Empathy goes a long way in weight loss discussions
Female patients are more likely to step up weight loss efforts when a physician shows empathy and offers support
Gathering data
1. Phone survey before patient visit. We telephoned those patients who did not refuse participation and conducted a baseline survey. We asked about date of birth, race, marital status, level of education, income, weight, height, history of weight loss attempts, and whether this was their first visit with that physician. We categorized women with a BMI ≥25 but <30 as overweight, and those with a BMI ≥30 as obese.12
We also assessed each patient’s
- self-efficacy—that is, confidence in their ability to lose weight. We asked: “How confident are you that you can lose weight?” (1=not at all confident, 5=extremely confident).
- readiness to lose weight. We asked: “Are you seriously considering trying to losing weight within the next 6 months?” and, if yes, “Are you planning to try to lose weight in the next 30 days?”13 Those not considering trying to lose weight were staged as precontemplation; those who were considering trying but not planning to try in the next 30 days were staged as contemplation; and those who were planning to try to lose weight in the next 30 days were staged as preparation.
2. Office visit. When patients came in for their appointments, the research assistant gave them consent forms to sign. The assistant then escorted the patient to the examination rooms and started the digital audio recorder. The exams typically took 27 minutes.
Immediately following the exam, the research assistant surveyed the patients. The assistant asked 2 questions we’d asked at baseline: “How confident are you that you can lose weight?” and “Are you seriously considering trying to losing weight within the next 6 months?” (If yes, “Are you planning to try to lose weight in the next 30 days?”) She also made an appointment to conduct a 1-month follow-up telephone survey.
3. One-month follow-up survey. During a follow-up phone survey, we asked patients whether they had attempted to lose weight by changing their diet, exercise patterns, or both. Subsequent to this call, we sent the study participants a $25 check.
Analyzing the patient-physician discussion
Content. Two authors coded 9 topics that physicians and patients discussed that were “weight-related.” Topics included: physical activity, diet, BMI, psychosocial issues, referral to a nutritionist, weight loss surgery, goal setting, weight loss medications, and health care avoidance. We also coded who first brought up the topic.
Time spent. We calculated time spent discussing weight-related topics and also the total time of the patient’s visit.
Motivational Interviewing. Two coders assessed MI. To assess fidelity to MI principles, we used sections of the Motivational Interviewing Treatment Integrity scale (MITI)14 to rate patient interactions on a scale of 1 (low) to 7 (high) in 2 categories: empathy and MI spirit.
- Empathy is when physicians convey understanding of patients’ perspective.
- MI spirit includes evocation, collaboration, and autonomy. Evocation is when physicians draw out patients’ own reasons for change. Collaboration is when physicians act as partners, supporting and exploring patients’ concerns. Autonomy is when physicians convey that decisions to change lie completely with patients. Inter-rater reliability for the Empathy and MI Spirit was adequate (ICC=.94 and .97, respectively).
- MI-adherent behaviors were those where the physician asked permission to do things, affirmed statements, offered words of support, and emphasized patient control. For instance, the physician might say, “It’s great that you have stopped drinking sweetened tea” or “Whether you lose weight is up to you.”
- MI-nonadherent behaviors were those where the physician advised without asking permission. For example, the physician might say, “Let me tell you what you need to do to make this work…” or “Well, if you want to continue on the way you are, you know your diabetes is only going to get worse.”
These were combined to create a ratio of percentage MI-adherent behaviors by dividing MI-adherent by MI-nonadherent. There was an excellent level of agreement between coders for MI-nonadherent (kappa=.80) and a moderate level of agreement for MI-adherent (kappa=.52) behaviors.
Data analysis
We used Spearman correlations to assess the relationship between our predictors, quantity (time spent and whether weight was addressed) and quality (MI techniques), and mediators of behavior change (readiness to lose weight and self-efficacy to lose weight) and behavior change (attempts to lose weight, change in diet, and change in exercise patterns). We used SAS 9.1 (SAS Institute, Inc, Cary, NC) for all analyses. The study was approved by the Duke University Medical Center Institutional Review Board.
Results
