Family Medicine

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World Book of Family Medicine – European Edition 2015 Fig 4: The health vortex as a metaphor for the health system. Note the changes between certainty and complexity at the various levels within the health vortex. Take Home Messages Complexity and uncertainty are core characteristics of primary care Variables in “living systems” have non-linear (long-tail) distributions Small changes in a single system variable can result in largely divergent system behaviours Applying system tools helps to understand complex problems and guides the development of solutions Simple rules arising from a shared common focus (value) provide the operating principle for all system agents Original Abstract http://www.woncaeurope.org/content/56-complexity-and-primary-care References 1. West BJ. Homeostasis and Gauss Statistics: barriers to understanding natural variability. J Eval Clin Pract. 2010;16(3):403– 8. 2. Sturmberg JP, Martin CM. Handbook of Systems and Complexity in Health. New York: Springer; 2013. 3. Sturmberg JP, O’Halloran DM, Martin CM. People at the centre of complex adaptive health systems reform. Med J Aust. 2010;193(8):474-8. 4. Sturmberg JP, O'Halloran DM, Martin CM. Health Care Reform – The Need for a Complex Adaptive Systems Approach. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer; 2013. p. 827-53. 5. Sturmberg JP, West BJ. Fractals in Physiology & Medicine. In: Sturmberg JP, Martin CM, editors. Handbook of Systems and Complexity in Health. New York: Springer; 2013. 6. Sturmberg JP. Systems and complexity thinking in general practice. Part 1 - clinical application. Aust Fam Physician. 2007;36(3):170-3. 7. Katerndahl D, Parchman M, Wood R. Trends in the perceived complexity of primary health care: a secondary analysis. J Eval Clin Pract. 2010;16(5):1002-8. 8. Dörner D. The Logic of Failure: recognizing and avoiding error in complex situations. New York: Metropolitan Books; 1996. 36
World Book of Family Medicine – European Edition 2015 Siggy Rausch, MD siggyrausch@hotmail.de 10 – Motivational Interviewing in Family Medicine Siggy Rausch, MD Lecturer in Medicine University of Luxembourg, co-responsible for the organization of the Specific Training in General Medicine at Uni Luxembourg Lecturer in Medicine, Free University of Brussels (ULB) Member SSLMG (Scientific Society of General Medicine in Luxembourg) “People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the minds of others.” Blaise Pascal When we, as family doctors, have to deal with physical ailments, we can offer explanations, good advice and healing treatments and, for the most part, there is a successful outcome for the patients. However, we are often faced with more challenging situations. When the issue relates to dangerous behaviour, such as smoking, alcohol abuse, drug abuse, excessive eating, lack of exercise, not adhering to prescribed treatments etc., we can be faced with a resistance to our best efforts at advice and treatment - where people continue to behave in self-defeating ways. In this situation, our helper role often proves ineffective: when we have given our best advice and stressed the importance of a change in behaviour, we are often left with the frustrating feeling of failure. Patients can react in unexpected ways. They sometimes resist our advice and, indeed, argue against it. They can get angry and defensive, thus provoking feelings of frustration in us. We may even think that he/she “has bad will or is too silly to follow our advice”. Motivational Interviewing (MI) was developed more than 30 years ago in the setting of alcohol dependence treatments. The approach to counselling advocates is particularly relevant in the above context (2). We doctors are trained to use what can be called the “Deficit Model” which implies that “my patient lacks something (insight, information, understanding) and my role is to give him what is missing. The word “docere (to teach)” which is the origin of “doctor” is the basis for this “deficit model”. In MI the approach is different and has to do with “E-ducere (to draw out)”. That means search and draw out what is already present which includes what the patient himself may know. With this approach, the doctor and the patient search together, for a solution. Instead of focusing on the failings of the patient (which may be important) we focus on his/her resources, possibilities, wishes, hopes, strengths and capacity to change. Our efforts are twofold First, we encourage our patient to find arguments himself/herself, in favour of change. Second, we listen carefully to every element of “change talk” the patient expresses, we support his/her ideas for change and help develop them into a strategy that he/she will be able to apply. Ambivalence about the problematic behaviour is the starting point for MI intervention. Possibly, our first goal is to reveal this ambivalence. To get to understand the specific nature of our 37
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Family Medicine

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