People are creatures of habit, and GPs have a key role to play helping patients tackle their harmful behaviours.
Given they see 85% of the Australian population at least once a year, GPs are key in delivering effective messages of preventive health.
You’re sitting in your practice when a new patient walks in. After an initial consultation, it becomes clear that many of his health problems are linked to unhealthy lifestyle choices – from a lack of exercise to heavy drinking.
The question with which you are now faced: how do you suggest he makes changes to how he lives without provoking a backlash?
This question – how GPs can boost preventive healthcare – is increasingly important. Almost two-thirds of Australians were overweight or obese as of 2015, smoking remains a major cause of death and one in six Australians drinks enough alcohol to put themselves at a lifetime risk of related disease.
It is widely acknowledged that GPs, who see 85% of Australia’s population at least once a year, are vital to preventive healthcare. And it’s proven that GPs can affect positive change in their patients’ lifestyles. A 2013 meta-analysis of 205,000 patients found that patients do attempt to lose weight after their doctors raise the issue.
The problem, however, is that people don’t like to be told they are doing something wrong. So what do you do?
Here are three suggested expert methods to tackle entrenched bad habits.
An evidence-based approach designed to help patients overcome internal resistance to change, motivational interviewing works well as a complement to the 5As approach to lifestyle risk factors – Ask, Assess, Advise, Assist/Agree, Arrange – outlined in the RACGP’s Guidelines for preventive activities in general practice (Red Book).
Psychologist and Deakin University academic Dr Kate Hall notes that the vital first part of motivational interviewing is resisting the top-down approach in which practitioners recommend the ‘right’ path.
‘You inhibit your own advice-giving tendencies, and switch to asking questions instead,’ she told newsGP.
The reason is that giving advice – a large part of a GP’s role – can often backfire when it comes to behaviour change.
In a 2012 study on motivational interviewing, Dr Hall and her co-authors write that advice-giving can ‘often have a paradoxical effect in practice, inadvertently reinforcing the argument to maintain the status quo … [e]ssentially, most people resist persuasion when they are ambivalent about change and will respond by recalling their reasons for maintaining the behaviour’.
When a patient is ambivalent about certain behaviours, a doctor can focus instead on understanding their patient’s motivations – it is their reasons that will actually lead to change, Dr Hall said.
The key, Dr Hall says, is to get the patient talking. Motivational interviewing works on the assumption that people already have the knowledge – it is finding out their reasons for change that can actually work.
‘The motivation for change is presumed to reside within the patient,’ Dr Hall said.
For instance, a doctor might ask a lifetime smoker who has expressed reservations about her habit why, exactly, they want to quit. Who would it benefit? How? Have they previously thought about quitting? What happened when they tried the last time?
‘The amount of talking about change that the patient does is predictive of behaviour change,’ Dr Hall said.
This approach relies on active listening, open questions, and a focus on the positive outcomes of a patient’s suggested lifestyle change, rather than the negatives of the status quo.
‘You don’t need an hour to do motivational interviewing. Five minutes can be all it takes,’ Dr Hall said.
While people often resent being told what to do, that is particularly true if there is societal stigma involved. According to University of New South Wales Professor Mark Harris, a patient’s weight is the issue around which to tread most carefully.
‘One reason people don’t want to hear these messages is if they feel stigmatised, and that often has to do with language around weight,’ he told newsGP.
For example, while ‘obesity’ is a medical term, it is one with a significant stigma, Professor Harris said.
‘Weight is hard to control. But diet and physical activity are more within our control,’ he said.
‘It’s important to talk to people and say, let’s not focus on weight, let’s focus on positive behaviours. Scaring people doesn’t work.
It can help if practitioners communicate with patient as a fellow human rather than as a distanced expert. Studies show that if doctors can draw on their own experience in combatting an unhealthy habit or boosting your physical activity, for example, the approach is more likely to succeed than an approach focusing on negatives or risks, which a patient may perceive as criticism.
Talking about a patient’s need to, for example, ‘cut down on drinking’ can come across as not specific enough.
An MJA study interviewing people in the community about their experiences of preventive care revealed that patients often found preventive advice too superficial, giving examples of broad statements around losing weight. Participants wanted specific advice or referrals to experts such as dietitians.
Participants felt ignorant about what prevention they needed to undertake and when. They wanted to be better informed so that they could take action. Receiving reminders or letters of invitation from their GP prompted action, particularly if these targeted their age or life-stage. Many were also unaware of preventive activities that qualified for Medicare rebates (eg the 45–49-year-old health assessment), with very few participants being offered this or similar services by their GP.
The RACGP’s Red Book states that for patients from a low socioeconomic status background, ‘individual behavioural counselling is more likely to be effective for patients from disadvantaged backgrounds if linked to community resources, and if financial and access barriers are addressed’.
Experimenting with these types of techniques may prove a useful complement to a GP’s existing skillset, particularly as lifestyle diseases look to stay put as the major cause of death and illness in Australia.
The RACGP’s Guidelines for preventive activities in general practice (Red Book) are designed to support evidence-based preventive activities in primary care. The RACGP’s Putting prevention into practice (Green Book) includes a detailed section on motivational interviewing and strategies for boosting adherence to GP advice.
The RACGP’s ‘Putting prevention into practice’ (Green Book) is currently being updated, with the new edition to be available from late May. Email qualitycare@racgp.org.au for more information.