Pharma, adherence and motivational interviewing
Andrew Tolve explores how the technique of motivational interviewing can improve adherence rates
Every day, patients around the globe receive telephone calls from pharmacists and nurses informing them that they’re late refilling their medicine. And every day, those pharmacists hear a litany of explanations, complaints, or excuses as to why patients have lapsed: pain, forgetfulness, discomfort, or lack of pain and discomfort, suggesting that the medicine has already run its course. Whatever the reason, pharmacists suddenly find themselves on the frontline of the health system’s adherence problem.
Trouble is, handling these situations in a short amount of time in a non-face-to-face environment is tricky. Pharmacists can easily come across as judgmental, dismissive, or chastising. Patients can easily get defensive. And when communication breaks down, patients hold the ultimate leverage, as they can simply hang up the phone and go on living their lives however they choose.
Enter motivational interviewing (MI). Originally developed by clinical psychologists to address substance abuse, the process attempts to deal with patient ambivalence and resistance toward behavior change, whether that change involves taking medication, losing weight, ceasing to smoke, or abstaining from alcohol. At the heart of MI lies the belief that healthcare providers (HCPs) don’t manage illness, patients do. The HCP’s role is to provide support, information, and tools so that the patient can succeed in their own management.
“Motivational interviewing grants that patients ultimately decide what they want to do,” says Bruce Berger, an MI expert and the man widely credited with bringing MI from the field of substance abuse into the healthcare arena. He likens the situation to a bus in which the patient is the driver and the HCP a passenger helping to give directions: “The healthcare provider is an expert on the direction, but you, the patient, are the expert on where you want to go.”
How MI works
Aligning the patient’s ultimate destination with HCPs’ recommended directions is the art of MI. The process provides a framework for HCPs to assess a patient’s motivations and then provide tailored information that responds to that patient’s unique challenges or concerns. Motivational interviewing is thus a misnomer. You’re not talking to patients in order to motivate them; you’re talking to them to assess their motivations and then set them up to succeed.
“If you think your job is to motivate patients, you have an impossible job,” says Berger.
When working with HCPs, Berger likes to point to the example of Adam and Eve. God told them not to eat from a tree, and they were non-compliant. “That was God,” Berger says, “and you’re not.” Innate to the human condition is the ability to make good and bad decisions, and often those decisions are not rational. In the Biblical story, Adam and Eve choose to bite an apple despite the risk of getting banished from Eden. In today’s world, patients choose to overlook or avoid medications despite the documented risk to their own health and wellbeing.
In order to overcome this fundamental human quality, MI uses a combination of psychology, empathy, and facts to encourage patients to make the recommended decisions for themselves.
1. Listen
MI starts with listening. If, for example, a patient is 30 days late refilling a 90-day supply for high blood pressure medicine, the pharmacist would ask if the patient is aware that he or she has not refilled the medication and, if so, why that is the case. It might be because the patient feels fine, or because his blood pressure is never higher than 156 over 110, which he believes to be healthy. Whatever the reason, the HCP listens, looking specifically for the patient’s “core concern” and “line of reasoning.” “If you don’t know what they know, you don’t know what to tell them or the information that they need,” says Berger.
2. Respect and reflect
Once HCPs have listened to the patient’s explanation, MI suggests that they respect the core concern that the patient has expressed and do so by reflecting it back without being judgmental. “Reflecting it back” in MI terms means restating precisely what the patient has said, so that the patient can hear it from the HCP’s mouth and know that they’re listening.
In the case of the high blood pressure patient, the HCP would say something to the effect of, “So because you’re feeling good and your blood pressure never goes above 156 over 110, you’re wondering what’s the big deal?”
“You want that patient to hear, ‘I’m on your side. I’m not agreeing, but I’m an ally,’” says Berger. He adds that HCPs should shy away from saying, ‘I understand’ at this step, even though it’s a natural impulse when patients relay their stories. “‘I understand’ is not only cliché, it’s presumptive,” says Berger. “I don’t determine if I understand, you do.”
3. Provide tailored information
After reflecting the core concern, patients’ natural response will be ‘Yeah, that’s exactly right, I am wondering what’s the big deal.’ At this point, HCPs validate the concern and ask if they can give more information that responds to it. The nature of this information will vary widely based upon the situation, and therefore this step is where MI requires the most of its practitioners, being able to summon the most compelling information for a specific scenario—on the spot.
“You can see the folly of looking at a patient and saying, ‘Get this under control,’ if that patient doesn’t understand that this is a problem in the first place,” says Berger.
In the case of the high blood pressure patient, the HCP would explain that, unfortunately, high blood pressure is one of those conditions that don’t have symptoms—and that’s part of what makes it dangerous. The first symptom is usually a stroke or a heart attack. We know that when blood pressure goes below 140 over 90, the risk of stroke or heart attack goes way down. This patient’s blood pressure is quite a bit above that, which puts him at elevated risk for stroke or heart attack if it remains unchecked, even if the patient feels okay.
“The pharmacist needs to present this information in an empathetic tone that gets the patient’s line of reasoning corrected without causing face loss or defensiveness,” says Berger.
4. Enabling the patient to make the right decision
Once HCPs have presented the tailored information, they close by saying something to the effect of, ‘With that in mind, where does that leave you now in terms of taking the medicine more often?’
The goal here isn’t to impose a goal on the patient. Imposed goals often fail. Instead, the goal is to make the light bulb go off in patients’ heads so that they’ll change their position and alter their line of reasoning by their own free will. “I don’t draw conclusions for the patient,” says Berger. “That’s for the patient to draw.” Put another way, “I’m not here to be your parent to dictate what to do, I’m here to provide information so that you can see the right path for yourself.”
The pharma factor
Studies show that telephone counseling delivered with the MI method can have significant impacts on adherence rates. One study consisting of 367 smokers found that among those who didn’t receive MI support, 8.7 percent ceased taking their medication. Among those who did, the noncompliance rate was 1.2 percent.
Berger did research for Biogen and its AVONEX drug for MS. The control group experienced a dropout rate of 13 percent per year, whereas the treatment group with MI support was again 1.2 percent. A 1.2 percent non-adherence rate is the sort of figure that makes pharma execs’ eyes go wide, and which can balloon bottom lines in spite of difficult market conditions.
Not surprisingly, pharma has already started to integrate MI in one of several ways. The first is as a training source for internal use. Directors of disease categories, for instance, have hired the likes of Berger to come in and work with their entire teams, who, in turn, can channel that understanding into support systems and interactions with the HCP community. Berger has also run seminars with sales reps to teach them how to leverage MI to communicate with customers.
A second opportunity is to sponsor workshops with external partners, especially pharmacists. As Berger puts it, “Pharma generally understands that MI is powerful. The problem is getting pharmacists involved.”
That’s starting to change. Berger is currently working with pharmacies and drug chains, including Kerr Drugs, Kinney Drugs, London Drugs and Meijers Drugs in the U.S. and Canada. Amylin Pharmaceuticals sponsors his work with Kerr Drugs. In the other cases, the pharmacies are paying for the training directly. Nonetheless, Berger says there’s still resistance to changing the way telephone counseling is trained amongst pharmacists.
“The model with which we train healthcare professionals is broken,” he contends. “It’s a model in which we think we have the right to tell people what to do, rather than we have the right to be a caring, concerned resource and to help them make better balanced decisions. At the end of the day, we don’t decide, they do. It’s their life, and we need to approach them accordingly.”
For more on patient adherence, check out SFE USA on June 12-14 in Somerset, NJ.
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