Lecture_2_Doctor/Pt. Relationship II_Assessing Pt. Readiness to Change Using the Transtheoretical Model (Stages of Change) Flashcards
Key Dimensions of a helpful doctor/patient relationship:
Building patient cooperation:
The risk-benefit dilemma: different perspectives
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
Key Dimensions of a helpful doctor/patient relationship:
Building patient cooperation:
Factors affecting patient cooperation
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
Key Dimensions of a helpful doctor/patient relationship:
Building patient cooperation:
Major points to remember re: patient cooperation
- 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
Describe the scope of non-cooperation:
Patient non-cooperation:
Scope of non-cooperation among patients-examples:
- 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
Describe the scope of non-cooperation:
Patient non-cooperation:
Common human responses to suggestions (recommendations, orders) from others:
- acceptance
- modification (common)
- rejection
Detect signs of non-cooperation in a patient:
Patient non-cooperation:
Frequently encountered signs & behavioral presentations:
These may suggest non-cooperation
- dependency
- manipulativeness
- angry, demanding
- withdrawn
- fearful
- depressed
- help-rejecting
Describe the scope of non-cooperation:
Patient non-cooperation:
Avoiding a judgemental stance:
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
Determine a patient’s stage of change:
Optimizing doctor-patient cooperation:
Therapeutic Goals:
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
Determine a patient’s stage of change:
Optimizing doctor-patient cooperation:
Offer & encourage counseling support:
- 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
Determine a patient’s stage of change:
Optimizing doctor-patient cooperation:
When prescribing medications:
- 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
Determine a patient’s stage of change:
Optimizing doctor-patient cooperation:
Clinical mystery & dilemma
- 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
Determine a patient’s stage of change:
Optimizing doctor-patient cooperation:
Suggestions from the Literature:
- 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
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Key Features:
- 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
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Central Constructs:
- 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
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Processes of Change:
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
- cognitive change processes help people move through early stages of change
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
- behavioral change processes help people move through later stages of change
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Decisional Balance:
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)
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Precontemplation:
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
List helpful physician questions and behaviors appropriate to each stage of intervention:
Transtheoretical stages of change:
Precontemplation: Opportunities for Physician Intervention
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
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Contemplation:
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
List helpful physician questions and behaviors appropriate to each stage of intervention:
Transtheoretical stages of change:
Contemplation: Opportunities for Physician Intervention
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.”
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Preparation:
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
List helpful physician questions and behaviors appropriate to each stage of intervention:
Transtheoretical stages of change:
Preparation: Opportunities for Physician Intervention
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
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Action:
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
List helpful physician questions and behaviors appropriate to each stage of intervention:
Transtheoretical stages of change:
Action: Opportunities for Physician Intervention
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
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Maintenance:
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.
List helpful physician questions and behaviors appropriate to each stage of intervention:
Transtheoretical stages of change:
Maintenance: Opportunities for Physician Intervention
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?”
Determine a patient’s stage of change:
Understanding the change process: Transtheoretical Model–stages of change
Relapse:
- 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
List helpful physician questions and behaviors appropriate to each stage of intervention:
Transtheoretical stages of change:
Relapse: Opportunities for Physician Intervention
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
- 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?
- 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.”
- 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?
- 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.”
