A Little More Thought On A Somewhat Controversial Post

motivational-interviewing-what-it-is-and-why-you-should-be-using-it-11-638In my last post, Doctor, Judge Thyself, I described how I go to great efforts to help patients make healthy lifestyle changes, and I admitted that I get frustrated and judgmental when met with great resistance.

The post generated significant page views and commentary, which signals to me that it’s worth continuing this conversation!

In all honesty, most of my patient encounters are positive. As long as someone is engaged and maintains even a modicum of a good attitude, I am thrilled. If they want to work with me, I love to work with them.

Even when a patient declares that they don’t want to change a thing, like “I’d rather smoke ’til I’m dead”,  I can walk away without a fight and without stressing about it. I have several patients with whom this type of flat-out refusal is a running joke:

“I know what you’re going to say, doc, and you know what I’m going to say, so why don’t we talk about baseball instead?”

I can laugh and retort with: “Okay, humor me with my little shpiel so I can write that I told you so in the chart.”

It’s only when I am met with the baffling “I want to change, doc, but I just can’t…” that I bang my head against the exam table, and that is what the post was about. It’s the help-seeking-then-rejecting thing. Drives me nuts. I don’t handle those situations well.

One physician, I believe an internist (Jay, please correct me if I am wrong) brought up the motivational interviewing technique, which is very good, and I do use this, though probably not enough, and not very well with the “I can’t”. Dr. Mom (Family practitioner) shared a method I hadn’t heard of that sounds particularly sanity-saving: “Goalification”. The technique is described in a very short, highly enjoyable article by Greg Dubord, MD in Canadian Family Physician:


It’s totally worth taking a few minutes to peruse this, if solely for the entertainment value of the sample encounter. I could see trying this in practice.

Eve Shvidler, an OB/GYN at https://burningtheshortwhitecoat.wordpress.com, commented about the techniques she uses, such as obtaining more details about diet and exercise. I think this is a very good idea, though I often feel like I need more education in nutrition counseling… and more time. At the very least, I need to find better resources for patients.

In the end, there is much food for thought here. I’m always open to hear more… There’s so much pressure on physicians, especially those of us in primary care, to push the masses towards better health. What else can we do… or not do?

6 thoughts on “A Little More Thought On A Somewhat Controversial Post”

  • It’s funny, your post made me more aware of addressing this issue with patients again. We often slip away from it as we become comfortable with our returning patient panels, etc. tonight, I saw a neighbor friend at a BBQ. He’s always been overweight. Always. But now, he lost 50 lbs. so, remembering your post, I just had to ask.
    “How did you do it?”
    He said that his whole family had been on his case for years and he was always resistant to changing his lifestyle and eating habits. A few months ago, he went to see his ARNP provider who said,
    ” you know, you are starting to turn your body into being more feminine with all the extra estrogen in your system…”
    Kid you not. The thought of man-boobs totally freaked him out.
    Anyway, I know that technique won’t work on most people, but had to share as it was the LAST answer I thought I would hear. I did encourage him to connect with his ARNP and show him what a difference he had made as that would make the provider feel pretty good about making a difference.
    I guess every person is different and what triggers their desire to make that change can vary.
    That being said, my neighbor said the protein shakes were a real winner! I swear by my morning breakfast filling protein shake. Id be happy to share the recipe sometime if you are interested.

    • That’s hilarious. But hey, we all have our tipping point… I quit smoking when I dated someone who was grossed out by the smell of smoke. And, I’d love the shake recipe!

      • Protein Powder: BIOCHEM 100% Whey Protein, Vanilla Flavor is the brand I use.

        1/2 cup 2% milk
        1/2 tablespoon protein powder
        1/2 cup strawberries
        1/4 cup blueberries
        crushed ice as needed

        the blueberries can be substituted for 1/2 cup raspberries or 1/4 banana

        Add a cup of coffee in the morning and six cashews or a cheese stick for a midmorning snack and that holds me over to lunch.

  • A reply posted on Facebook, by a psychologist from Guatemala: “I feel so related in this topic of “i want to but I cant” . After reading a lot and from clinical experience (no matter the field of your work as long is one where the patient/ person/ client) puts you in a power-authority position) they try to rely all the responsability in others… If you search deeper you’ll find they blame the partner, mother, father, boss and a long etcetera, so we only become one more in the series of people-things to blame for their suffering. As long as I came to understand that, my question to them is: if you can’t , and you are with yourself 24/7, what makes you think that I can when you come to me only once a week? That affirmation puts back the responsability in the patient and they either engage or look for someone else to blame… As for me, i can sleep well at night knowing that our work as care givers has as much limits as the patient wants. Hope this testament helps!”

  • Yup, internist (currently working in hospice/palliative medicine). I think I missed the precise dynamic you’re struggling with in your first post – the clarification is interesting. I find it helpful to emphasize with what they can do (“I hear how much this means to you…I’m glad you keep your appointments”) and try to help them set realistic and achievable goals that are *meaningful to them*. I’ll look at the goalification piece. I also do a lot of what the MI folks call “developing the discrepancy” – “so I hear you telling me that you’re worried about your lungs and I see that you’re still smoking. Tell me more about that”.

    • Thanks Jay- I actually used a version of that this week- “It’s a huge step in the right direction that you come to these appointments! Good job!” I feel like I need a degree in psychology to be more effective. Or, as someone else commented, a whole team…

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