Lecture_2_Doctor/Pt. Relationship II_Assessing Pt. Readiness to Change Using the Transtheoretical Model (Stages of Change)

Question 1

Key Dimensions of a helpful doctor/patient relationship:

Building patient cooperation:

The risk-benefit dilemma: different perspectives

Answer 1

Assessment of behavior RISKS:

• patient views risks as low
• physician viewes risks as high

Perceived benefits of behavior:

• patient views as high
• physician views as low

Question 2

Key Dimensions of a helpful doctor/patient relationship:

Building patient cooperation:

Factors affecting patient cooperation

Answer 2

Patients are more likely to cooperate when they:

• perceive high severity of illness and consequences
• feel highly susceptible to the disease
• are capable of performing a behavior to reduce risk
• are confident treatment will reduce risk

Role of physician–to facilitate dialogue that helps the patient connect these elements with his/her own circumstance

Question 3

Key Dimensions of a helpful doctor/patient relationship:

Building patient cooperation:

Major points to remember re: patient cooperation

Answer 3

• humans naturally prefer to be actively engaged in “making something their own.”
• resistance is to be “courted”-like a beloved
• relapse is a part of any change process

Clinician must practice & learn how to:

• develop a sense of what direction the patient is moving, and
• how to work with it, rather than against it
  
  • examples: riding a wave, getting off a ski lift, martial arts, dancing, gettting on the interstate

Question 4

Describe the scope of non-cooperation:

Patient non-cooperation:

Scope of non-cooperation among patients-examples:

Answer 4

• Patients fail to keep between 10 and 20% of appointments made
  
  • when sent for diagnostic testing, non-attendance jumps higher
• patients only fill about 30% of prescriptions written
  
  • for those filling prescriptions, chance of completing a 10-day course is about 80%
• patients on long-term medication for chronic disease take prescribed medication about 50% of time

Question 5

Describe the scope of non-cooperation:

Patient non-cooperation:

Common human responses to suggestions (recommendations, orders) from others:

Answer 5

• acceptance
• modification (common)
• rejection

Question 6

Detect signs of non-cooperation in a patient:

Patient non-cooperation:

Frequently encountered signs & behavioral presentations:

Answer 6

These may suggest non-cooperation

• dependency
• manipulativeness
• angry, demanding
• withdrawn
• fearful
• depressed
• help-rejecting

Question 7

Describe the scope of non-cooperation:

Patient non-cooperation:

Avoiding a judgemental stance:

Answer 7

Instead of viewing non-compliance as an “act of defiance”, look for reasons behind the person’s behavior “failing to coincide with medical advice”

• view this as a SYMPTOM requiring exploration into cause
• ask yourself: “What can this pt. teach me that I need to know?”

Non-cooperation is a shared responsibility

–it is helpful to address the attitudes and beliefs pts. have about their illness and treatment as early as possible

Question 8

Determine a patient’s stage of change:

Optimizing doctor-patient cooperation:

Therapeutic Goals:

Answer 8

Goals:

• when considering therapeutic goals:
  
  • elicit feedback on patient’s perceived ability to achieve goals
• renegotiate goals based on patient feedback and clinician constraints
  
  • accept outcome
• be positive about ability to achieve goals
• inquire about goal acccomplishment every visit
  
  • what worked, and what didn’t
• use ancillary staff to take advantage of every encounter to focus on achieveing goals

Question 9

Determine a patient’s stage of change:

Optimizing doctor-patient cooperation:

Offer & encourage counseling support:

Answer 9

• elicit commitment to ongoing counseling support
• add counseling support in step-wise fashion as goals are set and achieved
• be willing to stop unsuccessful counseling and try different approach

Question 10

Determine a patient’s stage of change:

Optimizing doctor-patient cooperation:

When prescribing medications:

Answer 10

• integrate into daily routine
  
  • encourage keeping diary to monitor medication
• anticipate adverse effects
  
  • adjust therapy to prevent, minimize, or ameliorate them
• use written instructions
  
  • for prescriptions and other therapy

Question 11

Determine a patient’s stage of change:

Optimizing doctor-patient cooperation:

Clinical mystery & dilemma

Answer 11

• difficult to predict which patients will have trouble following treatment plan
  
  • patient attitudes in office are not an accurate predictor of cooperation once they leave
• always consider non-compliance when evaluating the cause of:
  
  • treatment failure, and/or
  • recurrance of a medical complaint

Question 12

Determine a patient’s stage of change:

