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Changing our Thinking about Changing our Patients

Posted By Suzanne Bailey, Thursday, May 24, 2012
Poor treatment adherence is a systemic problem. It impedes treatment outcomes, complicates treatment planning, and frustrates providers. I have yet to meet a healthcare provider who entered the field to argue with their patients, but I have met many passionate providers who are frustrated with the seemingly apathetic responses of seriously ill patients. A primary care colleague recently commented regarding a mutual patient with a history of nonadherence with his diabetic treatment regimen, "I have told him a thousand times. He just doesn’t care.”

The management of most chronic conditions requires behavior change. However, patients often underestimate their ability to modify their lifestyle and positively impact their health status. Instead, they expect their visit to the doctor to result in a prescribed treatment or medication that will cure their condition or at least alleviate their symptoms. Thus, when the prescribed treatment involves behavior change, resistance is often created. "I have pain every day and you are telling me to exercise and eat healthily?”

Prochaska and DiClemente (1984) described a model of assessing patients’ readiness to change and tailoring interventions to enhance patients’ willingness and ability to engage in behavior change. As healthcare providers, we are always in the "action” stage. We assess and diagnosis conditions and prescribe behavior change interventions to improve health status.

Suzanne Bailey
Viewing ambivalence as a normal part of the chronic disease process allows us to treat ambivalence as a component of the disease.
 However, our focus on overall health may not be patients’ priority and patients are often not in the "action” stage. Many of us can relate to the patient with an A1C of 13 who wants the focus of their primary care visit to be their back pain. It is difficult to focus this patient on their diabetes in the context of the medical visit, much less encourage them to leave our office and make meaningful lifestyle changes to improve their A1C.

Too often these patients become labeled "difficult patients,” as if something were inherently wrong with the patients. However, viewing ambivalence as a normal part of the chronic disease process allows us to treat ambivalence as a component of the disease. We must accept that we cannot force our patients to change. Rather, we must help our patients decide to engage in behavior change. Motivational Interviewing, a style of interacting with patients developed by Miller and Rollnick (1991), addresses this ambivalence by eliciting motivation to change from the patient through guided conversation.

At Cherokee Health Systems, a FQHC and CMHC with an integrated care model that blends behavioral health and primary care where I work as a Behavioral Health Consultant, we’ve learned that we must change our thinking about changing our patients. We serve a population of largely indigent patients with multifaceted behavioral health, primary care, and social needs who present across the continuum of readiness to change. Thus, we have instituted brief, basic trainings in Motivational Interviewing for our primary care providers. They are, in fact, the gateway to behavior change in an integrated model, either through direct conversation with patients or by "closing the sale” and facilitating a warm hand-off to a Behavioral Health Consultant. In implementing this training, we have learned that brief training can be effective in equipping providers with the skills to motivate patients’ behavior change and reducing provider frustration with "difficult patients.”

As we continue to address ambivalence as part of the chronic disease process and work to motivate behavior change, I am continually reminded that motivation truly is elicited and developed collaboratively in the context of the patient-provider relationship. I recently had a patient explain, "I don’t want to change, I just want to feel better.” There is perhaps no better foundation on which to begin a guided conversation about behavior change.


Suzanne Bailey, Psy.D. is a Licensed Clinical Psychologist and Behavioral Health Consultant at Cherokee Health Systems. She earned her doctorate in Clinical Psychology at Xavier University in Cincinnati, Ohio. Dr. Bailey practices in an integrated primary care clinic at Cherokee Health Systems’ Center City office in downtown Knoxville, TN, which serves a population of primarily indigent, homeless patients. She is the Director of Cherokee Health System’s Intensive Outpatient alcohol and drug Program and Supervisor for Case Management Services.

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Peter Y. Fifield says...
Posted Thursday, May 24, 2012
like true gospel. Thanks Suzanne.
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