Transforming patient care with motivational interviewing [PODCAST]

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Gastroenterologist Steven Pearce, health care consultant Bruce A. Berger, and physician advocate Kim Downey discuss their article, “How motivational interviewing transforms patient care and outcomes.” They explore the transformative power of motivational interviewing (MI), an evidence-based, patient-centered approach that enhances patient engagement and adherence by exploring motivations rather than persuading or correcting. Bruce shares practical strategies for clinicians to connect authentically with patients, Steven reveals how seeing patients’ “loving essence” reshaped his practice, and Kim emphasizes MI’s role in fostering meaningful health care relationships. Listen to discover actionable insights that can elevate your patient interactions and improve outcomes.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Kim Downey. She’s a physician advocate, and once again she brings together two individuals. We’re going to talk about motivational interviewing: gastroenterologist Steven Pearce and health psychologist Bruce Berger. The KevinMD article is “How motivational interviewing transforms patient care and outcomes.” Everybody, welcome to the show.

All right, so Kim, as always, my first question always goes to you. What brought everyone together, and what about this topic intrigued you?

Kim Downey: Sure. So a little over a year ago, I had my first conversation with Steven, and we had such a great talk. He had a film, Love Evolved, that he sent me, and that was so beautiful. Part of what we talked about is he told me he was involved with transformative storytelling. And Bruce and I had been following each other for a while on LinkedIn, and I was excited to speak with Bruce, and he told me he’s a pioneer in motivational interviewing.

So even though they weren’t the same thing, they’re just such nice guys, I’m like, “This would be a great conversation.” So I had them on together, and what I really loved is how interested Steven was in what Bruce had to say. There was one point I tried to bring it back to Steven, and he was almost taking it back. He’s like, “Wait a minute, I’m sitting here saying I can’t wait for Bruce to give me more examples, because I’m going to go use them in about an hour.” Because during our conversation, he was at work. We even had to postpone it about fifteen minutes; he was in a procedure. And I just loved all of it. It was a great conversation, and I thought more people should know about it.

Kevin Pho: All right, Bruce, you’re an expert in motivational interviewing. So just to get everyone on the same page, give us a definition and some context for our conversation. So let’s start: What is motivational interviewing?

Bruce A. Berger: Well, it’s really both a skill set and a way of being with patients. It’s patient-centered, and it started in substance abuse. I brought it into health care thirty-five, forty years ago, because it’s still the most effective intervention for substance abuse, with the lowest rate of relapse and recidivism. I thought, “My goodness, if they could do this with serious substance abuse, can’t we apply this to chronic illness, for example?” And we started doing that and found that it worked beautifully.

And again, it’s a patient-centered approach. It’s kind of a misnomer, because we’re not really trying to motivate patients. What we’re trying to do is talk to them to begin to understand: How motivated are they to take their medicine, to treat their diabetes? What would make them more motivated? What’s getting in the way? Really trying to assess where their gaps in understanding are, which often affect their motivation also. So it’s really a conversation to explore with a patient their motivations about treating a chronic illness, for example.

Kevin Pho: So Bruce, in the context of chronic illness, tell us about some of the questions that a clinician would ask that patient in the exam room.

Bruce A. Berger: I would, for example, ask questions like, “Tell me in your own words what diabetes means to you. What’s your understanding of what the medicine can do in treating your diabetes? What’s your understanding of the importance of changing your diet, getting more exercise?”

Some other questions we ask, for example, if a patient is, say, nonadherent to a health behavior like taking their medication: “What’s making it difficult for you to take the medicine?” Too often we’re very prescriptive, and we often do this kind of stuff with patients: “You know, we’ve gone over this. You need to take the medicine. Why aren’t you taking it?” Rather than really trying to understand what’s getting in the way, what would make it more important to the patient, etc.

So it’s really exploring, again, what’s going on with the patient. I call it a meeting of experts. We may be experts on health care, but the patient’s an expert on how they are making sense of what’s happening to them. If I don’t understand how they’re making sense, I don’t know how I treat them.

Kevin Pho: And Bruce, that makes so much sense. It resonates with me. Whenever I’m seeing a patient in a primary care setting, I always say that patients are going to know their own bodies so much more than I can, just meeting them for the first time, or even me seeing them in a chronic setting like that. And they’re going to know what diabetes means to them in very specific ways; for each patient, the meaning will be different.

Steven, you’re a gastroenterologist. Tell us about how motivational interviewing intersects with what you do every day.

