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Gastroenterologist Steven Pearce, health care consultant Bruce A. Berger, and physician advocate Kim Downey discuss their article, “How motivational interviewing transforms patient care and outcomes.” They explore the transformative power of motivational interviewing (MI), an evidence-based, patient-centered approach that enhances patient engagement and adherence by exploring motivations rather than persuading or correcting. Bruce shares practical strategies for clinicians to connect authentically with patients, Steven reveals how seeing patients’ “loving essence” reshaped his practice, and Kim emphasizes MI’s role in fostering meaningful health care relationships. Listen to discover actionable insights that can elevate your patient interactions and improve outcomes.
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Transcript
Kevin Pho: I’d welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Kim Downey. She’s a physician advocate. And once again, she brings together two individuals. We’re going to talk about “motivational interviewing, gastroenterologist, Steven Pearce, health psychologist, Bruce A. Berger.” The KevinMD article is “How motivational interviewing transforms patient care and outcomes.”
Everybody welcome to the show. Thanks, Kevin. All right. So, Kim, as always, my first question always goes to you. What brought everyone together, and what about this topic intrigued you?
Kim Downey: Sure. So, a little over a year ago, I had my first conversation with Stephen, and we had such a great talk. And he had an evolved piece that he sent me and that was so beautiful.
Part of what we talked about is he told me he was involved with a transformative storytelling, and Bruce and I had been following each other for a while on LinkedIn. I was excited to finally speak with Bruce. He told me he’s a pioneer in motivational interviewing. So, even though they weren’t the same thing, they’re just such nice guys. I’m like, this would be a great conversation. So, I had them on together, and what I really loved is how interested Stephen was in what Bruce had to say. And there was one point I tried to bring it back to Stephen, and he was almost taken aback. He’s like, “Wait a minute, you know, I’m sitting here saying I can’t wait for Bruce to give me more examples, because I’m going to go use them in about an hour,” because our conversation—he was at work. We even had to postpone it about 15 minutes; he was in a procedure. I just loved all of it. It was a great conversation, and I thought more people should know about it.
Kevin Pho: All right. Bruce, you’re an expert in motivational interviewing. So just to get everyone on the same page, give us a definition and some context for our conversation. Let’s start: What is motivational interviewing?
Bruce A. Berger: Well, it’s really both a skill set and a way of being with patients. It’s patient-centered, and it started in substance abuse. I brought it into health care 35 or 40 years ago because I thought, “My goodness, if they can do this with serious substance abuse—lowest rate of relapse, recidivism—can’t we apply this to chronic illness?” We started doing that and found that it worked beautifully. Again, it’s a patient-centered approach. It’s kind of a misnomer because we’re not really trying to motivate patients. What we’re trying to do is talk to them to begin to understand how motivated they are to take their medicine to treat their diabetes, what would make them more motivated, what’s getting in the way—really trying to assess where there are gaps in understanding, which often affect their motivation also. It’s really a conversation to explore a patient’s motivations about treating a chronic illness.
Kevin Pho: Bruce, in the context of chronic illness, tell us about some of the questions that a clinician would ask a patient in the exam room.
Bruce A. Berger: I would ask questions like, “Tell me in your own words what diabetes means to you. What’s your understanding of what the medicine can do in treating your diabetes? What’s your understanding of why changing your diet and getting more exercise is important?” If a patient is nonadherent to a health behavior—like taking their medication—I’d ask, “What’s making it difficult for you to take this medicine?” Too often, we’re very prescriptive and say, “We’ve gone over this. You need to take the medicine. Why aren’t you taking it?” instead of really trying to understand what’s getting in the way or what would make it more important to the patient. I call it a meeting of experts. We may be experts on health care, but the patient is an expert on how they’re making sense of what’s happening to them. If I don’t understand how they’re making sense, I don’t know how to treat them.
Kevin Pho: Bruce, that makes so much sense. It resonates with me whenever I’m seeing a patient in a primary care setting. I always say that patients are going to know their own bodies so much more than I will, especially if I’m just meeting them for the first time or even if I’m seeing them in a chronic setting. They’re going to know what diabetes means to them in very specific ways—each patient’s meaning will be different.
Steven, you’re a gastroenterologist. Tell us about how motivational interviewing intersects with what you do every day.
Steven Pearce: I think that’s why I was so fascinated with Bruce—because what he speaks to is, for me, so critical. Bruce, Kim, and I have talked about this before, but I wasn’t very good at this when I started. I had a lot of trouble making sure I was just checking the boxes and asking all the required questions so I could walk out of the room and tell the attending what was going on. That had nothing to do with connecting with the patient. As I’ve progressed in my own career, that connection with the patient is probably the most critical thing.
