American College of Physicians: Internal Medicine — Doctors for Adults ®

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Strategies to help patients change their behavior

While relapses may be seen as a failure, they are a critical time for physicians to intervene

From the June ACP Observer, copyright © 2004 by the American College of Physicians.

By Deborah Gesensway

NEW ORLEANS—While physicians have a clear role in counseling patients to change their behavior—whether it's stopping smoking, losing weight or cutting back on drinking—the particular approach they take can make a dramatic difference in their patients' success.

At an Annual Session presentation on counseling for behavior change, panelists discussed strategies to help patients make critical changes. They stressed that while virtually all patients will falter in their quest for change at one point or another, relapses represent a critical time for physician intervention.

By listening carefully at the time of relapse, expressing empathy and helping patients make their own decisions, they explained, physicians can help stop patients from just giving up and push them to give change another try.

Getting started

When patients are at the "precontemplation" stage of change—not even considering changing their unhealthy behavior—the best approach physicians can take is to educate them. It helps to offer a personalized message about changing behaviors, to both assess patients' understanding of the problem and gauge their reaction to the concept of changing. That reaction can give you clues to their readiness to consider change.

If they resist the notion, presenters suggested that you try to raise patients' awareness by asking if they would be willing to do some homework—such as keeping a diary about their smoking habit, for instance—or at least think about stopping smoking or starting to diet or exercise.

What doesn't work is lecturing, scolding or frightening patients into trying to change. Those approaches can lead to patients feeling humiliated, explained presenter Robert B. Shochet, FACP, assistant professor of medicine at Baltimore's Johns Hopkins University School of Medicine, and tend to shut them down instead of motivate them.

Co-presenter F. Daniel Duffy, MACP, adjunct professor of medicine at the University of Pennsylvania in Philadelphia, told attendees that they should keep in mind that some patients will remain stuck at this stage for quite a while. As a result, doctors shouldn't waste too much time trying to motivate such a person.

"Not everybody changes right away," Dr. Duffy said, "but giving advice about change can plant a seed that may grow in the future."

However, when patients move to the contemplation stage and are almost ready to attempt a major behaviorial change, physicians can help patients overcome their resistance to change. One popular strategy is to repeat and summarize for patients their ambivalence about change, while shifting that feedback to amplify the reasons they want to change.

This kind of reflective listening, Dr. Shochet said, can help ambivalent patients move forward.

"They start to think, 'Did I really say that?' Paradoxically, it helps people focus on the positives," he said, as they weigh, consciously or unconsciously, the pros and cons of trying to change their behavior.

Supporting action

When patients are done contemplating and are finally poised to act, physicians can often offer the most help. Unfortunately, Dr. Duffy said, physicians are often ill-prepared to help patients at this stage.

Physician practices, he explained, need to train their staff to help patients at this critical point. They can do something as simple as keep written educational materials on hand or go as far as creating programs to help move people through the process.

They also need to understand patient preferences and prescribe, if possible, methods—such as a patch for smoking cessation—that patients themselves have said they want to use.

According to co-presenter Michael G. Goldstein, MD, from New Haven's Bayer Institute for Health Care Communication, doctors also need to understand how convinced patients are about their need to change and how confident they are of succeeding.

"Asking patients to rate their confidence and conviction on a zero to 10 scale can be very enlightening," Dr. Goldstein said. "It gives you opportunities to brainstorm ways to strengthen their confidence and determination."

When patients' confidence level is low (eight or less), Dr. Duffy said that physicians can ask, "What will it take to move to a nine?" Using this technique, you can help patients clarify what they can do to boost their confidence level.

'Reframing' relapses

Studies have shown that it takes an average of 3.5 attempts for motivated people to actually quit smoking, Dr. Duffy explained. Instead of viewing relapses as failures, he said, it is important to "reframe" them as learning opportunities. "We can use relapse as a motivator," he said.

For example, physicians can start by reminding patients that every relapse was preceded by initial success at maintaining change for a period of time.

"Empathizing with the person who relapsed can move a person quickly through contemplation into action," he said. "Failing to address relapse can turn people into 'recalcitrant pre-contemplators,' " people who seem stuck or unwilling to even contemplate making a change.

Because physicians need to be able to talk to patients regularly—particularly once individuals have begun making lifestyle changes—Dr. Duffy said he recommends physicians schedule frequent follow-ups with these patients.

"I have come to believe that we should follow up with patients who are making difficult changes in seven days, not six months," he said. Patients do not necessarily have to make a visit to see a doctor, he said, but can talk with a nurse, a patient educator or another trained member of the staff, or a community resource.

Dr. Duffy offered another tip for keeping patients on track: Studies have shown that it helps to simply ask patients to call the office and leave a message about their progress, then receive a call back from a particular staff member about how their process of change is progressing.

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