Motivational Interviewing by Podiatric Physicians

Abstract

Foot ulceration and lower-extremity amputation are devastating end-stage complications of diabetes. Despite agreement that diabetic foot self-care is a key factor in prevention of ulcers and amputation, there has only been limited success in influencing these behaviors among patients with diabetes. While most efforts have focused on increasing patient knowledge, knowledge and behavior are poorly correlated. Knowledge is necessary but rarely sufficient for behavior change. A key determinant to adherence to self-care behavior is clinician counseling style. Podiatrists are the ideal providers to engage in a brief behavioral intervention with a patient. Motivational interviewing is a well-accepted, evidence-based teachable approach that enhances self-efficacy and increases intrinsic motivation for change and adherence to treatment. This article summarizes some key strategies that can be employed by podiatrists to improve foot self-care.

Foot pathology is a key complication of diabetes leading to an increasing global burden of lower-limb amputation. Although foot self-care behaviors in ‘‘at-risk’’ patients can prevent diabetes-related foot pathology, adherence to these recommended behavioral strategies is suboptimal. [1] Most interventions to improve self-care behaviors have focused on increasing knowledge, [2,3,4] although the assumption that transferring knowledge will improve health outcomes has little empirical support. It is increasingly clear that counseling style can foster, diminish, or wither patient adherence to recommendations. [5,6,7,8] The traditional health-care provider style is often highly directive and is sometimes restricted to demanding adherence to a list of behaviors with little input from patients. One promising evidencebased teachable counseling technique used with multiple chronic diseases in different settings is motivational interviewing (MI), which elicits the patient’s own intrinsic motivations for making changes and helps providers with the counseling skills needed to become more effective agents for behavior change. Podiatric physicians, who are on the front lines of diabetic foot care, have a unique opportunity to explore MI approaches to change patient behavior and, hence, improve quality of care and patient outcomes.

Limited Success in Influencing Patients’ Foot Self-care Behavior

Published guidelines on diabetic foot self-care for atrisk patients are essentially ‘‘do and don’t lists,’’ with recommendations falling into two types: adopting ‘‘new’’ preventive self-care actions (eg, daily foot self-checks) and avoiding otherwise ‘‘normal’’ but now potentially self-damaging behaviors (eg, barefoot walking). [9,10] Despite agreement that diabetic foot self-care is a key factor in the prevention of ulcers and amputation, there has been only limited success in influencing these behaviors in patients with diabetes and even in those at high risk. [2,3,4]

Foot ulceration and lower-extremity amputation are devastating end-stage complications of diabetes and are a major public health concern due to their substantial socioeconomic burden. [3] Thus, the lifetime risk of foot ulcers in people with diabetes may be as high as 25%, [3] and up to 80% of amputations in diabetic patients may be preceded by a foot ulcer. [11] The estimated cost of treating a diabetic foot ulcer in the United States in 2004 was $13,000 per ulcer episode, [12] and that for diabetic amputation was $51,000. [13] Foot outcomes are thought to be highly behavior dependent, although conclusive evidence of this view is still lacking. [2,3,4] Despite great progress in identifying high-risk persons with a simple clinical assessment [14] and recommending behaviors to prevent progression of the high-risk foot, rates of ulceration and amputation are decreasing very slowly in the United States. [15] Furthermore, 5-year mortality after new-onset diabetic ulceration have been reported to be 43% to 55%, and mortality is even higher for patients after lower-extremity amputation (74%). [16] Strategies to improve self-care behavior directed at preventing ulceration, repeated ulceration, and amputation hold significant promise to improve on these sobering statistics.

