The modern physician: Consultant, Motivator or both?

As physicians, are we just consultants? Or are we more? Beyond just presenting facts, should we play a part in motivating patients to heed our advice? Many would say yes to the latter; physicians must not only educate but they must motivate as well.

In the book we're reading in school, The Medical Interview: The Three Function Approach, we find the following:

Some might argue that a physician should not be in the business of motivating patients to change. Perhaps physicians should just inform patients of their condition and make recommendations. Perhaps patients should have the right to decide independently whether they want to follow treatment recommendations, without the added burden of physicians' attempts to motivation.

This is essentially my current sentiment about what the legitimate role of the physician should be. But I'm amenable to changing my stance if I can get a better reason than the one offered by the author of the quote above. His dismissal of the 'doctor-as-consultant' position is merely that:

While there is certainly some merit to this position, most physicians accept that health enhancement strategies are part of the modern practice of medicine.

All right, so most doctors accept that 'health enhancement strategies' are part of the modern practice of medicine. But why?

I have several reasons for thinking that the 'doctor-as-consultant' rather than the 'doctor-as-motivator' is the legitimate one and it has mostly to do with my view of individual responsibility and freedom.

Patients freely engage in a relationship with a doctor for the purpose of improving their health. They are paying the doctor for his time, his training, his expertise and his recommendations. The doctor's duty is to give the patient these things and to make sure that the patient understands the options at hand as best he can. Beyond that, in my opinion, it is the responsibility of the patient to weigh those options, and to decide whether to accept the recommendations and treatments of the doctor.

So long as the patient is informed of the consequences of taking one action over another, I don't think the physician has an obligation to motivate the patient toward any decision.

My hesitation with the 'doctor-as-motivator' role is that it is paternalistic, even if at the core the intentions of the doctor are beneficent and altruistic. By going the extra step and saying, "Now, Mr. Smith, do you think you can eat a little less salt? If you don't do that, you could end up with much bigger problems down the road. That wouldn't be good for you and your family," I think you step over the line of patient autonomy. I realize that there is so little objection to physicians trying to motivate their patients to change because there is no ill will or malice in that action. It is, after all, the patients interests we have in mind. But that's precisely the problem for me. When I try to motivate a patient to change, it's MY desire that I'm imposing on the patient, not his own. I am supplanting his decision making process for my own.

I know I might be over thinking this. I admit that being inspired or motivated to change could very well be part of the total service physicians offer. That might be what the patients are paying us for, in which case, I don't have a problem being a motivator because it's the patients desire to be motivated. But I just have a hard time swallowing the fact that people should need to be prodded or nudged to care about their health. I'm also pretty cynical when it comes to the idea of changing minds. I don't really think you can change a person's mind. They have to change their own minds, and that requires information and will power. I can offer the information but not the will power.

One of my classmates said to me, "Alex, you just don't like being told what to do, and that's why you have a problem with this motivation stuff." And I said, "Yes, you're right. But I have an even bigger problem telling other people what to do. I don't feel like it's my place. People are free to make good and bad decisions without my coaxing. That's what it means to be free."

What started this whole dilemma was a simulated patient we had in our practice course. She was the 'difficult' or 'resistant' patient. Essentially, this woman had high blood pressure and was making poor lifestyle choices. She was sent to the doctor by her husband because he worried she might be at risk for heart problems. True to life, this patient kept insisting that nothing was wrong with her, that she was in great shape, that she felt fine, and that she had absolutely no desire to change anything. Admittedly, this was patient was really an actor, but our instructors confirmed for us that this type of patient scenario was very common in the clinic.

Which got me thinking about all of this. If a patient is utterly uninterested in improving her health and is unfazed by the potential consequences of her actions (presented by the doctor), what more can we do? What more should we do? As an adult, its your responsibility to decide what's important to you in your life. If eating certain foods or living a certain way is more important to you than the prospect of better health and a longer life, who am I to try to change your mind. Some might say, 'well, that's what doctors' goal is - to improve patients' health'. Yes, it is, but it's our goal only if it is their goal. It can't be our goal and not theirs. And I would add to that, we shouldn't have to make it their goal. Our proper role is to give them all the information and expert opinion for them to deliberate and decide if their goal is going to be improved health, but we can't force it on them, nor should we.


As I said, I'm not completely convinced that my position is the correct one, and I'd love to start a conversation on this. I welcome any and all comments.