Optimizing doctor-patient cooperation:

Suggestions from the Literature:

Answer 12

• always anticipate possible non-cooperation
• support and empathize with patient
• focus on quality of life
  
  • encourage positive life-style modifications
• patients are most receptive to information & education about condition and treatment in preparation & action stages
• keep care inexpensive and simple

Question 13

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Key Features:

Answer 13

• change is a process–not an event
• patient moves gradually from being uninterested, to considering to change, to deciding and preparing to make a change
• people typically cycle through the stages of change
• movement through the stages can be facilitated by intervening in particular ways

Question 14

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Central Constructs:

Answer 14

• processes of change
• decisional balance
  
  • does the importance of the pros outweigh the cons?
• stages of change
• self-efficacy (agency)
  
  • confidence in ability to manage high risk specific situations without returning to old behavior
• temptation
  
  • intensity of the urge to engage in a behavior in particular situations

Question 15

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Processes of Change:

Answer 15

Cognitive & Emotional:

• changes in the way people think and feel about their health risk behavior
  
  • cognitive change processes help people move through early stages of change
    
    • i.e. from not thinking about quitting to deciding to quit

Behavioral:

• changes to health risk behavior
  
  • behavioral change processes help people move through later stages of change
    
    • i.e. from taking steps to change to maintaining change

Question 16

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Decisional Balance:

Answer 16

Cons of change

• perceived negative consequences
• costs of changing
• (regress)

vs.

Pros of change

keeping a positive balance toward pros.

• perceived positive consequences
• the benefits of changing
• (progress)

Question 17

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Precontemplation:

Answer 17

Precontemplation: –“not ready”

• not thinking about change
• may be resistant to change
• may be resigned–feeling of no control
  
  • obese patients may have tried unsuccessfully many times to lose weight and have given up
• denial–do not believe it applies to them
  
  • patients with high cholesterol levels may feel immune to health problems that strike others
• believe consequences not serious–or pt. is unaware of consequences
• cons of change outweigh the pros

Question 18

List helpful physician questions and behaviors appropriate to each stage of intervention:

Transtheoretical stages of change:

Precontemplation: Opportunities for Physician Intervention

Answer 18

Goal: patient will begin thinking about change

• build a relationship
• express caring concern–don’t use scare tactics
• personalize risk factors
  
  • use pt’s. own assessment where possible
  • give data about vitals, lab results, etc. as compared w/norm
• educate in small bits–repeatedly over time
• use teachable moments & pt’s own awareness
• ask:
  
  • “how would you know if your…was a problem for you?”
  • “If you wre to decide to change, wht do you imagine might be some advantages?”
• validate lack of readiness
• facilitate self-exploration vs. action

Question 19

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Contemplation:

Answer 19

Contemplation–“Some day–getting ready–thinking about it”

• acknowledging a problem, but
• not yet committed to change
• ambivalent about change, but giving it serious consideration
• giving up an enjoyed behavior causes sense of loss despite perceived gain
• assess barriers
  
  • (e.g., time, expense, hassle, fear) “I know I need to, but…”
• assess benefits

Question 20

List helpful physician questions and behaviors appropriate to each stage of intervention:

Transtheoretical stages of change:

Contemplation: Opportunities for Physician Intervention

Answer 20

Goal: elicit from pt. reasons to change & consequences of not changning

• explore ambivalence
  
  • praise pt. for considering difficulties of change
• restate both side of the ambivalence
• question possible solutions for one barrier at a time
• pose advice gently to reduce natural resistance
  
  • e.g.- “This course of action has been effective for some of my pts. It might be adaptable to you also.”

Question 21

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Preparation:

Answer 21

Preparation–“Ready”

• Has decided change is needed
• preparing to make a specific change
• experimenting with small changes as determination to change increases, e.g.:
  
  • sampling low-fat foods may be an experimentation with or move toward greater dietary modification
  • switching to different brand of cigarettes
  • decreasing alcohol use–frequency, amount
  • contemplating (imagining) scenarios for leaving an abusive relationship

Question 22

List helpful physician questions and behaviors appropriate to each stage of intervention:

Transtheoretical stages of change:

Preparation: Opportunities for Physician Intervention

Answer 22

Goal: Pt. will discover elements necessary for decisive action

• has decided a change is needed
• encourage the pt’s efforts
• encourage taking small steps
  
  • definte these with the pt
  • ask what strategies pt will use in risk situations
  • ask about setting a change date

