Medication non-adherence leads to preventable hospitalizations and costs US healthcare $500 billion each year. Bruce Berger explains how motivational interviewing can help, with Jim Cagliostro. 

 

Episode Introduction 

Bruce explains that motivational interviewing is still the most effective intervention for substance abuse, why adherence hasn’t improved in 40 years, and why discharge counseling should be provided the day before patients leave hospital. He also shares how MI interventions reduced the patient dropout rate from 13% to 1.2%, saving $93 million for one biotech company in four months, and urges healthcare leaders to stop objectifying patients. 

 

 

Show Topics

 

• Motivational interviewing (MI) began in the 1970s
• Why MI is not about motivating patients 
• All of us are sense-makers
• Genuinely connecting with what’s emotionally important to patients
• Restricting patient time is at the heart of burnout
• Healthcare needs to stop objectifying workers and patients

 

 

03:54 Motivational interviewing (MI) began in the 1970s

Bruce explained how MI was originally developed to treat people with substance abuse problems. 

‘’Well, motivational interviewing was first developed by a clinical psychologist named William Miller, and it was developed back in the '70s to actually treat people with substance abuse problems. And here's the irony, Jim, to this day, it is still the most effective intervention for substance abuse, and yet, we hardly hear about it in healthcare. We've got an opioid crisis, we've got substance use and rarely do you hear people talking about using motivational interviewing to intervene. And I've done a number of webinars on this. And here's one of the reasons why, we are huge in healthcare on evidence-based medicine, but not evidence-based communication. And in fact, this year, for the first time, the American Council on Pharmaceutical Education is including motivational interviewing as part of their accreditation standards. I'd like to think I'm part of the reason why, because I wrote a five-page single-space letter saying, how can you talk about evidence-based pharmacy and medicine, but not evidence-based communication?’’

 

05:17 Why MI is not about motivating patients 

Bruce said people might know how to communicate, but often lack the skills to be effective.

‘’And we graduate people who think everybody knows how to communicate, but that doesn't mean they know how to do it effectively. And so, what MI is, motivational interviewing is a set of skills and a way of being with patients. It's kind of a misnomer, it's not about motivating patients, it's an interview, in a sense, to explore the patient's motivation. "Okay, now you've found out you've got diabetes and the doctor has told you, "You got to take this medicine, watch what you eat, get some exercise." What do you think about all this? In other words, how important is it to you to get your blood sugar down? Tell me in your own words, what does having diabetes mean to you?" The idea behind motivational interviewing, because it's patient-centered, and you asked how is it different than what we do? We have this literally crazy idea in healthcare that we're driving the bus and the patient's a passenger, the reality is the patient has always driven the bus, what we're trying to do is influence the route. Does that make sense?’’

 

09:33 All of us are sense-makers 

Bruce said changing your approach to patients helps to overcome non-adherence. 

‘’….all of us are sense-makers. Even as we're talking right now, we're deciding whether we make sense of each other based upon what we bring to the conversation. So we're trying to train people to listen for, how is this patient making sense? And in their sense-making, what information is either missing or misinformation? Let me give you a really simple example. Patient with high blood pressure says, "I don't know why I need this medicine. I feel fine.’’ Now most healthcare professionals will look at the patient and say, "Listen, you can't tell when your blood pressure's up. You can't feel when it's up." And they might as well just say, "Stupid," at the end of that sentence. We would say, "Because you're feeling okay, you're really wondering, why do you need this medicine?" What's the patient going to say now? Exactly. And what will they have learned? That I've listened to them without judgment. Now I'm going to say, "That's a reasonable thing to ask. Would you mind if I shared some thoughts? And I'd like to hear what you think." You notice the sharing?’’ We're negotiating here. And so, now I would tell the patient that, "Unfortunately, high blood pressure is one of those conditions that doesn't have any symptoms, and the first symptom is stroke or heart attack. This medicine can greatly reduce your risk of having a stroke or heart attack even when you feel okay." I'm now not going to say, "Therefore, you need to take it," I'm now going to say, "Where does that leave you in terms of thinking about taking the medicine to reduce your risk?" So I've listened to what the patient has said, I've heard in their sense-making that their sense is that if you feel okay, everything's okay. My job is to help them understand how you can feel okay and be at risk.’’

