This essay is based on a talk I gave to medical students and faculty at the Perelman School of Medicine at the University of Pennsylvania on how physicians can help patients achieve behavior change.
This image is enough for most of you in the audience to start building your differential diagnosis. When this older gentleman shows up in your emergency department sweating profusely and complaining of chest pain, you’re going to instinctively reach for an aspirin and an EKG.
Much of our medical training is focused on these kinds of situations where procedural memory helps us act quickly and effectively. This is important because when we’re in a time limited and stressful situation, it can be difficult to think clearly and so we need to develop good instincts.
Yet let me turn the clock back twenty years, well before his coronary arteries are overrun with plaque. What happens when this same patient shows up to your outpatient practice and during a routine exam you find out that he smokes a pack of cigarettes a day?
You’ve got 5 minutes until you see your next patient. Once again, you’re time limited and stressed. What do you do? Are you still ready to act?
I want to talk today about behavior change because our ability to act effectively in that outpatient moment is just as important as our ability to act effectively in the ED. Whether in 2 hours or 20 years, a life saved is a life saved, and we can and should be prepared for both.
I want to give you a framework for approaching that outpatient encounter so that you can feel more competent and confident when it comes to behavior change.
At the heart of this framework is an understanding of ambivalence.
Here’s our patient during his annual physical, feeling ambivalent about smoking. To him, whether consciously or unconsciously, the benefits of smoking outweigh the costs and as long as this remains the case, inaction will prevail.
He’s seen the surgeon general’s warning, he notices how much a carton of cigarettes costs. Yet, he enjoys taking smoking breaks throughout the day. It’s a nice chance to stop and think. He knows how crappy he feels when he doesn’t smoke and would rather not deal with that right now. And you know, when he takes a drag, he genuinely feels better. In fact, its the best way he knows how to deal with stress.
The Righting Reflex
When confronted with this balance, our first instinct is to try to emphasize the costs in some way. We’ll talk about cardiovascular health risks or we’ll emphasize how expensive the habit is.
This is called the righting reflex. We see this ambivalence and think we can tip the balance ourselves. However, to tip these scales compels change. It mains giving up the comforts of the familiar and launching into the uncertain. Tipping these scales means committing to the long and arduous process of quitting smoking and that’s not why this patient came to talk to you today.
So, what does our patient do? He justifies the status quo.
You tell him that he’s losing five years off his life expectancy, and he thinks, “That’s not going to happen to me.” You tell him how much money he’s wasting on this habit, and he thinks, “It’s not all that expensive.”
And here’s the thing, because people are more strongly persuaded by what they hear themselves say, all you’re doing is helping the patient talk himself into his habit. This is why throughout this process it’s important to resist the righting reflex. It’s confrontational and it’s counter-productive.
As an alternative to this confrontational style, what we’re going to do is use targeted questions to help our patient explore his ambivalence more thoroughly than he may have done in the past.
Now, we wouldn’t be initiating this conversation with our patient if we didn’t suspect that the harms of smoking outweigh the benefits. However, the spirit of this conversation is not one of manipulation but one of inquisitiveness. We’re not trying to trick the patient into quitting, but rather working together with them to understand where smoking fits into their life, their priorities, their values, and their goals.
As we ask questions to better understand our patients ambivalence, we’re going to prompt and listen for change talk. This includes statements about their Desire, Ability, Reasons, and Need to make change. As they mention these things, we’re going to use reflective listening skills to repeat their words back to them, emphasizing this self-generated and thus emotionally salient information.
In doing so, you empower the patient to shift the balance of their ambivalence themselves with you as an ally, not as an opponent. And when they’re ready, you support them to make a commitment to behavior change on their own terms.
To give you an example of what this looks like as a brief clinical intervention, here are three questions I might use when I encounter a patient who tells me they’re a smoker.
“Have you ever thought about quitting smoking before?”
Follow up: What made you consider it? Has anything changed since then?
I like opening with this question because starting our inquiry in past motivations diffuses some of the emotional charge of the conversation. Here we can start to explore past ambivalence safely without it having implications on present behavior. By asking clarifying questions about the different motivations that they share with you, you can get a good sense of their decisional balance.
“Have you ever tried to quit smoking before?”
Follow up: What did you try? What was helpful? What was unhelpful?
This is a nice follow up question because not only does it validate the effort that the patient has already put into behavior change, it’s a great way to explore a patient’s feelings of self-efficacy about behavior change. As you find out more about what they find helpful or unhelpful about past strategies, you can file this information away in the back of your head for when the conversation eventually shifts to making changes today.
“Are you currently thinking about quitting smoking?”
After opening in the safe space of the past, this is a nice way of transitioning to the present to start exploring whether the patient is amenable to talking about change today.
Behavior change in context
By being ready with questions like these, you can be ready to start exploring a patient’s ambivalence and listening for change talk when you identify an opportunity for behavior change.
The point is not to try to accomplish this change in five minutes. After all our habits are built up over months and years and it can take just as long to reform them. Rather, this is a good way to work toward behavior change through a series of brief interventions in the context of a longitudinal relationship with a patient. However, even if you don’t have that longitudinal relationship, doing your part to help a patient understand their own ambivalence about behavior change will make it that much easier for them to accomplish that change in the future.
The next time you encounter a patient who has an unhealthy behavior that they feel ambivalent about, try this approach:
- Ask the patient permission to engage in this conversation,
- Explore their ambivalence,
- Resist the righting reflex,
- Repeat change talk, and
- KEEP Practicing.
Getting comfortable with these conversations takes time and you won’t be good at it right away. However, the more you practice these skills the more confident and competent you will be. And some day, when your patient tells you that he’s a smoker, you’ll be ready to save a life.
As a medical student, I own up to the fact that my clinical experience is limited. I recognize that my approach to behavior change will likely evolve over time, and I’m happy to hear the perspectives of more experienced practitioners on how you’ve found success helping patients achieve behavior change.