Effective patient–provider communication is not a primary focus of medical school curricula. Motivational interviewing (MI) is a patient-centered, directive communication framework appropriate for in health care. Research on MI’s causal mechanisms has established patient change talk as a mediator of behavior change. Current MI research focuses on identifying which provider communication skills are responsible for evoking change talk. MI recommends informing, asking, and listening. Research provides evidence that asking for and reflecting patient change talk are effective communication strategies, but cautions providers to inform judiciously. Supporting a patient’s decision making autonomy is an important strategy to promote health behaviors.
Key points
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Patient–provider communication is a key clinical skill linked to better patient satisfaction and improved outcomes for both patients and providers.
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Motivational interviewing (MI) is a patient-centered, yet directive method of communication suitable for most clinical encounters.
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Emphasizing behavior change autonomy is important, particularly for adolescents actively engaged in becoming independent and seeking out opportunities to make their own life choices.
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Providers integrating MI into practice are encouraged to ask open-ended questions and reflect patients’ own change talk back.
Introduction
The primary treatment strategy health care providers use when treating patients is communication. Providers engage their patients in conversations to understand their medical history and illness experiences, and to formulate treatment recommendations. These conversations fulfill task-oriented (eg, exchanging information, facilitating patient comprehension of medical information, engaging in informed and collaborative decision making, enabling patient self-management) and socioemotional functions (eg, fostering an interpersonal, healing relationship, responding to and regulating patients’ emotions, and managing uncertainty).
Benefits of Patient–Provider Communication
The benefits of effective patient–provider communication and its relationship to medical care outcomes have long been highlighted in the chronic illness literature. Better patient–provider communication is linked to patient satisfaction with medical care and medical care providers. Patient satisfaction is critical because it is an indicator of how well the provider is meeting patients’ health care needs, expectations, and preferences. Multiple research studies have positively linked patient–provider communication to patient adherence to treatment recommendations and better medical outcomes. Actively involving patients in their medical care affects adherence to treatment recommendations directly and through improved comprehension, understanding, and negotiation of treatment recommendations.
Effective patient–provider communication not only leads to a better medical care experience and improved outcomes for patients, but benefits also extend to providers and society. Improvement in provider communication skills is associated with greater satisfaction with patient interactions, increased self-confidence for treating “difficult” patients, and decreased malpractice claims. Improved patient–provider communication may also pose benefits society as a whole through decreased health care costs.
Patient–Provider Communication in Pediatrics
Patient–provider communication in the pediatric health care setting differs dramatically from adult patient–provider communication in that the patient is a child and the responsible party is the child’s caregiver. This presents a dilemma for the provider; with whom should the provider communicate, the caregiver or patient? Research suggests that providers spend more time communicating with caregivers than with their pediatric patients. Specifically, pediatric patients, regardless of age, are typically engaged in less than 20% of the communication in a typical medical care visit. When pediatric patients are engaged in the conversation, they are generally included in social aspects and the provision of medical history with the treatment decision making typically completed by the provider and caregiver. When providers attempt to increase pediatric patients’ participation, caregivers often disrupt this effort by interrupting and responding to questions and statements directed to the patient rather than supporting and encouraging the patient’s active involvement. This dynamic may have unintended consequences. Pediatric patients, particularly adolescents, report feeling marginalized when they are excluded from conversations about their own health, which may lead to disengagement and disinterest in their own health care.
Direct communication with pediatric patients, on the other hand, builds trust and rapport, helps to socialize children into the patient role, and, in the adult literature, has been identified as a primary mechanism for patient adherence to behavioral recommendations. With the top 4 causes of early mortality—namely, cardiovascular disease, cancer, respiratory disease, and stroke—tied to modifiable behaviors such as poor diet and lack of physical activity, there is a critical need for providers to communicate with their patients to change their behavior in these areas. Pediatricians, in particular, play a critical role in identifying children who are at risk for obesity and these life-threatening diseases and to encourage these children and their families to change their unhealthy dietary and activity patterns early, before the detrimental effects of unhealthy behavior patterns begin to unfold.
The Skill of Communicating Well
The National Academy of Medicine (formerly the Institute of Medicine) recognizes patient–provider communication as a key clinical skill as does the international medical community, medical schools, and professional medical organizations. Although these organizations offer recommendations regarding the qualities of effective patient–provider communication, few offer concrete guidelines for how to effectively communicate. This poses a dilemma for the provider because patient–provider communication skills are not innate. Like any other skill, effective patient–provider communication must be systematically learned and repeatedly practiced.
