Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St. Pomona, CA

Counseling Patients

When working with patients, often the most challenging part is not the medical aspect but rather the social. This week, I had one particularly challenging patient. My interactions with this patient had me thinking about the best way to counsel patients, especially when it comes to bad news.

Here's the story.

I was consulted to see an elderly diabetic patient who had suffered a fall with a nondisplaced fibular fracture treated nonsurgically with a weightbearing fracture boot. Unfortunately, this was a giant mistake because six weeks later the patient's ankle fell apart in the way most of us are only too aware...order up a large serving of Charcot.

What made this situation go from bad to tragic was the patient's accompanying comorbidities: severe cardiac disease currently under workup, worsening renal disease with an upward trending creatinine, and - here's the saddest part - severe occlusive peripheral arterial disease with dry gangrenous ulcerations on the affected limb.

The short of it is I recommended a limb amputation rather than the very long reconstructive route. The patient and I had two long conversations about the reasoning behind my recommendation and the benefits of the amputation, among other things. After these conversations, the patient was not sold on my idea, thinking I just wanted to "cut" without giving him alternatives (obviously, I wasn’t going to do the amputation myself).

Without going into the details, I didn't think the patient had any good alternatives. However, in the end I suggested the patient see another physician for a second opinion, and that is where we stand currently.

Tonight's Premier Lecture is
Nutrition and Neuropathy
Allen Jacobs, DPM

Agree or disagree with my recommended course of treatment, my primary issue of discussion is how we can most effectively counsel our patients. You see, I came out of our discussions with two major conclusions. One, I failed miserably to confer my level of concern for this patient. Part of this was likely due to a language barrier problem, requiring a translator. The second was that I recommended what sounded to the patient like an overly aggressive treatment option without somehow first establishing a trusting relationship. As a result, what I was recommending was too much for the patient to handle.

So, here I am wondering, "What could I have done differently to effect a better overall result?" My first step in our brave new world of evidence-based medicine is to look at the medical literature. What does the research say about patient counseling?

One important issue the research points out first, is just how difficult effective counseling is and the fact that the medical community has a hard time with it. Take, for example, a study published in the journal Medical Care, in which researchers found a decreasing amount of weight loss counseling by physicians over a recent ten year period.⁽¹⁾ Despite the fact that obesity has been increasing over the past few decades, the number of primary care physicians providing counseling has declined, indicating just how difficult it is to deal with this problem. I don’t blame PCPs for these declining numbers. Obesity is a difficult disease to treat, requiring a lot of dedicated time that physicians just don’t have.

If we think counseling patients to lose weight is difficult, imagine adding on all of the other comorbidities that go along with patients with diabetes, and even more so, one facing a major amputation. It’s no wonder I failed miserably with my patient.

But there may be hope for us in the form of "Motivational Interviewing (MI)." MI, in contrast with directive-style counseling in which the provider educates the patient and instructs what the patient should do, is a counseling method in which the provider helps his patient explore and resolve ambivalence.⁽²⁾ This method is focused on changing patient behavior. The basic idea is as follows. Instead of telling the patient what they have to do, or else, the provider has an open-ended conversation with the patient, eliciting their feelings about the situation while remaining supportive of the patient’s ability to change. Argumentation or direct attempts at persuasion are considered counterproductive. If a patient resists, this is viewed as a sign to change strategy rather than a judgment of noncompliance. Through this method, the patient comes to her own conclusion and is thus empowered, with the end result being improved outcomes.

Gabbay and associates simplifies this approach using the mnemonic OARS:⁽³⁾

O – Open-ended questions
A – Affirmations to encourage the patient
R – Reflecting patient comments to help process thoughts
S – Summarize the discussion for clarity

Randomized controlled trials of this counseling method in various health settings, including smoking cessation and alcohol abuse treatment, among others, have shown promising results. Gabbay, et al discussed the use of this method in counseling diabetic patients, arguing podiatric physicians are well situated for this method.⁽³⁾ I highly recommend this interesting article as well as the others below for a more detailed discussion of motivational interviewing.

I wonder if I had approached my patient utilizing motivational interviewing, perhaps I might have had a better response both for me and my patient. Perhaps we all would. Best wishes.