Tools for Increased Efficacy with Challenging Patients

Dr. Baruch Roter

My patient Michelle isn’t doing so well. Her A1C is stuck at 8 and her BP is too high. She takes her meds and comes in, but she drinks soda and doesn’t exercise or check her blood sugars. It’s pretty frustrating!

Studies show that many patients don’t follow the guidance of their physicians. This results in bad health outcomes as well as discouraged clinicians. What can be done?

The good news is that there are well-proven methods for working more successfully with these challenging patients. In this blog, I will introduce basic ideas and practices for building effective partnerships with our patients. Then I will share simple ways to use two behavior-change methods to empower your patients and help them make improvements in their health behaviors.

Our capacity to be present, compassionate, and nonreactive increases our effectiveness and also helps us manage our own stress when working with challenging patients. All this is supported by personal development work.

The first step in creating a truly effective relationship with our patients is to build rapport with them. The more our patients feel connected to us and trust us, the more power we have to influence their choices. Taking a moment to ask patients about nonmedical issues tells them that we care about them as a person, not just as an object of our medical attention. We can meet the patients’ need to be heard, as well as garner important information, by asking open-ended questions, giving them time to express themselves, and using reflective listening in which we offer the idea back to them to confirm that we have understood them correctly.

The better we understand their thoughts, feelings, and beliefs concerning their health, the better we can build consensus with them. If we present a plan as a done deal, we may not know that they actually don’t agree and that the plan seems to be in conflict with their desires or beliefs. Actively soliciting their feelings and input on a co-created plan greatly increases the chances of their following through with that plan.

So, once we build a strong therapeutic connection with Michelle, how do we get her to actually change her unhealthy behaviors? A core tenet of behavior change is that the more a person believes that he or she has the capacity to change, the more likely it is that he or she will be able to make that change. This is known as self-efficacy. The other basic notion is that behavior change is supported more by affirming patients than by talking about their unhealthy behaviors in a way that leaves them nihilistic and feeling bad about themselves.

Appreciative Inquiry (AI) is a method of behavior-change dialogue in which only positive statements are made. A simple way to use AI involves asking patients to talk about a time in their lives when they felt healthier—what did they do to be healthy, what motivated them, and what strengths of theirs does that illustrate? Then, ask them to describe their dreams for a healthy future. What would it look like, what would they be doing to be healthy, and how would they be supported in living healthy lives? In the last phase of AI, patients are reminded of the strengths and successes discovered in the discussion. We then help them figure out action steps they can take now. The big difference from the usual dialogue is that patients are discussing behavior changes in the context of an acute awareness of their strengths and their capacity to change, and that they have a clear vision of a healthy future to move toward with our encouragement.

Motivational Interviewing (MI) is another valuable and very easy-to-use method for behavior change. In MI, the patient’s motivation and confidence are enhanced. Let’s say the patient is supposed to stop drinking soda. The patient is asked, “How important is it to you to stop drinking soda? On a scale of one to ten, with one being not important at all and ten being the most important thing in your life, how important is it to you?” If the patient responds with a low number, the typical clinician response would be, “Why isn’t your number higher? Why aren’t you more motivated?” In MI, the patient is asked instead, “Why is your number that high? Why isn’t your number one or two?” The patient is prompted to make self-affirming statements, such as “I know it’s important for my health, and I really care about being healthy.”

The other question from MI that patients are often asked is, “How confident are you that you can stop drinking soda? On a scale of one to ten, with one being not confident at all, and ten being very confident, how confident are you?” Using a similar method to the one above, the patient is prompted to make self-affirming statements, such as, “I have been successful in the past in changing my diet.” These self-affirming statements build upon patients’ existing motivation and confidence and increase their self-efficacy.

We can learn to build mutually satisfying and highly effective partnerships with our patients. Using proven, simple, and efficient behavior-change methods, we can help our patients make critical lifestyle and health-behavior changes and very significantly improve their health. And that will increase our own self-efficacy, satisfaction, and happiness with our practice!

To see how I worked with Michelle and to learn much more about creating partnerships with patients and empowering them to change, please view the video webinar, Empowering Patients: Tools for Effective Partnership and Behavior Change.

Dr. Baruch Roter is a family physician with 25 years of experience teaching and working in community health centers. He teaches health-care workers about mindfulness, compassion, burnout prevention, happiness, patient-centered care, and behavior-change methods. He can be reached at

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