Motivational Interviewing, a Framework for Patient–Provider Communication
Motivational interviewing (MI) is an empirically supported approach to patient–provider communication that is characterized as “a therapeutic conversation that employs a guiding style of communication geared toward enhancing behavior change and improving health status.” (p2) The goal of MI is to increase patients’ intrinsic motivation and self-efficacy for engaging in health-promoting behaviors. Intrinsic motivation, engaging in an activity for reasons of personal interest or satisfaction rather than external consequences, has been linked to positive outcomes across multiple domains. MI was originally developed to treat adults in substance abuse treatment ; thus, there is a strong evidence base for its efficacy in that domain. Since its inception, MI has been adapted for multiple behavior change targets, including health care behaviors such as cancer-related fatigue, medication adherence in treatment of those with human immunodeficiency virus infection, diabetes management, and weight loss. Of particular relevance, physician use of MI has been linked to weight loss among adults and children who are overweight or obese and is a recommended approach for pediatric obesity.
MI has a highly specified framework that is both patient centered and directive, making it an ideal approach for health care providers. The principles of MI, including providing empathy, collaborating with clients, and supporting client autonomy, are elements of patient-centered care. MI emphasizes patients’ decision-making autonomy, which is the tenet of self-determination theory and empirically linked to increased adherence to medical recommendations, particularly when treating adolescents. In health care, autonomy-supportive environments are those where providers elicit patient perspectives, provide information and opportunities for choice, and encourage patient responsibility. These characteristics are implicit in MI’s core communication skills—informing, asking, and listening. Furthermore, MI is consistent with consensus recommendations for working with clients from different cultures in obesity treatment. Two metaanalyses have indicated that MI was more effective with blacks compared with whites, suggesting it may be a relevant framework for patient–provider communication in populations affected by health disparities.
Motivational Interviewing’s Causal Mechanisms
MI can be broken down into technical and relational components. The relational component of MI refers to the ability of the provider to understand the patient’s perspective and to convey that understanding in a positive, empathetic manner. These elements are referred to as the “spirit of MI.” Although these components are important for relationship building, they do not fully account for MI’s efficacy at evoking behavior change. The technical component of MI is the specific communication techniques that providers use during MI sessions to elicit and reinforce patients’ motivational statements about changing their behavior, that is, “change talk.” Patient change talk statements during clinical encounters consistently predict actual patient behavior change ( Box 1 ). In fact, 1 study with substance abusers found that patients’ change talk predicted marijuana use 34 months later.
Change talk is patients’ own statements about their own desire, ability, reason, and need to change their unhealthy behavior. The following statements are examples of patient change talk related to weight loss:
Desire: I want to lose weight.
Ability: I know how to read a food label.
Reason: I do not want to get diabetes!
Need : I need to be a role model for my child.
Commitment language is a special class of change talk that describes patients’ intentions and plans for enacting behavior change. Commitment language is more closely linked to behavior change than change talk.
Next time I go to the grocery store, I will not buy junk food.
Given the importance of change talk to patient outcomes, a primary focus of current MI research is identifying the specific provider communication behaviors that predict change talk and patient outcomes. Studies of MI provider communication behavior have confirmed that communication techniques consistent with the MI framework (ie, MI-consistent communication [MICO], illustrated in Table 1 ) are associated with increased patient change talk and improved patient outcomes. However, a methodologic limitation of many studies is the reliance on frequency counts of communication behaviors and correlational analytical techniques which limit causal inference. In other words, just because higher rates of providers use MICO communication techniques is correlated with better patient outcomes does not provide sufficient evidence to prove that MICO leads to outcomes.
