L21 - Motivating Patients: Evidence for the Importance of Autonomy-Support Flashcards
How can doctors motivate patients to adopt health-improving behaviours?
Toronto Globe and Mail Story
“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”
“I am surprised at how positive the reaction has been. The support was overwhelming, even from patients who smoke. Since I issued the ultimatum (stop smoking or get another doctor), I have had only 3 patients request that their file be transferred to another doctor”
What was Dr. Ross’ analysis?
“The patients’ response shows that most of them really want to quit but needed to be pressured to do it”
“I have 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 seemd to want my approval”
What are the patients’ comments on Dr Ross’ methods?
“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”
5000 patients, 10% smokers;
nationally; 25% of adults smoke
What is Dr. Geoff Williams’ story?
idealistic young internist
competent and committed
frustration but an impo. insight
- Patient motivation is a part of my job
- How I interact with the patient will have a major impact on their motivation
The 2 key motivational concepts
autonomous motivation
- “Feeling a sense of volition and choice in one’s behaviour”
autonomy support:
- take and acknowledging patient’s perspectives
- provide choices
- providing meaningful rationale
The specifics of autonomy support
make eye contact
ask open-ended questions
listen carefully
do not interrupt
encourage initiation and involvement
provide a rationale for your suggestions
What were the three studies conducted by Williams?
- Smoking cessation
- Medication adherence
- Diabetes control
doctor autonomy support –> patient autonomy motivation –> adherence to medical regimen
Describe the smoking cessation study by Williams
230 patients meeting with personal doctor who had been trained in National Cancer Associations Brief Motivational Interview regarding smoking
- ask 3 questions
- advise
- assist
- arrange (follow-up)
recent meta-analysis of motivational interviewing for smoking:
- signifianct positive effect
- especailly when delivered by MD
Study design
- 39 years of age, 26 years of smoking
- motivation assessed 2 weeks later
- Check-ups at 6, 12, 18 months
- Self-reports validated with chemical tests
Doctor’s interviews were tape-recorded and coded for autonomy support
- encourages questions and inititation by patient
- takes the patient’s perspective
- provides choices
Measured patient motivation 2 weeks after meeting with the doctor
- controlled vs. autonomous reasons:
– “I plant to quit smoking because…”
–I want others to see I can do it”
– I’ll feel like a failure if I didn’t”
– I’ve carefully thought about quitting and believe it’s the right thing for me to do”
Results
- 10% of Ps had quit smoking continually through 18 months
- autonomy support –> autonomous motivation –> abstinence
Describe the medication non-compliance study by Williams
125,000 deaths per year in US
1 in 5 never fill out prescription
1 in 3 never get refill
over 50% take prescription improperly
Most common reasons:
- Illness causes fewer symptoms than medication
- Incapable of changing habits (no drinking)
- Demands of work and family life
Results
- Dependent measure: 14-day prospective pill count
- perception of aut support –> autonomous motivation –> higher levels of adherence
Describe the Diabetes Management study by Williams
included physiological outcomes measures
perception of aut support –> autonomous reasons –> better glucose control
Current evidence for the model
meta-analysis of 184 data sets testing Williams model
autonomy support –> autonomous motivation –> positive health outcomes
What were the main findings of Williams’ studies?
motivation plays an important role in health settings
your interpersonal behaviour can foster autonomous motivation and better health outcomes
