Every primary care FNP runs into this. You give a patient a treatment plan they need. They don't follow it. Their blood pressure stays high. Their A1c climbs. Their depression doesn't improve because they're not taking the medication. They keep smoking, keep drinking, keep skipping meds.
The natural reaction is frustration. Sometimes lecturing. Sometimes (privately) judgment.
None of that works. The thing that actually works is a skill called motivational interviewing, and it has changed my practice more than almost any other communication tool.
People do not change because you tell them to. They change because they decide to. Your job is to help them get there.
What MI Is and Isn't
Motivational interviewing is a counseling approach developed by William Miller and Stephen Rollnick. The core insight: ambivalence — wanting and not wanting to change — is the normal state for most people facing a hard behavior change. The job of the clinician is to help the patient resolve their own ambivalence in the direction of change.
It is not:
- A pep talk
- A lecture
- Scare tactics
- "Have you tried just stopping?"
It is:
- Curiosity about the patient's values, desires, and current life
- Listening more than talking
- Reflecting back what you hear
- Drawing out the patient's own reasons for change (not yours)
The Four Pillars (OARS)
Open-ended questions
"What do you know about your blood pressure?" Not "Are you taking your medication?"
Affirmations
"You made it back to clinic today. I know that wasn't easy with everything going on."
Reflective listening
"It sounds like part of you wants to quit smoking, and part of you feels like it's the one thing in your life that's just for you."
Summaries
"So let me make sure I understand. You're worried about your blood pressure. You've tried medication before and had side effects. You're open to trying again if we can find one that doesn't make you feel that way. Is that right?"
The Magic Question
"On a scale of 0 to 10, how important is it to you to [change behavior]?"
If they say 6 — "That's interesting. Why a 6 and not a 3?"
Notice what you did. You did not ask why it's not a 9. You asked why it's that high. The patient will give you their reasons for change in their own words.
These reasons, coming from their own mouth, are 100x more powerful than anything you could tell them.
Pearl: Ask "why a 6 and not a 3?" Don't ask "why a 6 and not a 9?" The first elicits change talk. The second elicits defense.
What to Do When They Resist
If a patient pushes back, do not push harder. Roll with it.
Patient: "I'm not taking that medication. I read online it causes [bad thing]."
Wrong response: "That's not true. The studies show…"
Right response: "It sounds like you've been doing some research. What concerns you most about it?"
Then listen. Then address. The wrong response shuts the conversation down. The right response keeps it open.
The Stages of Change
Patients fall somewhere on this continuum for any given behavior:
- Precontemplation: not even considering change
- Contemplation: thinking about it
- Preparation: planning
- Action: doing
- Maintenance: sustaining
- Relapse: slipped back
Your intervention should match the stage. A patient in precontemplation does not need a smoking cessation plan. They need acknowledgment that change is hard and curiosity about their current situation. Trying to push them into action wastes both of your time.
When to Use MI vs. Direct Education
MI is for behavior change. Direct education is for facts and acute decisions.
"You need IV antibiotics tonight, your infection is severe" — direct education.
"We've been talking about your weight for a year" — MI.
Know which mode you're in.
The Hardest Part
The hardest part of MI is sitting with the discomfort of not telling the patient what to do. You will want to lecture. You will want to fix it. You will want to give them the answer.
Resist. The lecture creates resistance. The curiosity creates change.
Some patients you talk to with MI for two years and they never change. That is okay. The conversation is itself a form of care. Don't measure your impact by their progress on any one timeline.
A Real Example
Patient: 52-year-old woman, A1c 9.8, hasn't taken her metformin for 6 months.
Old me would have said: "We really need to get you back on metformin. Your sugar is at a dangerous level. Diabetes complications include…"
MI me says: "Tell me what's been going on with your diabetes since we last talked."
She talks. I learn she stopped because the medication gave her diarrhea, and she didn't want to bother me with it, and she felt like she was failing already. She thought maybe she'd just stop trying.
I reflect that back. I affirm how hard it must be to feel like you're failing at something that's largely outside your control. I ask what would make her willing to try again. We problem-solve together — extended release metformin, taken with food, slow titration. She leaves with a new prescription and, more importantly, a sense that we're partners in this.
She comes back in 3 months. A1c is 7.4.
The Bigger Truth
Behavior change is one of the most important things primary care providers do. We can affect more health by changing a behavior than by prescribing a medication.
Get good at this. It takes time. It is worth every hour you invest in learning it.