In my storytelling adventures in making films, I went and sat in a class for spiritual psychology for two years. A lot of what Bruce speaks to, I identify with from that class. It’s allowing somebody to come to their own realization of what’s going on with them, with you co-piloting where you’re going in that conversation—being a vessel to help them understand it. That is critical. That creates the connection between you and the patient. Over the years, I’ve found that connection to be the most important part to their healing, because so much more comes from that.
Kevin Pho: Steven, you mentioned that it was a bit of a transition going into this new framework of asking patients these questions. It’s not something that we’re taught in medical school—we sometimes just have to check boxes. That’s all the more important in primary care, where there’s so much pressure on us to check these boxes and ask specific questions. Talk more about your journey in overcoming that difficulty and becoming more motivational in your interviewing, building a stronger connection with patients.
Steven Pearce: Yeah, it came through failure. That’s how it came. Especially when I first got out of fellowship, you don’t truly know the impact you’re having on people because you see patients, then don’t see them, or they come back to different doctors. When I actually saw the impact—like I got the messages, “Hey, I don’t want to come back to you as my doctor. I didn’t feel like we had a good connection”—that’s painful. It’s painful to know someone is walking away from you.
That was probably 10 years ago. Then I took this psychology course, and that’s really where I got something similar to what Bruce is speaking to. And then, as Bruce and I have known each other, I’ve tried to incorporate some of his work. Really, truly seeing a human being and bringing humanity back into the room—that, to me, is what Bruce’s work allows us to do. It’s a tool that gives us practical ways to have that in the room with us. But yeah, I learned it through failure—the pain of thinking I was doing a good job, but the patient leaving—and then being willing to ask, “What can I learn from this? How can I do better for other people?”
Kevin Pho: Kim, you’ve told in your stories in the past that you’ve seen many clinicians before, and I’m sure you’ve seen a spectrum in terms of how they ask you questions. From a patient perspective, tell us the types of questions that you’ve been asked that really motivate you and help foster a stronger connection with physicians.
Kim Downey: Sure. I’ll share one specific story, because as you said, I’ve had all kinds of experiences—good, bad, and ugly. I could give so many examples. One that stands out is with my medical oncologist. Early on, when I was just getting to know him, he walked in the door, sat on the stool, did some stuff on the computer, then he went and sat on the most uncomfortable seat in the room—the footstool of the plinth—while I was in a chair. There was another chair, a stool, but he realized his patients with cancer feel vulnerable. By sitting lower than me, without even saying it in words, he was communicating, “We’re just going to sit here and have a conversation,” instead of him being on a high stool or a “high horse.”
That made it comfortable for us to talk about my cancer and treatment. Before my most recent surgery, I really didn’t want to do it. I was terrified of having a complication because I’ve had one before. Even though he wasn’t the surgeon, he took the time to ask me, “What are you most concerned about?” In a sense, he could have said, “Obviously you should do this. It could turn to cancer.” But because he asked me that question, it opened up a conversation we otherwise wouldn’t have. There are certain questions that are a lot harder to ask when you’re a patient because you feel embarrassed or awkward. But I felt OK telling him exactly what my fears were, and now I know we can talk about anything.
I’ll add a couple of things about him. He wears a bow tie, and he has a great sense of humor. After I’d seen about 40 doctors, this third cancer diagnosis finally allowed one support person because the pandemic rules had eased. So I brought my husband to meet him. When the oncologist walked in the room, I introduced him to my husband and said, “I just wanted my husband to know that every time I leave the house, I really am going to see a doctor.” The oncologist looked deadpan at my husband and said, “I’ve never seen her before in my life.” It was hilarious—we all laughed. It broke the ice, because I was facing another surgery and my husband had questions. That’s just an example of a doctor using both verbal and nonverbal communication in a way that made me trust him completely.
Kevin Pho: Bruce, as Steven and I mentioned, how we interview patients isn’t necessarily taught. Motivational interviewing isn’t necessarily stressed. Share some tips on how clinicians can be better interviewers in the exam room.
Bruce A. Berger: There are plenty of resources out there on motivational interviewing—books, articles. I wrote one specifically on motivational interviewing in health care. We also have an e-learning program on motivational interviewing. One of the reasons I connected so strongly with Steven is because I realized he sees relationships the way I do: the relationship is everything. You have to hold that relationship as sacred. Once you do, it’s like the right kinds of questions just start flowing. You create a space where it’s safe for the patient to push back if they disagree with you. I ask clinicians, “Would you like it if a patient told you that what you just said wasn’t important?” Some say, “What do you mean?” Well, wouldn’t you want to know if your patient doesn’t really think high blood pressure is all that serious because they feel fine? Then you have the opportunity to talk to them about how you can feel fine but still be at risk.
It’s creating a space where patients feel safe expressing how they see what’s going on. By “validating,” I don’t mean you agree that high blood pressure isn’t serious; I mean you let them know you understand why they might think that. Then you can help them realize they can be at risk while feeling fine.
