doctor’s interviews were…
doctor’s interviews were TAPE-RECORDED and CODED for AUTONOMY SUPPORT
all Ps meet with doctor, who gives them the interview
assumption that some people are MORE CONTROLLING NATURALLY
items that were coded:
- “encourages questions and initiation by patient”
- “takes the patient’s perspective”
- “provides choices”
Dr Williams smoking study - interviews were coded for what kinds of signs of autonomy support?
- encourages questions and initiation by patient
- take’s patient’s perspective
- provides choices
film clip of Keanu Reeves and Jack Nicholson from “Something’s Gotta Give”
example of an autonomy supportive doctor
he listens, acts like they’re on the same level, creates connection
not coercive, makes Nicholson feel relaxed
doesn’t pass judgement
and Nicholson asks 6 questions of the doctor (sign of comfort - in real life men normally don’t ask a single Q)
Williams smoking study - measuring patient motivation 2 weeks after meeting with doctor
controlled versus autonomous reasons:
“I want to quit smoking because…”
CONTROLLED:
“I want others to see I can do it”
“I’ll feel like a failure if I don’t”
AUTONOMOUS:
“I’ve carefully thought about quitting and believe it’s the right thing to do”
Williams smoking study results
10% of Ps had quit smoking through 18 months
autonomy support > autonomous motivation > abstinence
- the autonomy supporting interview alone had a beneficial effect
- the beneficial effect was even BIGGER if the doctor delivered it in a more autonomy-supportive way
Williams study 2
medication non-compliance
Williams medication non-compliance study background
125 000 deaths per year in US are caused by medication non-compliance
1 in 5 people never fill out prescription
1 in 3 people never get a refill
over 50% take prescription improperly
^ ie. chop up their pills
