To Advise or Not To Advise: That Is the Question

1. To Advise or Not To Advise:That Is the Question Geoffrey C. Williams M.D., Ph.D. 12-2-03

2. What I feel and think T Gordon, 1970 is different than What I say is different than What you hear is different than How you interpret what you have heard How you behave may be different than what you intend, and it is likely to be different than what I intended

3. Physicians Don’t Advise or Counsel • PHS 2000 Guidelines identify • 21% are counseled to quit • 67% have smoking status identified on chart • Assessments of Quality of Care identify that behavioral counseling is done less than 20% of the time (McGlynn et al. NEJM 2003)

4. Two Questions About Advice • Why do physicians not advise (or counsel) people about health related behavior? • Does direct advice from physicians increase or decrease motivation for health related behaviors (change or maintenance)?

5. Physicians don’t advise or counsel because • Literature indicates physicians feel they • lack knowledge • have inadequate institutional support • are too busy • don’t feel competent, or feel ineffective • Motivation theory suggests its that Dr.’s • are afraid it will undermine patient motivation • don’t value it as important as other things

6. Behavior change counseling is more effective than other physician interventions * USPSTF says NNT = 1,700

7. Health Benefits of Counseling • Physician advice alone is effective and brief counseling is even more effective. • PHS 2000 Cochrane Reviews • Advice 1.3 1.7 • Counsel 2.2 2.4

8. Importance of Advice & Counseling • 50% of deaths in the US are related to behavioral causes (McGinnis & Foege, 1993) • National Guidelines recommend counseling • JNC VII • Diabetes • Cholesterol • Tobacco Dependence • USPSTF • Its unlikely physicians are unaware of these

9. Knowledge • It is unlikely that physicians lack knowledge that behavior change counseling is recommended. • Motivational hypotheses left • They may not feel competent • They may not feel or be supported • They may be concerned it will lower motivation or satisfaction

10. Physicians & Psychologists Confuse Meaning of Autonomy • Two definitions of autonomy • Independence “without relation to others” • Volition “willingness to behavior” • Consistent positive health outcomes are associated with volition • Negative health effects with independence • Physicians abandon patients if the meaning is independence

11. Patient Satisfaction with Advice • Patients who smoke (n=1,900) report being more satisfied when physicians advise them to quit whether they wanted to quit or not. • 10 percentage point greater satisfaction • 5 percentage point lower dissatisfaction Solberg et al., 2001

12. Autonomy Support • Autonomy support is defined as • Elicit patient perspective • Acknowledge affect • Support patient initiatives • Provide information (advice) and rationale for behavior in a non-judgmental manner • Minimize control

13. Williams, Levesque, Zeldman, Wright, & Deci, HER 2003

14. Physicians don’t advise or counsel in part because • Longitudinal data suggest • clinician’s volition (or autonomy) for counseling is a strong predictor of change in their counseling behavior • Autonomy support from instructor increases volition • Autonomy support from work environment is strongly associated with volition

15. Two Questions About Advice • Why do physicians not advise (or counsel) people about health related behavior? • Its unlikely physicians lack knowledge • Lack of competence isn’t supported • Lack support from administrators/insurers • They lack volition • May confuse autonomy with independence and withhold direct advice • May be concerned patient satisfaction will be lower

16. Future Research • We need to understand more about how counseling and advice: • are experienced by patients • are experienced by physicians • how work climate effects physician behavior • meaning of not providing advice to patients • how to train clinicians to provide direct advice

17. Self-Determination Theory • Autonomy Autonomy support • Competence Competence support • Relatedness Relationship support

18. Self-Determination Theory • Autonomous motivation involves people feeling fully willing to regulate their behavior • Controlled motivation involves people feeling pressured by others or by themselves. • Internalization is an inherent, proactive process by which controlled motivations are transformed into autonomous motivation

19. Self-Determination Model for Health Autonomy Support vs. Control Health Care Climate (HCCQ) Mental Health Depression Somatization Anxiety Quality of life Autonomy (TSRQ) Competence (PCS) Relatedness Individual Differences Autonomous Orientation (GCOS) Physical Health Not Smoking Exercise Weight Loss Diabetes Control Medication Adherence Healthier Diet Intrinsic vs. Extrinsic Values

20. Autonomy Support (HCCQ) • Definition: The extent to which the practitioner listens to and acknowledges the patient’s perspective, supports initiatives, and minimizes control • I feel my HCP’s provide me with choices and options about my smoking (including not stopping) • My HCP’s try to understand how I see my smoking before suggesting a new way to do things.

21. Autonomous Motivation (TSRQ) • Definition: The extent to which the patient feels self-initiating and volitional • The reason I will take medications to quit smoking is: • I personally believe that these are important to remain healthy. • Other people would be upset, if I didn’t. • I would be ashamed of myself if I didn’t.

22. Perceived Competence • Definition: The extent to which the patient believes he/she can achieve the outcome • I feel confident in my ability to stop smoking completely • I feel capable of stopping smoking completely, now.

