Map of life expectancy at birth from Global Education Project.

Tuesday, October 26, 2010

Yabbut I thought of relativity before Einstein . . .

Okay, I didn't, I wasn't even born. However, before these researchers did this study, my colleagues and I already had pretty much the same idea. They were working on the problem of overweight and obesity, and we are working on medication adherence, but the issue is the same. Doctors do talk to their patients about these and other health related behaviors, but their usual approach is to scold, hector and generally threaten people with death.

That doesn't work, and it's not hard to see why. First of all, when somebody starts criticizing you, what are you likely to do? Push back, of course. Adults don't like to be judged, lectured and talked down to, so they're likely just to say, even if silently, screw you. Anyway, patients already know that their doctors think they should take their pills and maintain a healthy weight, and they've heard all about the consequences if they don't. Ergo, if they don't do those things, it isn't because they don't know any better and just repeating the information isn't going to solve the real problem, whatever it may be.

Equally obviously, whatever the real problem may be, it must take the form of conflicting motivations. Yeah, I don't want to get AIDS or diabetes, but there's something about taking the pills or skipping the doughnuts that I also don't like. What the doctor needs to do, instead of yelling at the person, is work with him or her to understand the issues and then see if there isn't a way to resolve those conflicting motivations that's going to be better for the person in the long term.

The method for doing this, developed in the field of alcohol and other drug abuse counseling and well supported by evidence, is called Motivational Interviewing. We have NIH funding right now to teach MI to doctors who provide HIV care, and our hope is that we'll see improvements in their patients' medication adherence as a result. (It's a dual PI project, my esteemed colleague is the contact person.)

The Pollak study is obviously encouraging for us. Long term, if we and others can reinforce, extend and deepen these findings, it will suggest that medical education ought to include a big component of communication and relationship skills training. Actually most people already believe that in principle, they just haven't had enough evidence about exactly what the doctors should be taught. We're finally figuring it out.

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