Question 23

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Action:

Answer 23

Action–“Taking steps to change”

• a stage physicians are eager to see patients reach
  
  • sometimes too eager
• patients take definitive action to change
• any action taken by patient should be praised
• demonstrates a desire for life-style change

Question 24

List helpful physician questions and behaviors appropriate to each stage of intervention:

Transtheoretical stages of change:

Action: Opportunities for Physician Intervention

Answer 24

Goal: patient will take decisive action

• reinforce the decision
• build and facilitate increased self-efficacy
• delight in even small successes
• view problems as helpful information
• ask what else is needed for success

Question 25

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Maintenance:

Answer 25

Maintenance–“Forever”–a process of keeping changes made in place

• patient incoporates the new behavior “over the long haul”
• broad implications for one’s life
  
  • self-image, social relationships, etc.

Question 26

List helpful physician questions and behaviors appropriate to each stage of intervention:

Transtheoretical stages of change:

Maintenance: Opportunities for Physician Intervention

Answer 26

Goal: patient will incorporate change into daily lifestyle (prevent relapse)

• continue reinforcement & support
• explore & lift up internal rewards & benefits from change
• identify risks for relaps and helpful strategies to manage them
  
  • this provides information helpful to other patients as well

“Have you noticed any changes that you like since you stopped/started doing X?”

Question 27

Determine a patient’s stage of change:

Understanding the change process: Transtheoretical Model–stages of change

Relapse:

Answer 27

• most pts find themselves “recycling” through the stages several times before change becomes established
• part of the change process, but not one of the stages
• points of caution and proactive planning
  
  • patient usually feels demoralized
  • discouragement over occasional slips (lapses) may hault change process and result in giving up

Question 28

List helpful physician questions and behaviors appropriate to each stage of intervention:

Transtheoretical stages of change:

Relapse: Opportunities for Physician Intervention

Answer 28

Goal: patient will communicate honestly with physician

• learn from the temporary successes
  
  • use this to re-engage the patient in the change process
• remind patient that change is a process, & most people “recycle”
• reframe the relapse
  
  • “failure” to “successful for awhile”
  • “new lessons for continued success”
• identify & evaluate triggers
• reassess motivation & obstacles

Question 29

• What stage is pt. in?
• What are the pt’s pros and cons for changing?
• What anticipated losses does pt. see?
• What is major barrier to change?
• How much self-efficacy does pt. have?

What should HCP do in action?

What can the HCP say to him/her to help improve chances of success?

Answer 29

• contemplative
• pros:
  
  • avoid arrest
  • law school admissions more likely
  • pt. has thought about quitting (thinking about it is a +)
  • better long term health
• cons (w/losses and barriers included):
  
  • losing relationships (girlfriend, friends)
  • losing an excuse for not succeeding (nobody in family successful)
  • losing excuse for inability to get good grades anyway
  • long process/large amount of effort required
• pt. does have some self efficacy in his choice, but not much overall, because he follows up all the (+’s) w/(-‘s). @ a crossroads and has the opportunity to choose.

HCP should do the following to build up pt.:

• praise for giving thought to such an important problem
• explore ambivalence
• elicit:
  
  • reasons for change
  • consequences of not changing
• explore other difficult decisions made by pt. in past
• explore possible solutions

HCP can say:

• “it sounds like you don’t enjoy this much.”
• “if you’re going to do something then you should have a reason for why you enjoy doing it.”

Question 30

• What stage is pt. in?
• What are the pt’s pros and cons for changing?
• What anticipated losses does pt. see?
• What is major barrier to change?
• How much self-efficacy does pt. have?

What should HCP do in action?

What can the HCP say to him/her to help improve chances of success?

Answer 30

• pre-contemplateive
• pros:
  
  • look good @ end of summer for sig. other
  • no need to “waste time” putting on sunscreen during/before shift
  • positive feedback from peers/others about looks
• cons (w/losses/barriers)
  
  • takes too long to put on sunscreen
  • headaches
  • fever
  • painful burn w/blisters
  • potential for skin cancer (if that’s been established during conversation)

HCP should do the following to build up pt.:

• start thinking about change:
  
  • build relationship
  • express concern
  • personalize risk factors
  • use teachable moments
  • validate lack of readiness
  • facilitate “self-exploration” in patient

HCP can say:

“tell me about your relationship with your significant other.”

“I want to express my concern for your health, given your healthcare-need here.”