| MICO Technique | Description | Example |
|---|---|---|
| Advise with permission | Offering advice, solutions, suggestions, or courses of action collaboratively (ie, in response to a patient’s request, asking permission) | Would it be okay with you if I explained what your healthy weight loss would be? |
| Affirm | Positive or complimentary statements that express appreciation, confidence, or reinforce the patient’s strengths or efforts. | It took a lot of willpower to refuse cake at a birthday party, good for you! |
| Emphasize control | Statements that directly acknowledge, honor, or emphasize the patient’s freedom of choice, autonomy, personal responsibility | This is your treatment and you get to choose how it goes. |
| Open question | Questions phrased to encourage patients to expand on their perspective, thoughts, emotions, and concerns | How has your weight affected your life? |
| Reflections | Simple: repeating back patients’ own statements | You want to lose weight, but you’re not sure how to get started. |
| Complex: repeating back patients’ own statements, but adding to the underlying meaning or emotion | You’re worried you might not lose weight even if you change your eating. | |
| Reframe | Suggesting a different meaning, explanation, or perspective for a situation a patient has described | Asking about your exercise plans might be your mother’s way of showing your she’s interested and cares about your weight loss goals. |
| Support | Statements that convey genuine support or understanding | That must have been difficult for you. |
Sequential Analysis
Sequential analysis is a statistical technique used to analyze the temporal sequence of patient–provider communication and, thereby, generate evidence for the temporal precedence of provider–patient exchanges, which is a step toward establishing causality ( Box 2 for an illustration). Moyers and Martin were the first to use sequential analysis to demonstrate that providers’ use of communication techniques consistent with the MI framework (MICO) was more likely to elicit patient change talk than MI-inconsistent communication techniques. Subsequent studies have confirmed the MICO–change talk link and spurred researchers to dig deeper to investigate which of the MICO communication techniques, specifically, are responsible for eliciting change talk. To date, 3 studies have identified providers’ use of reflections as the critical MICO communication technique, that is, empirically linked reflections to patient change talk. In one of these studies, other MICO techniques, including asking open-ended questions and an index composed of affirmations, emphasizing the patient’s control, reframing, and support actually decreased the likelihood of eliciting patient change talk. An important consideration of these studies are that 2 of the 3 were conducted with predominantly white adult patients who abuse substances. The third included minority adolescents, but was still within the substance abuse context. Our research group has begun to investigate the relationship between provider communication techniques and patient change talk in pediatric obesity.
In sequential analysis, the data are organized into a contingency table with the antecedent behavior in rows and the corresponding response behaviors in column. The cells of the table represent the transitions between antecedents and responses for a given time interval (ie, the lag). Each transition has a conditional probability that describes the extent to which the transition is more or less probable than expected by chance.
| Responses (t2) → Antecedents (t1) ↓ | Adolescent Response Statement 1 | Adolescent Response Statement 2 |
| Counselor Communication Behavior 1 | Transition probability 11 | Transition probability 12 |
| Counselor Communication Behavior 2 | Transition probability 21 | Transition probability 22 |
Effective Provider Communication with Minority Families in Pediatric Obesity
Our research group recently developed the Minority Youth Sequential Code of Process Exchanges (MY-SCOPE) to study communication in MI sessions with minority adolescents and their caregivers in weight loss sessions. The MY-SCOPE is an adaptation of the SCOPE and MISC, the code schemes used in the previous studies of MI’s causal mechanism, specifically for minority adolescents and their caregivers. Adaptations included culturally relevant examples of adolescent and caregiver language, examples of adolescent and caregiver language specific to weight loss target behaviors (ie, healthy nutritional changes, increased physical activity), and codes for provider communication behaviors not described in the MISC or SCOPE, such as eliciting feedback.
We used the MY-SCOPE to code 37 MI weight loss sessions with minority families to identify the provider communication techniques most effective at eliciting change talk. Because commitment language is more closely linked to actual behavior change than other types of change talk, we examined change talk and commitment language as 2 separate categories. Our research identified 3 provider communication strategies more likely than other communication techniques to elicit change talk and commitment language among both minority adolescents and their caregivers engaged in weight loss treatment:
- 1.
Statements emphasizing autonomy were more likely to elicit both adolescents’ and caregivers’ change talk and commitment language.
If you are not ready to cut out sweets, we can find another area to focus on.
You made that choice.
You’re the one who knows yourself best. What do you want to focus on?
- 2.
Open-ended questions were more likely to elicit adolescent and caregiver change talk and commitment language when specifically phrased to elicit change talk or commitment language.
In what ways has your weight been a problem for you?
What concerns do you have about your health?
What kinds of activity have you done this week?
- 3.
Counselors’ reflections of adolescent commitment language were more likely to elicit commitment language in response. In conversations with caregivers, change talk and commitment language were more likely to occur after the provider reflected a caregiver’s previous change talk or commitment language statement.