Steven Pearce: I mean, I think that’s what I was so fascinated with with Bruce, because what he speaks to is, for me, so critical. Bruce and Kim and I have talked about this before, but I wasn’t very good at this when I started. I had a lot of trouble with making sure that I was checking the boxes and making sure that I asked all the questions, so that when I walked out of the room I could tell the attending what was going on. That had nothing to do with connecting with the patient. And as I’ve progressed in my own career, that connection with the patient is probably the most critical thing.

In my life, in my storytelling adventures and making films, I went and sat in a class for spiritual psychology for two years, and a lot of what Bruce speaks to, I identify with from that class. It’s allowing somebody to come to their own realization of what’s going on with them, but you’re kind of co-piloting the direction and where you’re going with it. You’re just there to be a vessel to help them understand it. That is critical. That creates that connection between you and the patient, and for me, over the years, I found that that connection is the most important part of their healing, because there’s so much more that comes from that.

Kevin Pho: Steven, you mentioned that it was a little bit of a transition, kind of going into this new framework of asking patients these questions, and it’s not something that we’re taught in medical school. We sometimes have to check boxes, and that’s all the more important, certainly, in primary care. There’s so much pressure on us to check these boxes and ask specific questions. So Steven, talk more about that journey that you had overcoming that difficulty and becoming more of a motivational interviewer and building a stronger connection with patients. Talk about that transition.

Steven Pearce: Yeah, it came through failure. That’s how it came, especially when I first got out of fellowship. In residency and fellowship, I don’t know that you really truly know the impact that you’re having on people, because you see patients, but you don’t see patients come back. Sometimes you’re rotating through with different doctors. But when I got to actually see the impact of what I was doing, I actually got the messages of, “Hey, I don’t want to come back to you as my doctor. I didn’t feel like we had,” I think the word they used is “personality differences.” And I’m like, “Oh, I’m not sure what that means, but OK.” That’s painful. That’s painful, to know that somebody’s walking away from you.

So this was probably ten years ago now. But when I went through this psychology course, that’s really where I got to something similar to what Bruce is speaking to. And then, as Bruce and I have known each other, I’ve tried to incorporate some of his work. But really truly seeing a human being and bringing the humanity back into the room, I think, to me, that’s what Bruce’s work allows us to do. It’s a tool to do that, and it gives us information and ways to actually have that be in the room with us. But yeah, I learned it through failure and the pain of thinking that I was doing a good job for somebody when I wasn’t, and being willing to say, “OK, what can I learn from this? How can I do this better for other people?”

Kevin Pho: Kim, you’ve told us in your stories in the past that you’ve seen many clinicians before, and I’m sure that you’ve seen a spectrum in terms of how these clinicians ask you questions. So from a patient perspective, Kim, tell us the type of questions that you’ve been asked that would really motivate you and help you foster that stronger connection with physicians. Tell us some of the questions that they’ve asked you to foster that connection.

Kim Downey: Sure. So I’ll share one specific story, because, as you’re right, I’ve had all kinds of experiences, good, bad, and ugly. I could tell you all the kinds, maybe like the example that Steven shared, that weren’t so good. But with the doctors that I have now, I could share so many stories, and it’s about their verbal and nonverbal communication.

So just one story that I’ll choose to share is my medical oncologist. Early on, when I was just getting to know him, he walked in the door, he sat on the stool and did some stuff in the computer, and now I notice all of these things. And then he went and sat in the most uncomfortable seat in the room, which was the footstool of the plinth. So he had me sit in a chair, and there was another chair, and there was a stool. And I realized that he realizes that his patients with cancer feel vulnerable, and that he put himself there physically, because then he was actually lower than me. So it was kind of like, without saying it in words, “We’re just going to sit here and have a conversation,” instead of him being on his high stool, or high horse, right, or whatever you want to call it. And that really made it comfortable for us to talk about my cancer and my cancer treatment.

And then, prior to my most recent surgery a few months ago, I really didn’t want to do it. I was terrified of experiencing a complication, because I’ve had one. And again, he wasn’t even the surgeon, but he took the time to ask me. He actually said, “What are you most concerned about?” Because in a sense, he should be like, “Well, obviously, you should do this. It could turn to cancer.” But he actually asked me that question, and that opened up a conversation we otherwise wouldn’t have had, because it was awkward for me as a patient. Even though, when I was a physical therapist, patients could ask me anything, and you’re like, “OK, well, I’m just going to tell you the answer.” But if you haven’t been in that position as a patient, there are certain questions that are a lot harder to ask, and you feel embarrassed or awkward. But because he asked me that question, I’m like, “Well, I’m just going to tell him.” And now I know we can talk about anything.

