Ramales colectores

Most patients are genuinely interested in discussing their weight or strategies for losing weight, but they may find it difficult to broach the topic for fear of being lectured by the trainee. Similarly, major barriers to trainees discussing weight loss with their patients are the trainees’ perceptions and concerns that doing so will offend their patients. A good way to address this issue is to have a discussion with each patient about your per-spective on the trainee–patient relationship. You can discuss as much as you believe is important, but the highlights should be on your valuing a partnership between physi-cians and patients whereby each has something to contribute to developing individu-alized and effective treatment plans. It is important to point out that you realize you cannot control your patients’ behaviors and you will not try. Furthermore, you do not

Box 10.3 Importance and Confidence Rulers for Medication Adherence Adherence Importance Ruler

• “On a scale of zero to ten, how important do you think it is to take your medications?”

• “Why are you at a____and not a zero?” Reflect and explore by asking,“What else?” until the patient has exhausted all the reasons he or she can think of and says, “That’s all,” and then summarize what you have heard.

• “What would you need to do to increase the importance 1 or 2 points higher?”

Reflect and explore by asking, “What else?” until the patient has exhausted all the reasons and says, “That’s all,” and then summarize what you have heard.

Confidence Ruler

• “On a scale of zero to ten, how confident are you that you can take your medica-tions the way you have been instructed?”

• “Why are you at a____and not a (pick a number 3–4 points lower)?” Reflect and explore by asking, “What else?” until the patient has exhausted all the reasons and says, “That’s all,” and then summarize what you have heard.

• “What would you need to do to increase your confidence 1 or 2 points higher?”

Reflect and explore by asking, “What else?” until the patient has exhausted all the reasons and says, “That’s all” and then summarize what you have heard.

133Motivational Interviewing in Primary Care judge people or become frustrated or angry when your patients do not follow your recommendations. Rather, you view this as an indication that you do not understand the patient’s perspective well enough. You want to promote an atmosphere where your patients will be open with you because you want to understand where differences lie and work collaboratively to help them recover from illness and generally improve their health. Following this, ask the patient for his or her perspective if he or she has not already commented on the topic.

It is important to discuss weight loss, given the significant effects on individual patients and the cost of healthcare resources allocated to treating obesity-related health problems. With children, trainees can use growth curves to objectively com-pare weight and weight trajectory to age-based gender norms, and then invite com-parents’

and children’s perspectives on that information. With adults, we often lack such read-ily available graphics with population norms. A body mass index (BMI) chart can be helpful as long as it is used to facilitate a discussion about healthy weight range and the trainee invites and respects the patient’s perspective. Many EHRs allow plotting of weight over time, which may visually demonstrate when a patient’s weight has steadily increased, decreased, fluctuated up and down, or remained unchanged. It can be less threatening to focus on the trend in a patient’s weight, rather than the patient’s actual weight number. Furthermore, the trainee should be observant for opportunities to affirm the patient for any strategies, behaviors, or general indication that he or she has the proper perspective for promoting a healthy lifestyle related to weight, for example, eating healthy and exercising.

The goal is to be directive without being authoritarian. You can directly assess a patient’s level of concern about his or her weight by asking any of the following open-ended questions:

• “On a scale of 0 to 10, 0 not concerned at all and 10 extremely concerned, how concerned are you about how your weight is affecting your health?”

• “What concerns do you have about your weight?”

• “How concerned are you about your weight right now?”

You could also lead with statements such as “I’m concerned that your weight may cause you some health problems” or “I’d like to talk about how your weight may be affecting your health,” as long as the statement is followed with a question such as

“Would it be okay if we talk about it at today’s visit?” Most patients who are sensitive to such an approach are likely to have been sensitized by past experiences with friends, family, or other practitioners, so addressing the issue may require establishing a more longitudinal working relationship. If a patient refuses or declines to discuss weight at an initial meeting, it is appropriate to back off and resist the urge to pressure for change or even to have the patient talk about it. You can give the patient an autonomy sup-port statement such as “I respect your decision to hold off on addressing your weight.

You are the best judge of when it makes sense to discuss this. The door is always open, and I am ready to work with you on this when you are ready. What do you want to focus on for today’s visit?” This will help establish that the patient is in charge of the encounter and dictates the priorities, while strengthening the relationship for future interventions.

