BACKTALK
When Words Collide Bill Benda, MD, Associate Editor
I’ve been glancing through my editorial meanderings from the past few months, and I’ve come to the realization that I haven’t significantly irritated or offended anyone in quite some time. So I thought I’d take the opportunity to remedy this glaring deficit. Over the past couple of years, I’ve noticed a significant uptick in articles on “health coaching,” to the degree that several journals have dedicated entire issues to this topic primarily espoused by academic nursing (“Danger, Will Robinson!”). I personally have little knowledge of this recently developed field, so I cannot comment on its ideology or theory. But it has brought to mind a series of lectures during my tenure with the Program in Integrative Medicine at the University of Arizona from 1998 to 1999. The course was titled “Motivational Interviewing.” I’ve always had a problem with this title, as well as with the course itself. First of all, the 2 words really don’t go together. Interviewing is a process of obtaining clean, unbiased information as close to the unaffected truth as possible. Motivating, on the other hand, is the active process of influencing another person’s actions and behavior. When I interview a patient, whether in the emergency department, clinic, or county jail, I don’t want to influence the person’s story. I want as much purity of fact as possible—accepting there will be significant subjectivity on his or her part without my own personal meddling. Any subsequent motivating comes during discussions of therapeutic alternatives, including physical, social, and psychological options. But I have another, more visceral reaction to the concept of motivational interviewing. I object to the implied need to play word games to incentivize our patients to make decisions for their own good. They are adults, for goodness’ sake, and we should treat them as such. Part of the painful degradation of our health care system has been the steady, progressive abdication of personal accountability for one’s own well-being. And we as practitioners are now told to baby those under our care, being careful to not antagonize them—no matter how idiotic and irresponsible their behavior has been—or risk the dreaded negative patient satisfaction survey. Patients have, in turn, become more and more demanding and entitled—wanting the latest drug as seen on TV, or MRI for their tension headache, or bariatric surgery for their fat rather than simply go through the discomfort of making actual lifestyle changes. 64
Integrative Medicine • Vol. 13, No. 3 • June 2014
IMCJ_13_3.indd 64
I know many of you in the integrative field are thinking, “That’s not true! My patients are motivated and eager to learn about nutrition and stress reduction and selfcare!” Well, they probably are. But integrative patients are a rather elite, self-selected group typically possessing higher educational and social/financial standing than most. The vast majority of society does not seek integrative care, nor likely could they afford it—or both they and we would be retiring before age 40. “So why this rant, Dr Benda? Is there actually deeper substance to this editorial than your personal frustration?” Yes, there is. It is my experience and belief that our knowledge and technology will never, ever solve our health care crisis or even make much of a dent in it. No matter what new pharmaceutical we invent, bacteria will out-evolve it. No matter what vaccine we develop, viruses will outmutate it. No matter what antiobesity surgery we develop, or antidepressant we create, or motivational interviewing technique we use, people will out-eat it or out-stress it or out-lazy it. Add to this the fact that natural selection no longer holds sway on this planet (don’t get me started on that) and things look pretty grim on the evolutionary front. Although there is, actually, a solution. One that is very simple, although never likely to happen, as it is at the same time very, very difficult. Its name is personal responsibility. Yep. Where each individual actually accepts that it is his or her job to change his or her nutrition, exercise habits, or mindset, without the option of yet another drug to take or lawsuit to file. Our job, then, is to enable this behavior—in place of enabling the person—through honest, straightforward conversation about the plain and simple facts. Not by tricking them with wordplay during an interview. We have become overly spoiled, my friends, expecting that some new discovery will rescue us from climate change or pollution or a penchant for McDonald’s. Ain’t going to happen! No new iPhone app is going to save us from our own personal choices in this life. Of course, there is one other possible salvation, one that I personally pin my hopes on: space aliens! But more on this at another time …
Benda—BackTalk
5/6/14 12:13 PM
When Words Collide Bill Benda, MD, Associate Editor
I’ve been glancing through my editorial meanderings from the past few months, and I’ve come to the realization that I haven’t significantly irritated or offended anyone in quite some time. So I thought I’d take the opportunity to remedy this glaring deficit. Over the past couple of years, I’ve noticed a significant uptick in articles on “health coaching,” to the degree that several journals have dedicated entire issues to this topic primarily espoused by academic nursing (“Danger, Will Robinson!”). I personally have little knowledge of this recently developed field, so I cannot comment on its ideology or theory. But it has brought to mind a series of lectures during my tenure with the Program in Integrative Medicine at the University of Arizona from 1998 to 1999. The course was titled “Motivational Interviewing.” I’ve always had a problem with this title, as well as with the course itself. First of all, the 2 words really don’t go together. Interviewing is a process of obtaining clean, unbiased information as close to the unaffected truth as possible. Motivating, on the other hand, is the active process of influencing another person’s actions and behavior. When I interview a patient, whether in the emergency department, clinic, or county jail, I don’t want to influence the person’s story. I want as much purity of fact as possible—accepting there will be significant subjectivity on his or her part without my own personal meddling. Any subsequent motivating comes during discussions of therapeutic alternatives, including physical, social, and psychological options. But I have another, more visceral reaction to the concept of motivational interviewing. I object to the implied need to play word games to incentivize our patients to make decisions for their own good. They are adults, for goodness’ sake, and we should treat them as such. Part of the painful degradation of our health care system has been the steady, progressive abdication of personal accountability for one’s own well-being. And we as practitioners are now told to baby those under our care, being careful to not antagonize them—no matter how idiotic and irresponsible their behavior has been—or risk the dreaded negative patient satisfaction survey. Patients have, in turn, become more and more demanding and entitled—wanting the latest drug as seen on TV, or MRI for their tension headache, or bariatric surgery for their fat rather than simply go through the discomfort of making actual lifestyle changes. 64
Integrative Medicine • Vol. 13, No. 3 • June 2014
IMCJ_13_3.indd 64
I know many of you in the integrative field are thinking, “That’s not true! My patients are motivated and eager to learn about nutrition and stress reduction and selfcare!” Well, they probably are. But integrative patients are a rather elite, self-selected group typically possessing higher educational and social/financial standing than most. The vast majority of society does not seek integrative care, nor likely could they afford it—or both they and we would be retiring before age 40. “So why this rant, Dr Benda? Is there actually deeper substance to this editorial than your personal frustration?” Yes, there is. It is my experience and belief that our knowledge and technology will never, ever solve our health care crisis or even make much of a dent in it. No matter what new pharmaceutical we invent, bacteria will out-evolve it. No matter what vaccine we develop, viruses will outmutate it. No matter what antiobesity surgery we develop, or antidepressant we create, or motivational interviewing technique we use, people will out-eat it or out-stress it or out-lazy it. Add to this the fact that natural selection no longer holds sway on this planet (don’t get me started on that) and things look pretty grim on the evolutionary front. Although there is, actually, a solution. One that is very simple, although never likely to happen, as it is at the same time very, very difficult. Its name is personal responsibility. Yep. Where each individual actually accepts that it is his or her job to change his or her nutrition, exercise habits, or mindset, without the option of yet another drug to take or lawsuit to file. Our job, then, is to enable this behavior—in place of enabling the person—through honest, straightforward conversation about the plain and simple facts. Not by tricking them with wordplay during an interview. We have become overly spoiled, my friends, expecting that some new discovery will rescue us from climate change or pollution or a penchant for McDonald’s. Ain’t going to happen! No new iPhone app is going to save us from our own personal choices in this life. Of course, there is one other possible salvation, one that I personally pin my hopes on: space aliens! But more on this at another time …
Benda—BackTalk
5/6/14 12:13 PM
