Lecture 21: Motivating Patients Flashcards
Dr. Fredrick Ross
- In 2002, a Manitoba physician, Dr. Frederick Ross sent all of his patients an ultimatum telling them that they had to either quit smoking in 3 months or get another doctor
- He had a 50-year-old female patient who had to get a tracheotomy from smoking. After her tracheotomy, she went back to smoking
- “I got fed up with wasting my time treating people with smoking-related diseases. People who continue to smoke are not interested in maintaining their health.”
Koestner on Dr. Ross’ approach
Koestner disagrees with this; most smokers want to quit smoking but it’s really hard to do so
media response to Dr. Ross
The media response was overly positive
patient response to Dr. Ross
- 30 people told Dr. Ross that they wanted to come see him for help with their smoking
- “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.”
- “The patients’ response shows that most of them 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 seem to want my approval.”
- “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.” – Dr. Ross’ patient
prevalence of smoking in Dr. Ross’ patients
- Dr. Ross had 5,000 patients, 10% of whom were smokers
- Nationally, 25% of adults smoked at the time
problem with Dr. Ross’ approach
it relies on extrinsic motivation and control, which are good ways to motivate people
Dr. Geoff Williams
- Idealistic young internist
- Competent and committed
- He learned about motivation from Deci & Ryan
- Dr. Williams understands that patient motivation is part of a doctor’s job
- “How I interact with the patient will have a major impact on their motivation.”
power imbalance in the medical context
- We feel nervous when we see doctors, especially when there’s something wrong
- Doctors normally don’t worry about whether patients have gotten the message or understand what they have to do
- Doctors are busy and want to get on to the next patient
- Studies show that doctors let patients talk for an average of 6 seconds before interrupting them
autonomous motivation
feeling a sense of volition and choice in one’s behaviour
autonomy support
taking and acknowledging another person’s perspectives, providing choices and 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
three studies by Williams
- Smoking cessation
- Medication adherence
- Diabetes control
findings of Williams’ studies
doctor autonomy support -> patient autonomy motivation -> adherence to medical regimen
Williams’ study 1: smoking cessation
- 230 patients meeting with a personal doctor who had been trained in National Cancer Associations Brief Motivational Interview regarding smoking
- 39 years of age
- 26 years of smoking
- Motivation was assessed 2 weeks later
- Check-ups at 6, 12, and 18 months
- Self-reports were validated with chemical tests
- Doctors’ interviews were tape-recorded and coded for autonomy support
- Measured patient motivation 2 weeks after meeting the doctor: controlled vs. autonomous reasons for quitting
smoking and lifespan
Smoking shortens your lifespan by about 14 years and makes you more prone to illness
what is the recommended approach for doctors treating patients who smoke?
Doctors who treat smokers are recommended to conduct a motivational interview using the 4 As method with their patients once per year, where they use open-ended questions to assess their readiness to quit
4 As method
- Ask: Are you aware of the health consequences of smoking?
- Advise: Are you ready to quit? If not, what would it take for you to get ready to think about quitting? About 10% will say yes
- Assist: explore their ideas for how to quit and suggest some others
- Arrange (follow-up):
two tips for quitting smoking
- Take medication (ex. Nicotine patch)
- Get support from a doctor or nurse
smoking and pregnancy
Most women will quit smoking when pregnant but then go back to it
motivational interviewing and smoking meta-analysis
A recent meta-analysis of motivational interviewing for smoking found a significant positive effect, especially when delivered by a doctor
what criteria did Williams’ use to measure autonomy support
- Encourages questions and initiation by the patient
- Takes the patient’s perspective
- Provides choice
doctor autonomy support and patient motivation for quitting smoking
People with more controlling doctors elicited more controlled reasons for quitting
Williams’ study 1: smoking cessation results
- 10% of participants had quit smoking continuously through 18 months
- Autonomy support -> autonomous motivation -> abstinence
Dr. Williams’ smoking video
- The sooner you quit, the bigger the health benefit
- Celebrate your successes, even if they’re small
- Don’t try to quit alone
- Use medication
- Pick a date
- In the lead-up to quitting, change up your habits (ex. Smoking with a different hand)
medication non-compliance statistics
- 125,000 deaths per year in the U.S.
- ⅕ never fill out a prescription
- ⅓ never get a refill
- Over 50% take a prescription improperly
- Ex. Koestner’s brother taking ¼ of his pills
Most common reasons for medication non-compliance
- The illness causes fewer symptoms than the medication
- Incapable of changing habits (no drinking)
- Demands of work and family life
Williams’ study 2: medication non-compliance results
- Dependent measure: 14-prospective pill count
- Perception of autonomy support -> autonomous motivation -> higher levels of adherence
Williams’ study 2: medication non-compliance takeaway
If you have a doctor who listens to you, you will be more likely to come to them with problems and take your medication
Williams’ study: diabetes management
- Included physiological outcome measures
- Perception of autonomy support -> autonomous reasons -> better glucose control
current evidence for Williams’ model
- A meta-analysis of 184 data sets testing Williams’ model
- Autonomy support -> autonomous motivation -> positive health outcomes
motivating patients conclusions
- Motivation plays an important role in health settings
- Your interpersonal behaviour can foster autonomous motivation and better health outcomes
impact of ultimatums in the medical field
Ultimatums in the medical field will keep patients away and prevent them from getting better
medical malpractice lawsuits research
- The quality of a doctor’s interaction with their patient is correlated with whether the doctor will be sued for malpractice
- Doctors who behave in a more controlling way are much more likely to have malpractice suits against them
how can doctors motivate patients?
- Autonomy
- Patient-centred behaviours (ex. Listening, eye contact)
- Check if patients can integrate your recommendations
- Realize that most of us aren’t perfect
