How to motivate your patient

Alain Golay1, Francesca Amati1, Annick Riecker-Agranier2, J. Ybarra3
1Division d’enseignement thérapeutique des maladies chroniques,
Hôpitaux Universitaires de Genève, Geneva, Switzerland
2Prévention et Maintien de la Santé en Entreprise (PMSE), Le Lignon, Switzerland
3Departamento de Obstetricia y Gynecologia, Instituto Universitario Dexeus,
Universidad Autonoma de Barcelona, Spain
Correspondence: Dr Alain Golay, Division d’enseignement thérapeutique des maladies chroniques, Hôpitaux Universitaires de Genève, 1211 Genève 14, Switzerland.
Tel: +41 22 372 97 22, fax: +41 22 372 97 15, e-mail: alain.golay@hcuge.ch

We probably do not need to convince health care providers of the importance of making patients aware of their cardiovascular risk. Several large longitudinal studies have proven its efficacy. Nevertheless, we, as health care providers, have to tackle the issue of patient motivation to modify existing behaviors. We propose the use of a simple chart to identify, together with the patient, his or her cardiovascular risk factors (Figure 1). Let us take one example.

A 55-year-old businessman in good general health comes for a routine medical check-up. He has no symptoms of angina pectoris or peripheral vascular disease. He reports sailing during the summertime and skiing for 1 week during the winter. His father died at the age of 55 from acute myocardial infarction and his mother is currently being treated for hypertension. A physical examination reveals: good general health status, weight 80 kg, height 1.75 m, blood pressure 160/95 mm Hg; no xanthelasmas; no bruits on auscultation. Laboratory findings are: fasting blood sugar 6.1 mmol/L, total cholesterol 6.6 mmol/L, HDL cholesterol 1.2 mmol/L, triglycerides 2.3 mmol/L.
Based on the Framingham studies, we have developed a tool that allows us to assess cardiovascular risk. This chart, shown in Figure 1, calculates in a given individual his or her chances of experiencing an ischemic event during the next 6 years. This procedure is particularly helpful for the development of psycho-pedagogical strategies aimed at motivating patients to take control of their lives. The patient’s risk is calculated prior to the development of strategies.
If we follow the chart for the example above, our patient scores 4 points for his glucose intolerance, 6 points for his hypertension (160/95), and 27 points for his total cholesterol based on his age of 55, which gives him a total score of 37 points. In this setting, HDL cholesterol concentration acts as a correction factor for total cholesterol. For this particular patient, the correction will be 1 (´1). This makes a total score of 37. The right-hand column shows that his chances of having an ischemic event in the next 6 years approach 15.5%.

How to motivate your patient
This patient should be advised to control his food intake, lose weight, and exercise in order to reduce his cholesterol, glycemia, and blood pressure. But how can we promote a lifestyle change on a long-term basis? Motivation is the result of the interaction between personal goals (life project), an emotional stimulation (to feel like doing something) and self-efficiency. The patient’s life project is based on his targets, beliefs, and values. It is a mixture of his life history, his successes, and his feelings. The life project may not always be entirely clear to the patient himself; nevertheless, it is the root for his motivation.
The need for change becomes clear once the patient perceives a contradiction between his life project and current reality. This imbalance may prompt the appearance of negative emotions such as anger and fear, but these will likely encourage him to seek a new situation that is more in accordance with his personal life project [1, 2].
This course is not easily accomplished since the patient is confronted with the dilemma of change [3]: either continue with his current behavior and obtain immediate gratification but run the risk of further negative consequences, or change his current behavior, undergo the immediate negative consequences (eg frustration) but gain some potential benefits.
Depending on the patient’s capacity to solve this dilemma, he will choose either to change or not to change. At this point it is important to allow the patient to make a free choice that is not influenced by his immediate environment or the protective attitude of the health care provider. Any attempted influence could have the opposite effect and reinforce the patient’s defensive attitudes, manifesting in denial and/or resistance to the proposed remedy [4, 5].
Prochaska and Di Clemente [6] have formulated a model called the transtheoretical model, showing the chain of events which lead a person to make a successful change. Using it helps us to adapt our strategies according to the patient’s particular situation. Interestingly, it also requires some behavior modification on the part of the health care provider (Figure 2)

Figure 2: The transtheoretical model. After Di Clemente, Prochaska [6]..

How to help the patient accept physical exercise
Approximately 85% of patients find themselves in the precontemplation or contemplation stage (Table I), in that they do not feel like exercising. Unfortunately, we frequently tend to propose action strategies: “you just need to walk more,” “you must go to the fitness club, swim,” while patients just do not feel like moving at all. In the precontemplation stage, the negative aspects of exercising overcome the potential advantages. At this stage, patients often cannot bear the thought of exercising. Hence, we must, for the time being, limit ourselves to providing information.

Table I. Early stages of behavioral change with regard to exercise.

Later on, at the contemplation stage, the negative and positive aspects are still not yet in equilibrium and the patient feels ambivalent towards exercise. At this stage we can help by encouraging the thought that change is possible and by promoting its advantages.
Around 15% of our patients are in later stages. At the preparation stage, the patient catches a glimpse of undertaking physical activity under certain conditions: he will try to have a walk if it is sunny. This is the appropriate time to make plans to negotiate realistic objectives and identify the potential advantages of exercising. This stage is crucial before attempting to progress to the action stage.

Table II. Later stages of behavioral change with regard to exercise.

Once patients have embarked upon the action stage — exercising — they still have to make a considerable effort. It is important to reinforce and encourage success whilst providing help to overcome the remaining obstacles. The chances of quitting physical activity remain high within the following 6 months if the goals are unrealistic.
Finally, we reach the maintenance stage where patients discover more advantages than disadvantages, and sometimes even do not feel good unless they exercise. It is important to strengthen their commitment and continue to reinforce and encourage success while maintaining and identifying strategies to prevent relapse.
We, as health care providers, are frequently in a rush to go straight to the action stage and propose strategies that do not respect patients’ own pace. We must prepare our patients and wait for them. The patient’s inner change must take place before his external change. Finally, we must remember that the more accurate and reachable our goals, the greater our successes will be.

REFERENCES

2. Grueninger U. Education et hypertension: le patient, partenaire de santé. Bull Educ Patient. 1996;15:50–58.
3. Miller R, et al. Motivational interviewing. J Psychother Integr. 1991; 21:835–842.
4. Girard A, Maisonnave M. Traitement à long terme: difficultés des patients, stratégies pour le médecin. Med Hyg. 1998;56:1204–1210.
5. Lacroix A, Assal J-P. L’Education Thérapeutique des Patients: Nouvelles Approches de la Maladie Chronique. Paris, France: Editions Vigot; 1998.