You are worried that your weight is going to affect your health.
You want to be healthier.
Okay, so one thing you will try is eating a small meal at regular times, versus waiting until you are starving and overeat.
Recommendation: Reflect Patients’ Change Talk
Our finding suggesting that providers’ use of reflections was a critical communication technique in eliciting patient change talk and commitment language is in sync with the 3 previous studies of communication exchanges among adults who abuse substances. Reflections are a critical component of MI because they not only convey that the provider is listening to what the patient has to say, but that the provider is making a genuine effort to understand the patient’s experiences, feelings, and meaning. MI recommendations suggest that providers spend twice as much time using reflections than asking questions and, when reflecting, to go beyond simply repeating back what patients are saying to increase the complexity of their reflections to summarize their understanding of the patient’s experience, which conveys deeper understanding and greater empathy.
Recommendation: Emphasize Patients’ Decision-Making Autonomy
Emphasizing the patient and caregiver’s autonomy was not only more likely to elicit both change talk and commitment language in our sample, this communication technique was also less likely to elicit sustain talk (statements about why the patient or caregiver should maintain their current behavior, ie, the “status quo” ). This finding is supported by self-determination theory, which posits that all individuals have an innate need to experience one’s behavior as self-regulated and self-endorsed. Self-determination theory has explained exercise participation among teens and African American adolescents specifically and, recently, it has been suggested that MI is the primary intervention method of self-determination theory. The need for autonomy is particularly relevant among adolescents who are actively engaged in the developmental task of becoming independent. When providers use language that honors the adolescent patient’s autonomy, rather than feeling marginalized and excluded from their own health care, their motivation for participation seems to be activated.
Use Caution: Providing Information May Not Always Be Necessary
Although providing information is 1 of the 3 core communication skills (informing, asking, and listening) that MI recommends for the health care setting, our research suggested providers use caution when providing patients with health-related information. Even when providers used patient-centered communication techniques, such as asking permission, using the third person, and offering a menu of options, information provision resulted in decreased adolescent and caregiver change talk, decreased adolescent commitment language, and increased in “other” types adolescent and caregiver speech. It may be that in our weight loss intervention for adolescents with obesity, families already had sufficient knowledge of weight loss and previous experience with attempting to lose weight that providing weight loss information was counterproductive. In fact, in our adolescent analyses, provider information statements were followed by “other” patient statement of which 30% were patient recollections of past behavior. These recollections included rehashing past, failed attempts to lose weight rather than focusing on their present motivation for weight loss. To avoid such counterproductive discussions, we suggest providers carefully elicit and consider the patient’s current knowledge and experience before providing information related to changing health behaviors.
Introduction
The primary treatment strategy health care providers use when treating patients is communication. Providers engage their patients in conversations to understand their medical history and illness experiences, and to formulate treatment recommendations. These conversations fulfill task-oriented (eg, exchanging information, facilitating patient comprehension of medical information, engaging in informed and collaborative decision making, enabling patient self-management) and socioemotional functions (eg, fostering an interpersonal, healing relationship, responding to and regulating patients’ emotions, and managing uncertainty).
Benefits of Patient–Provider Communication
The benefits of effective patient–provider communication and its relationship to medical care outcomes have long been highlighted in the chronic illness literature. Better patient–provider communication is linked to patient satisfaction with medical care and medical care providers. Patient satisfaction is critical because it is an indicator of how well the provider is meeting patients’ health care needs, expectations, and preferences. Multiple research studies have positively linked patient–provider communication to patient adherence to treatment recommendations and better medical outcomes. Actively involving patients in their medical care affects adherence to treatment recommendations directly and through improved comprehension, understanding, and negotiation of treatment recommendations.
Effective patient–provider communication not only leads to a better medical care experience and improved outcomes for patients, but benefits also extend to providers and society. Improvement in provider communication skills is associated with greater satisfaction with patient interactions, increased self-confidence for treating “difficult” patients, and decreased malpractice claims. Improved patient–provider communication may also pose benefits society as a whole through decreased health care costs.
