SAN DIEGO – As pay for performance becomes more common, patient adherence could become a pocketbook issue for physicians, Dr. Robert F. Kushner said at the annual meeting of the American College of Physicians.
“A patient's behavior is shaped by their environment, lifestyle, and life experiences. People do what they do for a reason. No one is a bad patient,” said Dr. Kushner, a professor of medicine at Northwestern University, Chicago. “Your role is to find out why they're doing what they're doing.”
The first step is assessing the patient's readiness for change. But just asking a patient if he or she is ready isn't enough. “Very few patients want to be bad patients in front of your eyes,” he said. “Very few patients will say, 'No, I'm not ready, doctor.'”
Go deeper in understanding their readiness by evaluating their reasons and motivation to change behavior, previous attempts at change, the level of support expected from family and friends, and potential barriers. In addition, assessing whether patients have the time available to make the change is critical.
There are some tools available to help physicians make that assessment, Dr. Kushner said. Five models for understanding and changing behavior have been around since the 1970s: the health belief model, self-determination, motivational interviewing, social cognitive theory/ecological models, and stages of change.
“Intuition is not enough,” he said. “It really helps to know the theories and models and approaches that have been developed to help us understand why we do what we do.”
▸ Health belief model. Under this model, the patient might not understand the importance of making a behavioral or lifestyle change, or might be ignoring health risks. It is often helpful to educate this type of patient about susceptibility to risks, Dr. Kushner said.
▸ Self-determination. This involves the goal of helping patients find their own personal motivation for making a change. In general, patients are more likely to adopt healthy behaviors because they want to, not because they should or they have to. Dr. Kushner said he often evaluates patient motivation by asking them to assess, on a scale of 0-10, how hard it is to make the change. Patients who respond that the difficulty is about a 10 are unlikely to be able to maintain the change, he said.
▸ Motivational interviewing. With motivational interviewing, physicians can assess a patient's readiness to change by asking two questions: How important is this change on a scale of 0-10? How confident are you that you can make the change on a scale of 0-10? Typically, the confidence number will be lower than the importance number. That opens up a dialogue for the physician to ask what can be done to improve confidence.
The goal with motivational interviewing is to support the patients' own belief that change is possible, Dr. Kushner said, but not to get angry or argue with the patient.
▸ Social cognitive theory/ecological models. These look at the resources for or barriers to the patient making the change. “This is the most important theory I use on a daily basis,” he said. “It looks at the patient in the context of their life, their community, and their environment.” For example, can the patient afford to make changes to his or her diet? This model also depends on the patient's self-efficacy and the degree to which the patient believes that making changes will lead to a positive outcome.
▸ Stages of change. Under the stages of change model, the physician assesses the patients' readiness for change and tries to support movement to the next stage. The five stages of change are precontemplation, contemplation, preparation, action, and maintenance. The stages of change can be very helpful in choosing the most effective way to approach the patient, he said. For example, when patients are in the precontemplation stage, provide education and move on.
'Intuition is not enough. It really helps to know the … models and approaches that have been developed.' DR. KUSHNER