Kevin Pho: Bruce, what do you say to those physicians who always say, “We’re under so much time pressure, I don’t have 10 minutes in the exam room,” and that implementing these principles is going to take more time?
Bruce A. Berger: My response is twofold. First, nonadherence takes far more time. If you’re constantly talking to a patient who’s not taking their medicine or engaging in the health behaviors needed to manage a chronic illness, you’re going to spend a lot of time. Second, research shows that three minutes of motivational interviewing by a skilled practitioner is more effective than seven to 15 minutes of what we typically do. Because if you talk to the patient—say, about GI issues—and then ask, “Now that you’ve heard this, tell me what your thoughts are. How important is it for you to change your diet?” you’ll hear potential barriers right away. You can address them up front. People who are really skilled at motivational interviewing often find it takes less time because you get at the key issues more efficiently than when you simply check boxes.
Kevin Pho: Steven, tell us a story about how these motivational interviewing tactics move the needle. Is there a particular patient example you could share?
Steven Pearce: Man, I can’t think of a single, specific story, because there are thousands. But the word Bruce used—”sacred”—is key. Internally, before I walk into the room, I think, “This is going to be a sacred interaction between two people.” It shifts how you interact. It fits with all the research Bruce has done. It’s the art of medicine. But if you want a general example, I’ve had thousands of these sacred interactions over the years. Also, I can think of thousands where I wasn’t in that frame of mind. When I do come in with that mindset, which actually starts when I wake up in the morning, it really changes the entire dynamic. It’s a small difference in how you approach things, but it can make a massive change in your interaction with patients. That’s why I think Bruce’s work is critical.
Bruce A. Berger: Kevin, can I give you one quick example? I was precepting some pharmacy students. A patient came in with a new diagnosis of diabetes. She handed the prescription to the pharmacy student and said, “Keep this back there for me. I’m not getting it right now.” The student asked, “Why not?” She said, “The doctor told me I have sugar, but I feel OK. I’ll start using it when I feel bad.”
The typical health care provider response is to immediately correct her, saying, “That’s not a good idea.” We always have to remember: if you can end your sentence with “stupid,” you’re going down the wrong path. Instead, we reflected back how she was making sense of it: “So because you feel OK right now, you’re going to wait until you feel bad to take it.” She said, “Right.” We asked, “Do you mind if we share a few thoughts, and you tell us what you think?” She said, “You can share, but I’m probably not going to start it right away.” “Fair enough—it’s your decision. But here’s something to consider.” Then we drew an analogy of syrup pouring on a stack of pancakes. At first, they look fine, but over time, they fall apart under all that syrup. If we don’t control the sugar in our blood, our blood vessels, eyes, and nerves can start falling apart too. By the time we finished, she said, “Wow, nobody explained it to me that way. I’ll take the medicine.” That conversation took four minutes.
Kevin Pho: We’re talking to Steven Pearce, Bruce Berger, and Kim Downey. The KevinMD article is “How motivational interviewing transforms patient care and outcomes.” I’m going to ask each of you to share some take-home messages you want to leave with the KevinMD audience. Kim, why don’t we start with you?
Kim Downey: Sure. Just last night, I shared a presentation for the American College of Physicians’ Virtual Doctors’ Lounge. One of the things I spoke about was how physicians’ relationships with patients can fuel them rather than drain them. Our conversation today dovetails perfectly with that. I recently interviewed Wayne Sotile, and he said, “Never lose sight of the meaning of what you’re doing. Even on your worst days, you’re miracle makers.” I want to add that you matter. My doctors are in my heart all the time; I love and appreciate them so much.
Find ways to be you. Take an active role in letting your patients see you as human—share little pieces of yourself. Don’t keep the armor on too tightly that you’re taught to wear as physicians. Forging relationships with your patients establishes mutual trust and respect. You and the patient are less likely to feel like cogs in a machine when there’s that personal connection. They’re more likely to trust you and follow your recommendations. It’s a win-win.
Kevin Pho: Steven, your take-home messages?
Steven Pearce: I don’t know that I have any take-home messages other than to say I deeply respect the work that both Kim Downey and Bruce Berger are doing. I hope we can continue to learn from them. What they’re doing is critical for a guy like me who’s in it every single day. I want to honor their work.
Kevin Pho: And Bruce, we’ll end with you. Your take-home messages for the KevinMD audience?
Bruce A. Berger: One is to keep asking yourself, “What in me gets in the way of seeing my patient as a human being instead of an object?” Because you can’t do motivational interviewing if you see a patient as an object. Second, will you allow yourself to see your relationship with a patient as a meeting of experts? Their expertise is every bit as important as yours. I need to understand how they’re making sense of their illness in order to be more effective.
Kevin Pho: Everybody, thank you so much for sharing your perspectives and insights, and thanks again for coming on the show.
