A 52-year-old man is evaluated during a routine examination. He is asymptomatic but is concerned about his weight. Medical history is significant for prediabetes and elevated cholesterol levels. He smokes one or two cigars a week. He drinks one or two alcoholic beverages a few nights each week. He does not get any regular exercise.
On physical examination, vital signs are normal. BMI is 33. The examination is otherwise unremarkable. The patient indicates he is ready to make important lifestyle changes to improve his health.
Which of the following is the best initial management?
A. Assess the patient’s confidence in making lifestyle changes
B. Determine which lifestyle change the patient believes is most important
C. Inform the patient he needs to lose weight
D. Provide advice on smoking cessation
MKSAP Answer and Critique
The correct answer is B. Determine which lifestyle change the patient believes is most important.
It would be appropriate to determine which lifestyle change this patient believes is most important to implement. Key features of motivational interviewing are that the patient chooses the agenda, the provider is not in “control” and does not tell the patient what he or she should do, and the provider assesses the patient’s sense of the importance of issues for them and their level of confidence in making these changes, which should be small and incremental. Physicians can support the patient’s choice and provide advice on how to overcome barriers to implementation.
The patient has indicated a willingness to make important lifestyle changes; he now needs to be empowered to identify those changes he wishes to make and identify barriers and facilitators to those changes. He does not need to be told to lose weight; the patient has already acknowledged the need to make lifestyle changes. After the patient identifies the changes that are important to him, it would be appropriate to ascertain his confidence in making those changes, but to do so prior to this step would be premature. Having the patient control the agenda and select the changes he believes are most important and identify the associated barriers and facilitators is more likely to be effective than the physician providing advice on smoking or other lifestyle changes that the patient may deem as less important.
- Key features of motivational interviewing are that the patient chooses the agenda, the provider is not in “control” and does not tell the patient what he or she should do, and the provider assesses the patient’s sense of the importance of issues and level of confidence in making changes.
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