May 17, 2014

Opportunity, Means, And Motive

David Hill MD, FAAP

“So, Doctor, what are some things people can do about this problem?” If you’ve ever faced a reporter then you’ve probably answered some version of this question. If you had adequate time to prepare, you may have even emailed your advice in advance to provide bullet points for the graphic. This is, after all, “news you can use!” (What would they call it if “news” and “use” didn’t rhyme?)

But do you ever wonder how many people actually do the stuff you recommend? I imagine it depends in part on the nature of the advice. “Keep your children indoors while these wildfires rage,” probably sees a lot of takers. “Be sure and get your child’s flu vaccine this season,” wins some, if not as many as we’d like. “Don’t let your child have a television in his bedroom,” gets...(crickets).

What do we hope to accomplish as pediatricians by engaging the media, aside of course from the fame, fortune, and autograph-seekers we so enjoy? Personally, I hope to extend my mission beyond the exam room into people’s living rooms, where my advice can help children live healthier lives. But if that’s our goal, how can we be best accomplish it?

In the clinic, I know the answer. My career has spanned the transition from a paternalistic model of behavior change (“Of course you’ll do what I say; can’t you see how crisply pressed my white coat is?”) to the awkwardly named transtheoretical model (“So is it okay if we talk for a moment about your habit of sharing cigarettes with your child?”). This transition has given birth to motivational interviewing, a technique that pretty much blows everything else out of the water when it comes to helping people embrace healthier behaviors.

Motivational interviewing is far too involved to fully explain in this space, but the four core concepts are pithy enough to hit. The first idea, “express empathy,” suggests we start by listening to where our patients are coming from and trying to connect, i.e., “I can see how smoking with your child gives you two a chance to bond.”

Second comes, “develop discrepancy,” meaning to help patients see how their current behaviors might lead to outcomes they don’t desire, as in, “You’ve said you wished you could quit smoking. How do you feel about your child smoking?” Third, and most alliterative, is, “roll with resistance,” meaning we must accept that patients’ reluctance to change is a normal part of human nature and not a moral failure, like, “It sounds as though you feel the time you share smoking with your child is strengthening your relationship. I see why you might not want to give that up.” 

This leads to the final step, “support self-efficacy,” a toughie; both because it’s nearly impossible to say three times fast and because it doesn’t just mean being supportive when patients do what we suggest. It means being equally supportive when they don’t, as in, “I’ve enjoyed our conversation today. If we can talk about this smoking thing again some time, please let me know!”

Motivational interviewing isn’t magic, but when practiced one-on-one it has posted impressive results for changing behaviors ranging from overeating to alcohol abuse. The question I struggle with is how to make this face-to-face intervention work when addressing a whole population, as we do in the media. Can we ask what people’s most common reasons are for, say, not vaccinating their kids? (It turns out more parents are worried about pain and fever than about autism.) Can we show empathy for those in our audience who may resist change, citing those reasons? Can we avoid moralistic language when talking about people whose decisions we think are unwise?

I don’t pretend to have mastered the art of translating motivational interviewing techniques to a sound bite that may last well under a minute. I do think, however, that those of us who can pull off that trick will be the most effective medical communicators ever. As for myself, I can live without autograph-seekers. I wouldn’t want them to wrinkle my white coat.