Christopher F. Bolling
TORONTO Pediatricians looking to change their patients unhealthy eating and lifestyle behaviors may need to pull their patients into a healthier lifestyle rather than push them, according to Robert P. Schwartz, MD, of the department of pediatrics at Wake Forest University School of Medicine, Winston-Salem, N.C.
Schwartz and Christopher F. Bolling, MD, an associate professor of clinical pediatrics at Cincinnati Childrens Hospital Medical Center, advocated a technique known as motivational interviewing at the Pediatric Academic Societies Annual Meeting held in Toronto.
Motivational interviewing was developed in the late 1980s and is a person-centered, directive communication method that uses the patients own goals and values to motivate them to make a change.
It is different in the way things are said. It is when the physician is pulling rather than pushing the patient, Schwartz said.
Motivational interviewing may improve patient outcome and adherence in a quick manner, Bolling said. We also hope that what may come out of a positive encounter is a new relationship with the family and with the patient; to be more collaborative and to no longer talk down on the relationship and the situation.
In a study by Schwartz et al, the researchers found that motivational interviewing is an effective office-based strategy for the prevention of childhood obesity.
In the non-randomized clinical trial, 15 pediatricians and five registered dieticians were assigned to one of three groups: a control group, a minimal intervention group or an intensive intervention group.
Results showed that at the six-month follow-up, there was a decrease in BMI of 0.6 in the control group, 1.9 in the minimal intervention group, and 2.6 in the intensive intervention group. Of the parents with children in the intervention groups, 94% reported that the intervention helped them think about changing their families eating habits.
This feasibility study demonstrates that pediatricians and registered dieticians can be taught to use some of the tools and techniques of motivational interviewing and that this approach is well-received by parents, the researchers wrote in the study.
The researchers recommended further studies to demonstrate the efficacy of this type of intervention on practice settings.
The transtheoretical model describes how people move toward making decisions about behavior change in their lives, and people transgress through stages of readiness to change certain behaviors. These stages are:
- Pre-contemplation: patients do not see a problem.
- Contemplation: patient recognizes the problem, but is unsure about change.
- Preparation: planning solutions to the problem.
- Action: actively modifying behavior.
- Maintenance: upholding the change.
- Relapse: an anticipated risk.
As physicians, we assume patients come to us ready to change when typically they are not anywhere close yet, Bolling said. The goal here is to get from pre-contemplation to action. But interestingly, moving even to contemplation or preparation phases seems to be related to beneficial behavior change. The key is moving forward. Pace is less important than direction.
The essential principles of motivational interviewing consist of being patient-centered, expressing sympathy, dealing with resistance and supporting self-efficacy.
Schwartz recommended several tools of the trade to aid in motivational interviewing:
- Establishing rapport: the patient should tell the physician about their day in detail.
- Agenda setting: let the patient choose the agenda.
- Getting permission: get permission to share information with them.
- Asking open-ended questions.
- Reflective listening: this shows the patient that the physician is listening.
- Affirmations: find the strengths of the patient.
- Consider pros and cons.
- Eliciting change-talk.
- Providing menus vs. single solutions.
- Provide information and patient interprets it.
- Summarize and close the deal.
The way to learn is really by trying these out. All the tools do not have to be used, just pick out a few, Schwartz said.
What motivational interviewing is not
Motivational interviewing is not arguing with the patient, offering advice without their permission, doing most of the talking or giving a prescription.
Physicians need to purge themselves of the phrases you have to do this and you must do that and understand that knowledge does not drive behavior. One must have the actual motivation to do it, Schwartz said. As physicians, we have been taught to be information givers; we have not been taught to interact with people to help them change their behaviors. Remember that motivational interviewing does not work with everybody, and patients should not be pushed when they are not ready. Just let patients know that we will be there for them when the time is right for them.
Many practitioners feel that asking How does that make you feel? sounds trite and insincere, Bolling said. Being facile with this type of interaction, like learning interviewing skills as a student, just takes time and practice. The questions may feel awkward or cheesy at first, but with practice and personalization, they can feel just as normal as other conversations with patients. – by Jennifer Southall