And just a couple things I’ll add about him: He wears fun socks, and he has a great sense of humor. I’ll just share one quick example. On my cancers, I had to do everything myself; it was during the pandemic, and my husband couldn’t come with me for anything. But by the time I had the third cancer, they were allowing one support person. By then I had seen, like, forty doctors, so I wanted to bring my husband to the appointment with this medical oncologist. When he walked in the room, I introduced him to my husband, and I said, “I just wanted my husband to know that every time I leave the house, I really am going to see a doctor.” And he looked deadpan at my husband and goes, “I’ve never seen her before in my life.” And that was just so funny, and we all laughed, and it kind of broke the ice, because I was going to have another surgery and my husband had questions. So that’s just a couple examples of what one of my doctors did.

Kevin Pho: Bruce, as Steven and I mentioned, how we interview patients isn’t necessarily taught. As we’re talking about today, motivational interviewing isn’t necessarily stressed. So share some tips in terms of how clinicians can be better interviewers in the exam room.

Bruce A. Berger: Well, I would say, if they want, there are certainly books out there on motivational interviewing. I wrote one specifically on motivational interviewing in health care. We have an e-learning program now, also on motivational interviewing. So there are lots of resources out there if they want to learn more.

I think one of the reasons that I connected so strongly with Steven is that when I first started talking to Steven, I learned, I got from him, that he uses the word “connection.” I use the word very similarly: The relationship is everything. You have to be willing to hold the relationship almost as sacred. And once you do that, it’s almost like the right kinds of questions start flowing. Can you create, are you willing to create, a space where it’s safe, for example, for a patient to push back?

I’ve asked clinicians before, “Would you like it if your patients told you they didn’t think what you just told them was important?” And they looked at me, and they’d say, “What do you mean?” I said, “Wouldn’t you want to know that? Wouldn’t you want to know that your patient doesn’t really think that high blood pressure is all that important because they feel fine? Because then you have an opportunity to talk to them about that and help them understand how they can feel fine and be at risk.” And so it’s really creating a space where patients feel safe to have how they make sense of what’s going on validated. And by validated, I don’t mean that you agree that high blood pressure is not serious. I mean that you understand why they don’t get that it’s serious, and you let them know that you get it.

Kevin Pho: And Bruce, what do you say to those physicians who always say, “We’re under so much time pressure. I don’t have ten minutes in the exam room, and sometimes implementing some of these principles is just going to take more time”? How do you respond to those physicians who say that?

Bruce A. Berger: My response is twofold. Nonadherence takes far more time, for one. If you’re constantly talking to a patient who’s not taking their medicine or engaging in the health behaviors necessary to manage a chronic illness, you’re going to be spending a lot of time talking to that patient.

Two, the research shows that three minutes of motivational interviewing by a skilled practitioner is more effective than anywhere between seven and fifteen minutes of what we typically do. Because with motivational interviewing, for example, you talk to the patient about whatever GI problems they may have. If you’re Steven, if you look at that patient and now say, “Tell me, now that you’ve heard all this, tell me what your thoughts are. How important is it for you now to change what you’re eating?” then you’re going to find out possible things that may get in the way that you’ll be able to cut off in the future. So again, people who are really skilled at motivational interviewing really take less time, because you get at the issues of the patient, rather than thinking, “My job is to check,” as Steven said, “check every box.”

Kevin Pho: So Steven, tell us a story about how these motivational interviewing tactics moved the needle. Is there a particular patient or story that you could share with us?

Steven Pearce: Man, I can’t think of a particular story, but the word that Bruce brought up is “sacred.” So the internal dialog for me, walking into the room with this type of idea of motivational interviewing, shifts your perspective of how you interact with people. And I guess I’m very publicly sharing something very private, but when I walk into the room, when I’ve decided that this is going to actually be a sacred interaction between the two people, between me and a patient, that really shifts it. Because it really does put you into the type of information that Bruce is sharing with us, with all the research, and it really becomes the art of medicine. That’s what it becomes. And I think Bruce, in this research that he’s done, really nails it. It really gets to that point.

But if you ask me about a particular patient, I can think of thousands where I’ve had that particular type of interaction. But also, as importantly, I can think of the other thousands where I didn’t, and I wasn’t in that state of mind. And I think it’s really valuable for us to be in that state of mind when we walk into that room, because it’s critical, despite all the time frames and the time constraints and all that stuff.