 

18:34 Genuinely connecting with what’s emotionally important to patients 

Bruce said it’s important to understand what’s meaningful to patients.

‘’….we had an asthma patient that wasn't using her daily inhaler. She said, "I just hate being reminded that I got this thing." And I said, "Let me ask you something. What could you do?" I said, "If your asthma was under control, what would that allow you to do that you find difficult now?" She teared up and she said, "I could play tennis again." Now we found out what's important to her. It doesn't matter what's important to me, she's only going to be motivated by what's important to her. And so, we then start talking about steps that she could take to play tennis again by using the medication, and she became adherent, but you had to explore what was meaningful to her….. And I'm not talking about being false, I'm talking about genuinely connecting with what's emotionally important to the patient, and you've got to do that in order to really have influence in a positive way. And so saying to that patient, "You love your grandkids. You miss not being able to spend time with them. You want a future where you can spend time with them." And you see what I'm doing? I'm helping build pictures.’’

 

22:53 Restricting patient time is at the heart of burnout

Bruce explained why healthcare has a systems problem which affects patient care and adherence.  

‘’One industry is moving in a totally opposite direction (to other industries), healthcare. There are so many toxic systems out there that are putting profits ahead of people, people meaning their workers and the patients. We are watching burnout at a level we've never seen before because healthcare systems are basing staffing on things like number of prescriptions dispensed, number of immunizations given, RVUs, "Oh, you should only be spending 11.2 minutes with the patient and no more, even if the patient needs more time in order to have an effective outcome." Somebody asked me the other day, "Well, what am I supposed to do if I only have, at most, 30 seconds with a patient?" Well, no amount of motivational interviewing training can solve that problem, that's a systems' problem. There's a couple of videos on YouTube with me showing what happened with an asthma patient. The patient's daughter had been in the emergency room three times that year because the mother wouldn't allow the daughter to use the chronic inhaler because she looked it up and saw it was a corticosteroid, she misunderstood what that steroid was. She didn't want her daughter using a steroid. Everybody chastised her at the emergency room. I showed her understanding and in fact, said to her, "You're really worried about your daughter using a drug that you think can harm her." And for the first time somebody understood her. After we were done, the whole conversation took six minutes, the kid had not been in the emergency room for at least three years after that……And what's really horrible is we have people that are graduating from nursing school, pharmacy, school and medicine, they have a code of ethics, they have standards of practice that put patients first, and yet they go to work for organizations that set up a moral conflict for them because if your primary goal is to put patients first and the staffing makes it impossible, this is the heart of burnout and chronic stress.’’

 

31:50 Healthcare needs to stop objectifying workers and patients

Bruce said if healthcare workers are objectified, they objectify patients, and care suffers. 

‘’…if there's one message that I would give leaders in healthcare, it was you have got to stop objectifying your workers and patients. In other words, when you treat people as objects or like they're replaceable, anybody could do the job, the job's interchangeable, and you don't even give them an opportunity to have input into what's happening, you're objectifying them. And objectification begets objectification. Oftentimes, when we objectify healthcare workers, they objectify patients. It's no longer a human being, it's the diabetic in 214, that's not a person. And I'm saying, objectification is a major source of organizational problems in the delivery of care. The people in charge have got to start allowing for input on how to fix these problems and the people that are working in them and take them seriously. Right now, they're not.’’

 

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You’ll also hear: 

 

Bruce’s inspiration behind motivational interviewing: ‘’We've got data that shows that for the past 40 years, the rate of non-adherence to medication regimens hasn't changed at all, it's almost 50% in year two of a chronic illness. And I wanted to understand better what's going on.’’

Why MI is a meeting of experts: ‘’You as a patient are an expert on what you know and understand about the illness. I need to be listening for where the gaps are.’’

How MI interventions reduced the patient dropout rate from 13% to 1.2% and saved Biogen $93 million, in four months. 

Discharge counseling should be carried out the day before patients leave hospital: ‘’They're a captive audience, they'd want to talk to somebody. When they're ready to get out of the hospital, they don't want to listen to us going through their med list.’’

Essential healthcare leadership advice: ‘’Human beings are hardwired relational. If leaders get that, they will treat the people they lead much differently. They'll know they couldn't have gotten to that place without so many people helping them.’’

 

 

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