Patient–Provider Communication in Pediatrics
Patient–provider communication in the pediatric health care setting differs dramatically from adult patient–provider communication in that the patient is a child and the responsible party is the child’s caregiver. This presents a dilemma for the provider; with whom should the provider communicate, the caregiver or patient? Research suggests that providers spend more time communicating with caregivers than with their pediatric patients. Specifically, pediatric patients, regardless of age, are typically engaged in less than 20% of the communication in a typical medical care visit. When pediatric patients are engaged in the conversation, they are generally included in social aspects and the provision of medical history with the treatment decision making typically completed by the provider and caregiver. When providers attempt to increase pediatric patients’ participation, caregivers often disrupt this effort by interrupting and responding to questions and statements directed to the patient rather than supporting and encouraging the patient’s active involvement. This dynamic may have unintended consequences. Pediatric patients, particularly adolescents, report feeling marginalized when they are excluded from conversations about their own health, which may lead to disengagement and disinterest in their own health care.
Direct communication with pediatric patients, on the other hand, builds trust and rapport, helps to socialize children into the patient role, and, in the adult literature, has been identified as a primary mechanism for patient adherence to behavioral recommendations. With the top 4 causes of early mortality—namely, cardiovascular disease, cancer, respiratory disease, and stroke—tied to modifiable behaviors such as poor diet and lack of physical activity, there is a critical need for providers to communicate with their patients to change their behavior in these areas. Pediatricians, in particular, play a critical role in identifying children who are at risk for obesity and these life-threatening diseases and to encourage these children and their families to change their unhealthy dietary and activity patterns early, before the detrimental effects of unhealthy behavior patterns begin to unfold.
The Skill of Communicating Well
The National Academy of Medicine (formerly the Institute of Medicine) recognizes patient–provider communication as a key clinical skill as does the international medical community, medical schools, and professional medical organizations. Although these organizations offer recommendations regarding the qualities of effective patient–provider communication, few offer concrete guidelines for how to effectively communicate. This poses a dilemma for the provider because patient–provider communication skills are not innate. Like any other skill, effective patient–provider communication must be systematically learned and repeatedly practiced.
Motivational Interviewing, a Framework for Patient–Provider Communication
Motivational interviewing (MI) is an empirically supported approach to patient–provider communication that is characterized as “a therapeutic conversation that employs a guiding style of communication geared toward enhancing behavior change and improving health status.” (p2) The goal of MI is to increase patients’ intrinsic motivation and self-efficacy for engaging in health-promoting behaviors. Intrinsic motivation, engaging in an activity for reasons of personal interest or satisfaction rather than external consequences, has been linked to positive outcomes across multiple domains. MI was originally developed to treat adults in substance abuse treatment ; thus, there is a strong evidence base for its efficacy in that domain. Since its inception, MI has been adapted for multiple behavior change targets, including health care behaviors such as cancer-related fatigue, medication adherence in treatment of those with human immunodeficiency virus infection, diabetes management, and weight loss. Of particular relevance, physician use of MI has been linked to weight loss among adults and children who are overweight or obese and is a recommended approach for pediatric obesity.
MI has a highly specified framework that is both patient centered and directive, making it an ideal approach for health care providers. The principles of MI, including providing empathy, collaborating with clients, and supporting client autonomy, are elements of patient-centered care. MI emphasizes patients’ decision-making autonomy, which is the tenet of self-determination theory and empirically linked to increased adherence to medical recommendations, particularly when treating adolescents. In health care, autonomy-supportive environments are those where providers elicit patient perspectives, provide information and opportunities for choice, and encourage patient responsibility. These characteristics are implicit in MI’s core communication skills—informing, asking, and listening. Furthermore, MI is consistent with consensus recommendations for working with clients from different cultures in obesity treatment. Two metaanalyses have indicated that MI was more effective with blacks compared with whites, suggesting it may be a relevant framework for patient–provider communication in populations affected by health disparities.
Motivational Interviewing’s Causal Mechanisms
MI can be broken down into technical and relational components. The relational component of MI refers to the ability of the provider to understand the patient’s perspective and to convey that understanding in a positive, empathetic manner. These elements are referred to as the “spirit of MI.” Although these components are important for relationship building, they do not fully account for MI’s efficacy at evoking behavior change. The technical component of MI is the specific communication techniques that providers use during MI sessions to elicit and reinforce patients’ motivational statements about changing their behavior, that is, “change talk.” Patient change talk statements during clinical encounters consistently predict actual patient behavior change ( Box 1 ). In fact, 1 study with substance abusers found that patients’ change talk predicted marijuana use 34 months later.
