How do clinicians work with patients who come in time and time again with uncontrolled diabetes, for example, but they won’t follow the health provider’s recommendations?
“There’s a bit of a proactivity involved in this, that if the patient comes in with a problem you feel like you have to do something about it,” says Victor Montori. But whatever clinicians do or suggest must make sense to the patient in that particular context, he says. You might write down your recommendation in the patient’s medical record and give yourself a gold star because you felt like you did something, but you didn’t really do anything if the patient left and nothing happened.
“The issue is, at least with chronic conditions, that many of the things we’re alarmed by won’t have a consequence immediately; we have time,” says Montori. “If we could build within the relationship the opportunity to make smaller changes, try figuring out together what to do, and demonstrate that you really mean it — that ‘you’re allowed to fail, and I will be with you if this doesn’t work’ and ‘if it doesn’t work, I have five other tricks we can try’ — then you will make progress.”
Montori mentions that some of his patients whom he has followed for the past decade are only now beginning to show evidence that they are better off than 10 years ago. “I’m not going to move in with the patient, but sometimes you probably feel like you want to be with them until the day where it all clicks,” he says. “And then when it happens, when it all clicks, of course the temptation is to think that you’re a genius, that you made it happen, but it’s actually the patient who made it work, and it just made sense, and it probably took 20 or 30 tries.”
In other words, clinicians need to have patience.
Kathryn Pollak shares an example from one of her colleagues, a kid who had ADHD and smoked pot. The clinician wanted his patient to quit smoking, but he refused. So the clinician asked if he could bring it up next time, and did. During the next couple of sessions, the patient continued to say no. But by the fourth session he said, “You know what? I think I’m going to consider stopping doing that.” The clinician, shocked, asked why. The patient’s response: “You didn’t force me. You let me come to it on my own terms.”
“That was critical, because our tendency is if they’re not doing something we want, we keep pushing, we keep pushing,” says Pollak. “All that does is put patients on the other side.”
From the NEJM Catalyst event Patient Behavior Change: Building Blocks for Success, held at Duke University, April 4, 2018.