We are rural.

–Dr. Tom Bibey

 The landscape may be in evolution, but some things never change. Spring planting will come around every year, and some of our patients will sit on the front porch and smoke cigarettes because that is what they do. Yeah, our patients eat too much at times and don’t exercise enough, and maybe they aren’t all that sophisticated, but don’t diss ’em. They are our patients. We are them, and they are us. We don’t talk bad about our own.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

 In rural health care we often live in community with our patients. As we’ve discussed in other posts, this poses challenges for confidentiality and privacy. [See October 3rd post] Familiarity can breed tolerating the status quo as well as understanding the underlying dynamics and issues that need to be addressed to help patients problem solve and make better choices in their lives. Sometimes a fresh perspective brings new energy and ideas. Often clinics like having students for those reasons. A new set of eyes can ask the same old question from a different angle, a mind fresh from training shares new information and new thinking. 

 There is value to understanding what cannot and will not change. It can save us lots of energy and head banging when working with patients. It is our job to present options to patients, but ultimately their choices are their own. There may be ramifications to those choices,  but it is the patient who has the power to change his/her behavior or his/her situation.  Understanding Prochaska and DiClemente’s http://www.motivationalinterview.org/ stages of change can help during patient care. The Transtheoretical model was developed in the 1970’s based on different psychological theories about how people make and adapt to changes in their lives. An individual cycles through various stages when deciding to change a problem behavior.  Precontemplation—you don’t think you have a problem; Contemplation—realize you do have a problem and examine the pros and cons to making a change; Preparation—gathering the tools and support to make a change; Action—actively taking steps to change a behavior; Maintenance—continue the change for more than six months.  Of course, patients cycle through contemplation and action and even maintenance repeatedly. Think of a person who quits smoking, loses weight or starts an exercise program.

 As a provider, when a patient is in precontemplation, it is my job to remind him/her that his/her behavior is a problem. “Losing even five pounds could make a big difference for your blood pressure control…” I won’t waste my words or time about how to do it if he/she isn’t really interested in making a change. If I receive the response, I like my cigs, doc, the I remind them with humor –“I wouldn’t be doing my job if I didn’t bother you about our cigs.” Humor almost always. When a patient is actively weighing the pros and cons, then it is worth my time to talk about the supports available for the behavior change–quitting smoking, exercise, etc. However, instead of lecturing, motivation interviewing helps the patient explore their assets and blocks for altering the behavior.

 Think about patients you’ve seen. Who was or was not ready to change his/her behavior? It is the new year, a time that many people take stock and make resolutions to change. Some will be successful, some will not.

Share the story without using identifying information.  Did the provider or nurse you worked with do a particularly good job of addressing behavior change with the patient? If so, tell us about it. If not, what could they have done differently that would have taken a motivational interviewing approach.


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