04 July 2012

Getting the patient on board

I spent several weeks seeing patients in an internal medicine clinic. Often the diagnosis and treatment were obvious, and the challenge was motivating the patients to take their medications and keep a healthy lifestyle. How could this be accomplished?

Interestingly enough, the patient interview can be used to encourage the patient to change their behavior for the better. "Motivational interviewing" involves structuring questions in a way that encourages the patient to alter their behavior for the better. If a patient smokes, I ask them if they have ever tried to quit. If they say yes (and nearly all of them do), I ask them why they had felt motivated to quit at the time. My follow-up question is whether the reasons they had back then still apply today. I might also ask the patient what their first step would be if they were to try quitting again. This line of questioning makes the patient more prepared to attempt to quit once more. Motivational interviewing is more pleasant and effective than simply admonishing patients that they need to stop smoking. [As a side note, the same concept underlies the contemptible practice of "push polling."]

During my interview, I like chatting to patients about their job, their hobbies, their kids, and their travels. Not only is it fun to get to know them, but it usually tells me things that I can later use to encourage them to adhere to their treatment plan.

One patient was the star running back of his high school football squad. For reasons that his doctor wasn't able to determine, his blood pressure was quite high. The high blood pressure had persisted for years, because the patient didn't feel like taking his blood pressure medications. He is hardly alone. It's particularly difficult to convince people to take their blood pressure medication. The side effects from the pills are immediate, but the injuries caused by high blood pressure often take decades to manifest. Most patients prefer feeling better now to the vague promise of feeling better later. How could the doctor convince this teenager to take his medication? Some chatting revealed an answer. The patient was angling to get a scholarship to a top football program. The doctor pointed out that until the patient brought his blood pressure under control, he would fail the medical clearances necessary for recruitment. Problem solved.

A diabetic teenager seen in clinic stubbornly refused to control his blood sugar. His girlfriend was with him in the exam room. The doctor casually mentioned that diabetes causes vascular problems that can disrupt several body parts: the kidneys, the toes, the penis, the retina, the fingers. The patient turned white as a sheet. "What happens to people's penises?" the patient asked. After the doctor discussed erectile dysfunction, the patient became much more keen on learning how to use his insulin.

The effective primary-care doctor apparently has to be something of a salesman.