Changing Self-care to Prevent Ulcers and Amputations

Most interventions to improve self-care behaviors have focused on increasing knowledge, [2,3,4] although the assumption that transferring knowledge will improve health outcomes has little empirical support. Indeed, knowledge and behavior are poorly correlated; thus, knowledge is necessary but rarely sufficient for behavior change. [17,18] Almost all studies have used educational as opposed to behavioral interventions to influence behavior, with inconclusive or at best short-lived behavioral outcomes. [2,3,4] Three recent systematic reviews [2,3,4] evaluated the effectiveness of educational interventions in preventing diabetic foot lesions with the general conclusion being that the poor methodological quality of these studies makes the available evidence generally unsatisfactory. Much has been learned in the past decade about strategies that are important for eliciting behavior change, and clinician counseling style has emerged as a primary factor. Theory-based behavior change strategies exist; however, only a single study, from 1991, [19] used a theory-based behavioral approach to improve foot self-care behaviors.

Podiatric Physicians Are the Ideal Providers of Brief Behavioral Interventions

Few studies [19,20,21] have explored the engagement of podiatric physicians in these interventions despite the fact that their primary role is the longitudinal care of foot problems in high-risk diabetic individuals most prone to amputations. Podiatric physicians have multiple potential opportunities to address unhealthy behaviors, and national guidelines recommend that high-risk patients see podiatric physicians routinely, with these services generally reimbursed by payers. American Diabetes Association guidelines recommend foot screening for all diabetic patients at least every 12 months, [14] whereas those at greater risk for serious foot problems should visit podiatric physicians an average of 3.7 times a year. Therefore, podiatric physicians are on the front line of care, providing longitudinal care for high-risk individuals with a potential opportunity to influence foot self-care, which is often neglected by other providers of diabetes care.

While performing foot care, podiatric physicians typically engage in casual rapport-building conversation, some of which may be opportunistically transformed into robust behavioral counseling. Most podiatric physicians, however, similar to other providers, typically do not receive formal training in behavior change counseling techniques and are often frustrated with attempts to influence patient behavior yet likely desire changes in foot self-care that can significantly improve patient outcomes.

A Key Determinant of Adherence to Selfcare Is Clinician Counseling Style

Evidence suggests that the approach that the provider uses, their ‘‘counseling style,’’ can foster, diminish, or wither patient adherence to recommendations. [5,6,7,8] Recently, the need for podiatric physicians to assume some of the responsibility for their patients’ nonadherence was advocated with some thoughtful approaches described by the authors. [18] Traditional health-care provider style is directive and expert advice giving. Two components of the traditional style are information exchange and persuasion, which can lead to resistance. One promising counseling technique used in a variety of clinical settings and with multiple chronic diseases is MI. [22,23,24,25,26,27]

MI as a Strategy to Promote Behavior Change

Motivational interviewing is a directive, clientcentered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence. [23,28] Initially, MI was a strategy used to treat health problems with high rates of recidivism, such as substance abuse, but it is now being applied to other chronic health conditions such as diabetes. [29,30,31,32,33] Its success is attributed to empowering patients, rather than professionals, with the ability to change behavior. Motivational interviewing elicits patients’ own intrinsic motivations for making changes and provides providers with the counseling skills needed to help them become more effective agents for behavior change. Examples of the contrast between MI and the traditional directive counseling style are listed in

Table 1. Comparison of Motivational Interviewing versus the Traditional Directive Counseling Style.

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Thus, MI is an evidence-based intervention that has been proved to be effective and well accepted, that has been applied to health issues, and that has been used to help patients address physical inactivity, smoking cessation, unhealthy diet, and medication adherence. [22,23,24,25,26,27] Several systematic reviews and meta-analyses demonstrate robust effect sizes of MI applied to numerous chronic health conditions. [24,25,27,34,35,36] For example, a systematic review [37] of 29 randomized trials examined the effectiveness of brief behavioral interventions adapting the principles and techniques of MI to four behavioral domains: substance abuse, smoking, human immunodeficiency virus risk, and diet/ exercise. Almost two-thirds of the studies yielded a significant behavior change effect size. There seemed to be no association between length of follow-up and magnitude of effect sizes across studies. Another meta-analysis [38] of 15 randomized controlled trials of MI interventions confirmed that brief MI is effective. However, several factors were identified that may influence the long-term efficacy of MI: initial expectations, readiness to change, and whether the population is drawn from treatmentseeking or non–treatment-seeking individuals.

