Posts Tagged ‘motivational interviewing’

How did those samples find me?

May 11, 2017

The samples can help people quit
Without the nicotine fit
Tobacco detox
In a little brown box
Came free, and it made quite a hit.


Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.


About ten days ago I found a box on my desk, sturdy cardboard, about 6 inches on a side. It held Chantix samples from Glaxo, Smith, Kline.
I hadn’t asked for the samples, I’d signed no papers for them, and I have no idea how GSK knew where I am. After all, I’ve only been here since February.
And they were the right samples to treat exactly one patient: a starter pack, because abruptly starting full dose Chantix risks major side effects, and two months follow-up therapy. Chantix turns out to work better in real life than it did in the lab; it works more consistently than anything besides quitting cold turkey.
The first patient of the day came in for other things (and gave me permission to write what I’ve written). But just like I do for everyone else, I asked if he smoked.
And, indeed he does.
I used to lecture people on the evils of smoking. By now, though, everyone already knows all the bad things about tobacco. Lecturing only brings antagonism into the relationship; “educating” the patient can thinly mask judging the patient.
These days I use a script from Motivational Interviewing, a technique that capitalizes on ambivalence. I hold my two forefingers a foot apart, and I ask, “On a scale of 1 to 10, where 1 means you’re not ready to quit, and 10 means you’re ready right now, how ready are you to quit?” If they say 1 or 10, I stop. For any other number, I ask, “Why not 2?” Mostly the smokers don’t get the question, and will tell me the bad things about tobacco. I interrupt them, explain that they weren’t ready for the question, and ask them the 3 best things about tobacco. When the patient understands what I’m asking, they mostly talk about stress relief, anxiety, and habit. A few talk about taste. One said “Breakfast, lunch, and dinner.” After they tell me their favorite things about tobacco, I give them a blank stare for 3 seconds, then change the subject. The idea of Motivational Interviewing is to get the patient to think.
But this patient gave me an enthusiastic 10. I don’t get many of those, just like I don’t get many 1s. And he’d done well with Chantix in the past. In fact, he wanted me to give him a prescription for Chantix. “I’ll do better than that,” I said, “I will give you the Chantix.” And 90 second later I reappeared with the samples.
He already knew how to use them, and he already knew about side effects.
I couldn’t think of a more appropriate way to use the samples. Tobacco makes any other medical problem worse.
I enjoy helping people, but certain parts of my work bring me disproportionate pleasure. A low B12, a high TSH, or curing someone by stopping their statin makes my day.
This one came close.


Alcohol: truth and fantasy

September 20, 2012

It seems to me this is bunk,

The uncomplicated life of a drunk

With a true loving wife

And a well-ordered life

And insight that comes by the chunk.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 48 hours a week.

I read over the information about the male patient, age 42.  The main reason given for the visit came down to concern with alcohol use.

He drinks 6 Jack and Cokes a night, 4 nights out of 7, more on the weekend.  Doesn’t smoke.  Married.  Employed.  Wife concerned he’s drinking more than he used to, and he confirms that over the last 4 years his alcohol use has accelerated.  He doesn’t have problems at work.

He maintains a normal blood pressure and pulse.  His blood work came back as normal with the exception of the liver functions, which, unsurprisingly, run high though not dramatic.  I asked for and received an acute hepatitis profile which came back normal, and I couldn’t order an ultrasound.

He has tried to cut down, he gets complaints from his wife about his drinking, those complaints annoy him.  But he has never had to have an eye opener, a drink to get going first thing in the morning.

I find no family history of alcoholism; he has no symptoms of depression, no tremor, no headache, and absolutely no sleep disturbance.  Sure that he is not an alcoholic, he notes that most of his friends drink more than he does and that most of his socializing has to do with alcohol.

And so the motivational interviewing starts.  No judgmental statements, just questions, like What is important to you?  How does your drinking fit in with that?  Visit after visit, he makes more and more progress whittling away at his tippling and then he starts going months without any alcohol at all. He changes friends, and he gets closer with his patient and loving wife.

The patient didn’t give me permission to write these details because the patient does not exist.  The information came to me in a case scenario, a clinical simulation, during my preparation for Family Practice recertification, in the module called Health Behavior.

The case presentation doesn’t match with the reality of my alcoholic patients.  As a group, none sleep well, all have family histories of alcoholism, all live in a continuous state of household chaos, going from one crisis to another, sabotaging success and intimacy.  A few have normal bowel habits, fewer live without headaches.   Most of my alcoholic patients have scintillating, quirky personalities and great senses of humor; yet prone to fits of unreasoning anger, occasional rages, and unrealistic demands on the people around them.  Despite tremendous generosity, they betray friends, lovers, spouses and children.  Embarrassing others in public leads to progressive isolation.  All but the homeless drunks have an enabler, who will sabotage progress towards sobriety.  They rarely stay dry without a 12 step program.

Even when sober, they generate chaos, though if they get religion (AA is a religion) they generate less chaos as time goes by.

With all their problems, they’re still fun and exciting to be around. Unlike patient case scenarios.