WASHINGTON The key to motivational interviewing is raising a subject without generating resistance, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.
"People are more likely to change when there is a discrepancy between their current behavior and their goals," said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.
Once the physical exam and behavioral assessment are completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.
The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:
▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, "You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health." The doctor states a discrepancy in the behavior, compared with what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, "What do you think about that?" But when time is at a premium, move on to the next point.
▸ Responsibility. Make a statement that reasserts that problematic behavior, and the patient's reaction is up to the patientfor example, "What you do about your drinking is up to you."
▸ Advice. Doctors who avoid the use of the words "should" and "need," when offering advice are less likely to generate resistance in patients. "I encourage you to consider reducing your drinking" is better; the doctor communicates respect for the patient by the way he or she phrases the advice.
▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.
▸ Empathy. Tell patients that, "It might be hard for you to make this change," because sometimes it is. However, Dr. Weir said that he avoids saying that "it is hard" to change, because for some people it is not, once they make up their minds.
▸ Self-Efficacy. A statement such as, "But I'm confident that when you make up your mind to change, you will be able to do it," reinforces the fact that behavior change starts with the patients, but the doctor believes in their ability to change and will support their efforts when they are ready.
"This FRAMES moniker is a way to give advice about a lot of things in a short period of time," Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.
In his work with medical students, Dr. Weir teaches a 30-second version of FRAMESa short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors. For example:
"Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options."
Dr. Weir said that he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. "It's like a rosary chain; you need to touch all the beads," he said.
Dr. Weir also explained what motivational interviewing is not. "It is not arguing that a person has a problem and needs to change, it is not giving a solution without the patient's permission, and it is not taking an 'expert' stance," he said.
"Knowledge is not as much of a deficit as ambivalence," he added. Patients usually have feelings about their behavior, and it can be important to let them hear themselves talk about these feelings and have the opportunity to reflect on them.
Dr. Weir recalled that as a younger physician, he sometimes felt that his own value was negatively affected if a patient persisted in an unhealthy behavior.