Motivational interviewing has also been demonstrated to facilitate behavioral changes in patients with diabetes. In a randomized controlled trial, [39] 66 teenagers with type 1 diabetes attending diabetes clinics in South Wales, United Kingdom, were assigned to either MI or standard support groups. The mean hemoglobin A_1c level in the MI group was significantly lower after the intervention than that in the control group after adjusting for baseline values. This difference in glycemic control was maintained at 24 months. The MI group also showed improvements in psychosocial variables, with enhancements in well-being, quality of life, and personal models of illness. Motivational interviewing can also be a beneficial adjunct to behavioral obesity treatment for women with type 2 diabetes. [40] In a randomized controlled trial, women in the MI group lost significantly more weight at 6 months and 18 months; greater weight loss in the MI group was mediated by enhanced adherence to the behavioral weight control program. The MI group also had a significantly greater reduction in hemoglobin A_1c levels. In another study, [41] MI significantly enhanced adherence to program recommendations and glycemic control. Several other studies are under way evaluating the impact of MI delivered by different health professionals, including nurses, [42] and MI teaching has entered into the medical school curriculum at some institutions.

Classic MI is less suitable for medical encounters because of the time constraints of a typical 10- to 20-min provider office visit. To address the time constraints of the medical setting, a more succinct version—brief MI—has been developed. [37,38] Brief MI has been used in the medical setting, including in smoking cessation, medication adherence, risky alcohol drinking, obesity, physical activity, and diabetes mellitus. [22,23,24,25,26,27] Two encounters seem to be needed to have an impact (per the published data). There is, therefore, a unique opportunity for podiatric physicians to apply the principles of brief MI to help improve diabetic foot self-care. [18]

Motivational interviewing seeks to explore a patient’s ambivalence to change and help him or her overcome any resistance to change. Ambivalence is the key issue to be resolved if patients are to make healthy behavior changes. Patients may be ambivalent and resistant to change for many reasons. Many patients do not see the need, they do not know how to change, they do not feel they are able to change, or they just do not care or view the change as important. By definition, ambivalence is feeling two ways about the same thing (eg, ‘‘I really should check my feet more often, but I just don’t have the time’’).

Motivational interviewing is the practice of disentangling competing and often obscured motives related to a patient’s ambivalence. The traditional way of working with ambivalent patients has been to tell them to do something or to argue for one side of their ambivalence. This, however, usually leads the patient to be more resistant to change and has them arguing for the opposite side. A key element in MI is to help patients resolve their ambivalence so that they may choose change.

Motivational interviewing is essentially not argumentative or judgmental. An immediate outcome that providers note is an improvement in patient satisfaction because ‘‘we are really listening to patients and work with them on the goals that we have negotiated with them.’’ The ability to ‘‘roll with resistance’’ and accept the behavior change as the patients decision can also decrease personal frustration of the provider with ‘‘difficult’’ patients. Some key assumptions inherent in MI are described in

Table 2. Spirit of Motivational Interviewing.

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A variety of strategies can be used to help patients tip the decisional balance toward change. Typically, one transitions from the content of the usual visit by asking permission to talk about selfcare behaviors. This can be something like, ‘‘Do you mind if we talk about some things that affect your risk of foot ulcers/healing/etc?’’

Specific MI Strategies

One set of strategies can be abbreviated by the acronym OARS: open-ended questions to promote communication, affirmations to encourage the patient’s efforts at self-management, reflecting patient comments to enable them to process their thoughts, and summaries to let the patient know that the provider has heard and understood what he or she was saying.

