Doctors, Is It O.K. if We Talk About Why Finger-Wagging Isn’t Working? []


Doctors give a lot of very good advice. Over the years, my primary care doctors have suggested better eating habits, more exercise, improved sleep hygiene, not carrying such a heavy shoulder bag, even exercises to improve my posture. The problem is, I am not sure I have ever made any changes in my behavior as a direct result. That would not come as a surprise to Ken Resnicow, a professor at the University of Michigan School of Public Health. “Finger-wagging doesn’t work,” he said.

“There’s excellent data directive advice doesn’t work, when you use what we call the language of control: you must, you should, you have to,” he said. And usually, “when a doctor uses any of those approaches, both parents and children respond aversely.”

So what does that say about all the good advice I give parents in my own exam room moments? Is it actually realistic to expect that complicated behaviors like eating and sleeping are changing, patterns which reflect family habits and cultural practices and emotions and social relationships? Some doctors use an alternative approach called motivational interviewing, which trains doctors to discuss the changes that might help people be healthier, while emphasizing respect for the patient’s volition and autonomy.

“We work with patients till they feel they want to do it on their own terms,” Dr. Resnicow said. “Both parents and children do better when they are given volition — to parents, we talk about ‘you provide, they decide.’”

Motivational interviewing was developed for adults who had substance use problems, and then spread to other clinical situations in adult medicine, said Melissa A. Faith, a child clinical psychologist at Johns Hopkins All Children’s Hospital, who has trained many clinicians in using the approach. It was successfully tried with adolescents, she said, and has now been shown to be effective with children as young as second or third grade, especially around food habits and physical activity.

There is particularly strong evidence that this approach works for helping overweight children, Dr. Resnicow said. In one randomized trial funded by the National Institutes of Health, overweight children from 42 different pediatric practices whose parents received motivational interviewing counseling from their primary care provider as well as a registered dietitian reduced their body mass index by 4.9 percentile points over two years compared to children receiving usual care, who dropped by 1.8 percentile points.

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