I identify with what Bruce is saying, because when I come in with that state of mind, and certainly it doesn’t just start right before I open the door, it starts when I wake up in the morning, that I’ve decided that I’m going to really, truly be there for these people, this space, the research, and the information that Bruce speaks to, I think, comes alive in that way. Because you’re just there for them differently. But I think that also comes from the years and years of doing something over and over and over again. You get these small little differences that you can bring into something that you suddenly realize can have a massive change for your interaction with people. So I just think Bruce’s work is critical.

Bruce A. Berger: Kevin, can I give you one quick example of it?

Kevin Pho: Of course.

Bruce A. Berger: I was precepting some pharmacy students, really working with them. We had a patient that came in with a prescription. She was newly diagnosed with diabetes. She handed the prescription to the pharmacy student and said, “You know, keep this back there for me. I’m not going to get it right now.” The pharmacy student said, “Why not?” And she said, “Well, the doctor said I have, you know, sugar.” That was her term. “I have sugar, but I feel OK. I’ll start using it when I start feeling bad.”

Now, the typical health care provider response is to immediately correct her and to say something like, “Well, no, that’s not a good idea.” You know something I always tell people? If you say a sentence to a patient and you can end it with “stupid,” you’re going down the wrong path, OK? And so many of the statements we make to patients could be ended with “stupid.” “OK, you don’t need to be doing that, stupid.”

Anyway, so what we did is we looked at her and we said, “OK, so because you’re feeling OK right now, you’re thinking you’ll get the prescription at the point at which you start feeling bad.” So the very first thing we did was we reflected back how she was making sense, right? And then she said, “Right.” And we said, “Do you mind if we just shared a few thoughts with you, and you tell us what you think?” Notice it’s conversational. We want to know what she thinks. She said, “You can share some thoughts if you’d like, but I’m still probably not going to take it right away.” And we said, “Fair enough. This really is your decision.”

But here’s what we did. We drew an analogy for her, and I’m not going to go through the whole analogy, but we drew the analogy of a bottle of syrup continuously pouring on a stack of pancakes, and that over time those pancakes, which look fine right now, will start to fall apart. And that if we don’t control the amount of syrup, sugar, in our body, our blood vessels, our eyes, our nerves, they’ll start falling apart also. By the time we were done, we looked at her and said, “So what are your thoughts now?” And she said, “Wow, nobody ever explained it to me that way. I’ll take the medicine.” And so it was very powerful. The whole conversation took four minutes.

Kevin Pho: We’re talking to Steven Pearce, Bruce Berger, and Kim Downey. The KevinMD article is “How motivational interviewing transforms patient care and outcomes.” Now I’m going to ask each of you just to share some take-home messages that you want to leave with the KevinMD audience. Kim, why don’t we start with you?

Kim Downey: Sure. So just last night, I shared a presentation for the American College of Physicians virtual doctor’s lounge, and one of the things I spoke to was how physicians’ relationships with patients can fuel them rather than drain them. So our conversation today is a perfect dovetail to that. And I recently interviewed Wayne Sotile, and he said, “Never lose sight of the meaning of what you’re doing. Even on your worst days, you’re miracle makers.”

And I want to add that you matter, and that my doctors are in my heart all the time. I love them, and I appreciate them so much. And find ways to be you. Take an active role in your patients seeing you as human. Share little pieces of yourself, and don’t keep that armor on too tightly that you’re taught to wear as physicians. Forging a relationship with your patients helps establish mutual trust and respect, and you and the patient are less likely to feel like cogs in a machine. When you build that personal connection, it all gets back to that, and they’re more likely to trust you and follow your recommendations. It’s a win-win.

Kevin Pho: Steven, your take-home messages.

Steven Pearce: I don’t know that I have any take-home messages other than the fact that I deeply respect the work that Kim Downey and Bruce Berger are doing. I hope that we can continue to learn from both of them. This is critical. What both of them are doing is critical for a guy like me that’s in it every single day. So I just really want to honor their work. That’s really what I want to do.

Kevin Pho: And Bruce, we’ll end with you. Your take-home messages to the KevinMD audience.

Bruce A. Berger: One is, as a health care practitioner, constantly be asking yourself the question: What in me gets in the way of seeing my patient as a human being, as opposed to an object? Kim just said, “I want my doctors to see me as a human being,” because you cannot do motivational interviewing if you see patients as objects, OK? The second message is: Will you allow yourself to see your relationships with patients as a meeting of experts? Their expertise is every bit as important as yours, meaning I’ve got to understand how they’re making sense of their world, in terms of their illness, in order for me to be more effective as a practitioner.

Kevin Pho: Everybody, thank you so much for sharing your perspectives and insights, and thanks again for coming on the show.

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