Open-ended questions promote dialogue by not allowing the patient to answer a question with a simple ‘‘yes’’ or ‘‘no’’ answer. It gives patients the chance to elaborate on what they are saying and typically provides richer information than a simple ‘‘yes’’ or ‘‘no.’’ Examples of closed- and open-ended questions are as follows: (1) ‘‘Do you examine your feet daily?’’ (closed) versus ‘‘Tell me a little about your daily foot-care routine’’ (open). (2) ‘‘Do you always wear your diabetic shoes?’’ (closed) versus ‘‘Tell me a little about how it’s going wearing your diabetic shoes’’ (open) or, if you strongly suspect adherence issues, ‘‘Many people find it challenging to wear these special shoes; how is it going for you?’’ (If you get ‘‘OK,’’ try, ‘‘I know for me it would be most difficult at home after work; I like to go barefoot in the house. When is it most difficult for you?’’)

Framing questions in an open-ended manner (and giving patients ‘‘permission’’ to not be perfect [‘‘I would have trouble doing this too ...’’]) is likely to provide answers that are more revealing and can uncover adherence issues in a nonjudgmental way. Once uncovered, one can help problem solve solutions by asking further open-ended questions. The key is to ‘‘guide’’ the patients to find their own solutions (eg, ‘‘What would it take to wear your diabetic shoes to church?’’).

Affirmations are used to recognize patients’ efforts, let them know you appreciate their efforts, and congratulate them on things they are doing right. This builds self-efficacy/self-confidence, which is a key factor in determining whether an individual is likely to change their behavior. An example is: ‘‘I appreciate your coming in today. Using your one pair of diabetic shoes for every step must be a really hard thing to do, but you are doing a good job in figuring out how to do it.’’

Reflective listening is a key skill and helps to move the conversation forward. The provider listens to what the patient is saying and repeats it back to the patient, often guessing at some of the content. It is a brief statement of your understanding of what the patient has felt/said. It helps to demonstrate a desire for mutual understanding and is a good follow-up to an open-ended question. An example is: [patient] ‘‘My feet are already numb and now I am developing calluses. My work schedule doesn’t allow me to follow a daily foot routine. I wear my diabetic shoes at work, but on the weekends I just can’t be bothered.’’ [provider using MI] ‘‘So you do a pretty good job of using your shoes during the week, but weekends are a problem?’’ (An open-ended question inviting the patient to problem solve the weekend issue would then follow.)

The final skill is summarizing. Summarizing allows the patient to hear what was discussed in the visit and lets the patient know that the provider was listening and heard what was said. It indicates attentiveness on the part of the interviewer (‘‘Let me make sure I’m getting this ...’’). It also allows patients’ statements to be clarified, consolidated, and reinforced. An example is: [provider summary] ‘‘Today we talked about ways you may better remember to take care of your feet, what some of the barriers for you doing this are, and ways of overcoming them. Looks like you have some good ideas on how to remember to wear your shoes but have trouble on the weekend. We also talked about how you are concerned about your feet and the chance of getting another ulcer, so where does that leave you on using your shoes on the weekends as well?’’

Resources

Podiatric physicians can learn MI through various methods. The most common (and probably most effective) way to learn MI is in a workshop format and involves one-on-one interaction with an official MI trainer. A list of such trainers is available at the MI Web site (www.motivationalinterviewing.org). In addition, there are several excellent books that can be a good guide to some of the basic techniques. [22,26] Finally, perhaps the most practically useful approach is to try some of these techniques in practice. Most instructive is to tape a patient visit (with permission) and then listen to it at a later time and assess your style, looking at the use of closedand open-ended questions and other OARS components.

Conclusions

Podiatric physicians, who are on the front lines of diabetic foot care, work with high-risk diabetic patients, where self-care is critical to reducing ulcer and amputation rates. Although there has been great progress in the past decade in podiatric medical care, amputation rates still remain high. A key determinant of poor foot outcomes is patients’ poor self-care; podiatric physicians understand their obligation to help guide patients toward better self-care but do not necessarily have the skills to do so effectively. Therefore, we believe that there is a great opportunity for podiatric physicians to explore MI and other behavior counseling approaches to change patient behavior. Improving the ability to listen and support difficult lifestyle changes in our patients will improve quality of care and patient outcomes. Learning to help guide patients toward appropriate foot self-care can have a profound public health impact given the number of at-risk diabetic patients who regularly see podiatric physicians.