Lecture 21 - Motivation in health settings

Question 1

Dr. Wields Stick Against Smokers:
Either Quit, or Get Another Doctor

Answer 1

Doctor
After woman treated for throat cancer started smoking again
Idea of tough love

“I got fed up with wasting my time treating
people with smoking-related diseases.
People who continue to smoke are
obviously not interested in maintaining
their health.”

30 said I want some help
3 said transfer me

 “I am surprised at how positive the reaction
has been. The support was overwhelming,
even from patients who smoke. Since I
issued the ultimatum I have had only 3 pts
request that their files be transferred to
another doctor.”

Question 2

Analysis of Dr. Ross

Answer 2

 “The patients’ response shows that most of
them really want to quit but needed to be
pressured to do it.”
 “I have had a lot of demand for the patch and
other methods of quitting. A lot of people are
telling me how they are trying to quit. They
seem to want my approval.”

=Extrinsic motivation

“I think its good. Its scaring me and I think he’s a good
doctor and I like him so I don’t have any choice but to
quit smoking.”
5,000 pts, 10% smokers;
nationally: 25% of adults smoke.

What struck the prof: exactly the opposite of what’s in Ed Deci’s book
It’s the wrong this to do: threat, pressure, coercion

To truly work long-term, must be intrinsic

Doctor’s Ross’ message was not autonomous motivation and support

Question 3

The 2 key motivational concepts:

Answer 3

 Autonomous motivation:
“Feeling a sense of volition and choice in one’s behavior”
 Autonomy support:
take and acknowledging pt’s perspectives,
provide choices,
providing meaningful rationale

Doctor’s Ross’ message was not autonomous motivation and support

Autonomy support:
Being patient-centered… listening, being empathetic

The specifics of autonomy support
 make eye contact;
 ask open-ended questions;
 listen carefully,
 do not interrupt;
 encourage initiation and involvement;
 provide a rationale for your suggestions;

Not a lot of opportunities to be listened to by the doctor
People also kinda confused after getting the recommendations

Question 4

Motivational Interviews

Answer 4

3 minute interview
Assess the readiness of patient to quit
4A interview (ask, advise, assist, arrange)
Ask: what do you understand about the health consequences of smoking? (do they have info?)
Advise: advise and ask are you ready to quit? (if not, ask what would it take)
Assist: suggest some ideas (don’t do alone, take medication too)
Arrange: a quit day and a follow-up
Especially good when done by doctor rather than nurse or counsellor
Must not be done in a controlling way

Question 5

Studies by Dr. Geoff Williams

Answer 5

Idealistic young
internist.
Competent and
committed.
Frustration but an
impo insight:
 Patient motivation is a part
of my job.
 How I interact with the
patient will have a major
impact on their motivation.

3 studies:
(1) Smoking Cessation
(2) Medication Adherence
(3) Diabetes Control

Study 1: Smoking Cessation
 230 patients meeting with personal doctor who had
been trained in National Cancer Associations Brief
Motivational Interview re Smoking.
 Ask – 3 q’s
 Advise
 Assist
 Arrange (Follow-up)
 39 years age, 26 years of smoking!
 Motivation assessed 2 weeks later.
 Check-ups at 6, 12, 18 months
 Self-reports validated with chemical tests.
Doctor’s interviews were tape-recorded
and coded for autonomy support
– encourages questions and initiation by patient
– takes the patient’s perspective
– provides choices

Keanu reeves in that movie would be an autonomy supportive doctor
-encourage intrinsic motivation

Measured Patient Motivation 2 weeks
after meeting with the doctor
 Controlled vs Autonomous Reasons:
“I plan to quit smoking because….”
 “I want others to see I can do it”
“I’ll feel like a failure if I didn’t”
 “I’ve carefully thought about quitting and
believe its the right thing for me to do.”

Results:
 10% of participants had quit smoking
continually through 18 months.
 Autonomy Support –> Autonomous Motivation –> Abstinence

Study 2: Medication Non-Compliance
 125,000 deaths per year in US
 1 in 5 never fill out prescription
 1 in 3 never get refill
 Over 50% take prescription improperly
Most Common Reasons:
 Illness causes fewer symptoms than medication;
 Incapable of changing habits (no drinking);
 Demands of work and family life;
(I never had a chance to discuss how to take the
medicine or what it would mean… Prof thinks doctors and physios etc should ask:
Do u think ull be able to do this
After prescribing you meds or exercises, etc.
)

Results:
 Dependent Measure: 14-day prospective pill
count;
 Perception of autonomy support –> Autonomous motivation—> Higher Levels of Adherence

Study 3: Diabetes Management
 Included physiological outcome measures.
 Perception of Aut Support–> Autonomous Reasons—> Better Glucose Control

Current Evidence for the Model
Ng et al 2012
 Meta-analysis of 184 data sets testing Williams
model
Autonomy Support–> Autonomous Motivation –> Pos. Health Outcomes

Question 6

Overall

Answer 6

 Motivation plays an
important role in health
settings.
 Your interpersonal
behavior (doctor’s) can foster
autonomous motivation
and better health
outcomes

Question 7

Return to Dr. Ross, Winnipeg Doctor

Answer 7

 “My husband, who is a diabetic, has not seen
the doctor in years because he still has not
lost the 10 pounds he was told to lose”

Another Doctor’s Comment
 “People need someone to calm their fears,
someone who will not scold them for being
less than perfect in health care and who is
available to answer seemingly minor
questions.”
-“A truly heartfelt understanding
of the patient’s experiences.

Another benefit of supporting autonomy
 Ambady research on malpractice law-suits
-Empathetic doctors less likely to be sued