A 45-year-old woman comes to the office for a routine follow-up. The patient feels well overall but mentions that climbing the last flight of stairs to her 3rd-floor apartment has become harder. She says, "Sometimes I have to stop at the landing to catch my breath." Medical history includes cocaine use disorder in remission for the past 4 years; it is otherwise unremarkable. The patient does not use alcohol or illicit drugs. She has a 25-pack-year smoking history and has been counseled to quit smoking in the past. The patient says, "I've tried to quit several times. I can cut down to a few cigarettes or half a pack for a day or two, but then it's just too difficult." Which of the following is the most appropriate response by the physician regarding this patient's smoking?
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This patient is struggling to quit smoking and is discouraged by repeated failures. Rather than repeat the health risks of smoking or prematurely focus on treatment, the physician can be more productive by using motivational interviewing to build and support the patient's motivation to change. Motivational interviewing is a patient-centered approach that invites collaboration, helps develop internal motivation to change, and enhances the patient's sense of optimism, self-confidence, and self-efficacy in reaching goals.
The physician's most appropriate response is to support the patient's sense of self-efficacy by helping her reflect on her past success and apply it to her current difficulties. By reviewing successful methods that enabled the patient to stop using cocaine, the physician can build the patient's internal motivation and belief that she can change her smoking habits as well.
(Choices A and D) This patient has been counseled about smoking and has tried to quit several times. She is likely aware that stopping smoking will improve her breathing and overall health. Rather than express concern and repeat the risks of smoking, the physician would be more effective by eliciting the patient's perspective and exploring her concerns about the effects of smoking on her breathing.
(Choice B) Although this statement is empathic, it prematurely focuses on treatment without attempting to elicit the patient's strengths and build her intrinsic motivation.
(Choice C) This statement is supportive and optimistic but reflects the physician's confidence, not the patient's. It does not help develop the patient's sense of self-efficacy.
Educational objective:
Motivational interviewing supports and develops patients' sense of self-efficacy in making behavioral changes. Eliciting patients' strengths and focusing on past successes can help build patients' internal motivation and confidence in their ability to make changes.