For patients who are not motivated to change, disinterest in addressing weight may arise from not seeing it as a health issue. In these cases, ask first what the

Motivational Interviewing134 patient knows about the health issues. If there is a lack of information or miscon-ceptions, offer information after asking for permission to do so and then assess how the patient receives the information. One way to do this is to ask: “Would it be alright if I told you a little bit about why we focus so much on weight, and you can tell me what you think of it?” Another option is to say: “Perhaps I could share with you one piece of information for you to consider, and you can tell me how it fits, or does not fit, with what you know.” The information you provide will be most effective when it is personalized to the patient’s current conditions so it can increase resonance either immediately or over time. For example, an overweight patient who has friends or relatives with diabetes would be a reasonable patient to offer infor-mation to about the causative relationship between obesity and type 2 diabetes mel-litus. Or a patient with complaints of knee pain may be quite interested in learning about the benefits of weight loss in reducing current pain and eventual risk of knee replacement. It is better to focus on the potential to prevent illness rather than on the dangers and negative outcomes of not changing course. People prefer to move toward a healthy, positive goal rather than to move away from a negative health consequence.

For patients who are more motivated to change, providing personalized feedback helps to tie weight issues to associated diagnoses or patient interests. While the train-ee’s primary concern may be health, social impacts may be a more predominant moti-vating factor for patients and must be appropriately addressed to help them resolve their ambivalence about change. Patients often say they are prepared to make changes when they still have remaining ambivalence about change. They may have attempted changes in the past and may be inhibited by feeling or believing that they will not be able to succeed at making a change. In this setting, it can be helpful to ask for state-ments of self-efficacy such as “How have you been successful with doing other things you wanted to do in the past? How could you apply that experience to this one?” Focus on past successes that the patient has had and validate the significance. Establish goals based on the patient’s interests, ensuring that they are realistic, time-framed, manage-able, and appropriate.

Trainees may perceive nutrition and weight issues as requiring a high burden of edu-cation, as patient and community knowledge and understanding may deviate sharply from nutritional information accepted within the medical community. Patients’ nutri-tional beliefs commonly display significant cultural variation, with an obese body habitus at times being perceived as “healthy.” Assessing a patient’s understanding of nutrition and access to nutritious foods is crucial to understanding barriers to change.

Patients who might benefit from more extensive education can be referred to a nutri-tionist if the patient accepts the offer of the referral.

Discussing Change

Providing a menu of options is key. Success is far more likely when patients see a vari-ety of choices and choose their own courses of action. Furthermore, how information is offered is important. Providing choices to patients in a limited, controlling man-ner reduces patients’ subjective sense of choice and compromises patient autonomy.

Therefore, it is best to offer it by using an open, informational style. A trainee might say, “Would you like to work on decreasing sugary treats in your diet or work on reducing fat?” giving the patient a choice but suggesting that it must be either one

135Motivational Interviewing in Primary Care or the other. It is preferable to offer several ideas together and encourage patients to weigh in on which they prefer, rather than to offer suggestions one at a time and sequentially. Offering isolated ideas often elicits sustain talk by inviting the patient to argue against each suggestion in turn. By presenting a selection of a few ideas, the patient can be redirected toward considering which option is the best, rather than why each idea won’t work (Miller & Rollnick, 2013). At the same time, it is also important to not offer too many options. Too large of a selection of options can be overwhelming and subsequently unmotivating, reducing a patient’s confidence in his or her capacity to make the right choice. It is always useful to finish an offering of sev-eral suggestions by saying, “or perhaps you have your own better ideas of what to do.”

Weight management is an ongoing series of behaviors toward a common goal.

Avoid suggesting or advocating for too many changes at one appointment. Guide patients to pick realistic, interim goals on which to build so they experience repeated successes rather than failures. Weight change requires many behavioral modifications, including changes in activity level, eating behaviors, social interactions, routines, and even daily planning. Discussing the range of ways patients can address weight manage-ment can give them optimism that they can succeed by making step-wise changes over time. Focusing on small changes that are achievable will help strengthen a patient’s self-efficacy, enabling further changes. Even small weight reductions have been shown to produce significant reductions in health risks. Patients are often unaware that these small changes can have a significant impact on health.