Motivational interviewing has been shown to be effective in improving general health status and sense of well-being, promoting physical activity, improving nutritional habits, encouraging medication adherence, and managing chronic conditions such as hypertension, hypercholesterolemia, obesity, and diabetes.35 A review of the literature on health behavior change demonstrates that motivational interviewing outperforms traditional advice-giving in the treatment of a broad range of behavioral problems and diseases.38
Motivational interviewing is focused on helping patients explore their ambivalence and identify individual barriers that are preventing change. The skill set that motivational interviewing provides can be modified for use in the brief patient encounters typically found in the primary care setting. For an example of how you might use motivational interviewing techniques with your CKD patients, see “Talking about change: A motivational interviewing conversation”.
Talking about change: A motivational interviewing conversation
Physician: Now that we’ve gone over your lab values and you don’t have any more questions, I’d like to take a few minutes to talk about how you’re doing with your treatment plan. Would that be okay with you?
Patient: Sure, doc.
Physician: You’re dealing with a lot of things all together—trying to change your diet, watching your weight, monitoring your blood sugar, and taking your medications.
Patient: It is a lot. Guess it’s obvious from my labs that I’m not doing so well. I feel like I get a handle on one thing but something else blows up.
Physician: Sounds like it feels a bit overwhelming right now.
Patient: Yeah, it really is…but I think I could do better.
Physician: Why don’t we start with reviewing what you’re doing well? you are getting your prescriptions filled, and it seems like you’re taking your medications regularly.
Patient: I really do, nearly all of the time.
Physician: What else are you doing well?
Patient: I’ve cut down on my salt intake. We’re using that salt substitute and it’s okay. Ummm…but I guess by the labs I’m not watching my potassium and phosphorus like I should.
Physician: What else are you doing well?
Patient: Well, my blood pressure is down from what it was. But my sugars are still out of whack and I can’t seem to lose weight.
Physician: Okay, so you’ve done a great job taking your medications and you’ve started to change your diet with the salt—both of which have really helped your blood pressure. As you say, there are some things we still need to tackle. But let’s break it down into small steps—forget the whole list. Can you think of just 1 or 2 more small things that you think you could do that would make a difference right now?
Patient: Well, my wife walks every evening after dinner. She’s been nagging me to walk with her. I guess I wouldn’t mind that so much as long as she doesn’t drag me too far. That would help me drop a few pounds and that might motivate me to be more careful with my diet. Plus, I know that exercise is also supposed to help my blood sugar.
Physician: So, a walk after dinner. Do you think you can do this?
Patient: Yes, I do.
Physician: When would you be willing to start?
Patient: Heck, I could start tomorrow. That’s something that wouldn’t be that big of a deal.
Physician: Great! Seems like a plan then. I’m confident that by taking these small steps like a walk every evening, you can get this under control. You have already improved in some important areas.
Patient: Thanks doc! I’ll see you next visit and hopefully my numbers will be better.
Your crucial role
CKD is well on its way to becoming a full-blown epidemic in the United States. Primary care providers carry the brunt of responsibility for the care of these patients, and with an increasing shortage of nephrologists, the scope of those activities will likely grow. Physicians in solo or small group practice must be prepared to deliver both the clinical and behavioral/lifestyle components of care themselves. While this is a challenging endeavor, we believe the framework outlined here will improve your ability to meet the complex needs of CKD patients.
CORRESPONDENCE Ariel Linden, DrPH, MS, Linden Consulting Group, 6208 NE Chestnut Street, Hillsboro, OR 97124; alinden@lindenconsulting.org