23. SHS Participants • 1006 smokers recruited from ads & MD’s • >4 cigs/day • Don’t have to want to quit, paid $35 • Exclusion criteria: • <18 yr/o, life expectancy <18 months • No history psychosis or dementia • Read and speak English

24. SHS StudyDesign • Randomized controlled trial of 18 months • Questionnaires at baseline, 1 months, 6 months and 18 months • Outcomes: • Serious quit attempts • Took Medication • Cessation at 6 months

25. Intervention & Control Conditions • Int: 4 visits regarding health and tobacco • Obtain medical and smoking history • Values interview • Reduction in 10 year absolute risk for CAD • Ask if they want to quit • If yes, problem solve, support, medications, F/U • If no, check back, review values • Control: Return chol., encourage MD visit

26. Hypotheses of SHS • SDT based intensive tobacco counseling will increase quit rates by: • being more autonomy supportive • by enhancing autonomy and competence • Medication use and competence will mediate the effect of autonomy on cessation

30. Baseline Autonomous Motivation 1-month Autonomous Motivation Medication Taking 1-month Autonomy Support 6-month Cessation 1-month Perceived Competence Baseline Perceived Competence Multi-Group Analysis SDT Process Model (.79**) .71** .22** (.26**) (.18**) .17** .29** .50** .39** (.33**) (.42**) (.79**) .08* (.09*) (-.12+) (.61**) .52** .29** Note: Model Fit: χ2(334)=945.50, p<.001; CFI = .94; IFI = .94; RMSEA = .052; Bolded paths vary significantly between groups;Values represent standardized path estimates, those in parentheses are for the Community Care group. + p < .10; * p < .05; ** p < .01.

31. Conclusions • PHS model for intensive treatment and SDT model of motivation were fully supported • Autonomy support to autonomy to competence was invariant across the two groups • Cessation was increased in those that wanted to quit and those that didn’t • The SDT intervention increased motivation for taking medications for cessation

32. The Five A’s • ASSESS: Ask about/assess behavioral risk • ADVISE: Be clear, specific, & personalize • AGREE: Collaboratively set goals • ASSIST: Aid the patient in achieving goals • information, skill training, social supports and pharmacotherapy • ARRANGE: Schedule follow-up contact Whitlock, et al., 2002

33. Autonomy Support • Elicit and acknowledge patients perspective (listen and reflect) • Provide effective options for change • Support patient initiatives for change • Provide a rationale for your suggestions • Minimize control • Focus on the person’s future goals

35. Conclusions • SDT/PHS model for intensive treatment was perceived as more autonomy supportive, increased autonomy, and competence • Cessation was increased in those that wanted to quit and those that didn’t • The SDT intervention increased motivation for taking medications for cessation • Those that quit reported reduction in depressive symptoms, & more vitality

36. Drs are less likely to advise when supporting autonomy • A study of 27 physicians trained to be autonomy supportive versus controlling in the 4A’s (Ask, ADVISE, Assist, Arrange) • Audio-tape ratings showed when being autonomy supportive direct advice was given only 90% (vs 98%, p=.06) of interviews Williams & Deci, Medicial Care 2001

37. Health Benefits of Counseling • Physician advice alone is effective and counseling is more effective. • PHS 2000 Cochrane Reviews • Advice 1.3 1.7 • Counsel 2.2 2.4 • Physician effect greater than non-physicians • Tobacco abstinence (PHS 2000): • Physicians = 2.2 vs. 1.0 or 19.9% vs. 10.2% • Non physicians = 1.7 vs 1.0 or 15.8% vs. 10.2%

38. Autonomy Support and Patient Centeredness • Patient centeredness technically means non directive counseling. • Physician would follow patient cues alone • Autonomy support is defined as • Elicit perspective, acknowledge affect, support initiative, minimize control, provide advice and rationale, support competence

39. Summary • Behavioral counseling by physicians is important because of its unique effect, and its unique impact on disease outcomes and quality of life for patients. • Autonomy support (pt centeredness) maybe misunderstood as leaving the patient alone (be independent) to manage health behavior.

40. Construct Measurement • Autonomy supportiveness (HCCQ) • 15 items self report (7point likert scale) • Autonomous, Controlled, Amotivated (TSRQ) • 15 self-report items • Perceived competence • 4 items self-report

41. Autonomy Support • Elicit and acknowledge patients perspective (listen and reflect) • Provide effective options for change • Support patient initiatives for change • Provide a rationale for your suggestions • Minimize control • Focus on the person’s future goals

42. Physician Impact is Important • Impact = efficacy x reach into population • Physicians: 10% eff. 70% reach • Beh specialists: 30% eff. 3% reach • 3.5 million vs 0.5 million ex-smokers • 7 times greater impact for physicians

43. Two Questions About Advice • Does direct advice from physicians increase or decrease motivation for health related behaviors (change or maintenance)? • Evidence is that direct advice and counseling results in healthier behavior and better health • Evidence suggests direct advice increases motivation for healthier behavior.