The Medication Interest Model: How to Talk With Patients About Their Medications, 2nd Edition
Shawn Christopher Shea, MD
Critical Acclaim from the Field:
“In the following pages, you are in for a treat. You are about to enter the very soul of what we do, and you could not find a better guide . . . . this little book, in my opinion, is destined to fill a giant void in the training of all medical and nursing students, as well as becoming a classic read for experienced clinicians in search of the art of medicine. My advice is simple – read it.”
Former Surgeon General of the United States (1981-1989)
C. Everett Koop, MD, ScD
Senior Scholar, C. Everett Koop Institute at Dartmouth
Review from the first edition of this book
This pioneering book on the clinician-patient alliance - written in a fast-paced, highly enjoyable writing style - shows medical, nursing, physician assistant, and clinical pharmacy students the importance of the principles behind shared decision making and how to transform those principles into clinical practice. Shawn Christopher Shea, MD, an internationally respected author, has a superb ability to perceive the complexities of clinical interviewing as applied to shared decision making, while creating frameworks and interviewing techniques that illuminate, clarify, and simplify those complexities so that young clinicians can immediately apply them. This book demonstrates the art of enhancing the therapeutic alliance by addressing one of the most, if not the, most important of interviewing tasks with regard to achieving successful healing: collaboratively talking with patients about their medications and effectively enhancing their medication adherence.
The Medication Interest Model (MIM) was developed by watching clinicians and case managers talk with their patients about their medications and holding over 150 MIM workshops with primary care physicians, nurses, mental health professionals and other allied health professionals. The result is a book filled with the type of wisdom and knowledge that can only be gained by learning from the skilled clinicians who talk with patients on a daily basis about their medications. Students (as well as experienced clinicians) will find this wonderfully practical resource to be a text they will frequently pull down from their shelves to absorb its wisdom long after they have left their training programs.
This highly acclaimed, Doody’s Core title has been thoroughly updated and expanded for the second edition: The Medication Interest Model (MIM), its motivational theory (the Choice Triad), and its over 100 easily learned and practical interviewing techniques are described and demonstrated with clear examples and compelling illustrative interview dialogue. Key features include:
Interviewing principles and techniques are easily learned and used, providing an ideal introduction to medical, nursing, physician assistant, and clinical pharmacy students on how to effectively create the therapeutic alliance while enhancing medication adherence.
Provides the most up to date information and nuances of the Medication Interest Model (MIM) from its creator and developer, a clinical model explicitly designed for effective use in the hectic clinical settings of primary care clinics, specialty clinics, and hospital units.
Presents more than 100 specific interviewing techniques that are equally useful for medications for all disease states – from hypertension, diabetes, hyperlipidemia, asthma, and congestive heart failure to cancer, AIDS, and PTSD.
Clearly shows how words powerfully impact whether or not patients are interested in taking medications and staying on them by providing the exact phrasings of 101 interviewing techniques while demonstrating - with clinical examples and clinical dialogue - all of their nuances for immediate, everyday practicality.
Contains a wealth of relevant information for physicians, nurses, physician assistants, case managers, and clinical pharmacists across disciplines from primary care to specialists in endocrinology, cardiology, neurology, rheumatology and psychiatry – and is equally valuable and relevant to both students and experienced clinicians.
User-friendly Tip Archive, with the exact wording of all 101 of the tips shown in the easily accessed e-book for quick referral by medical and nursing students during clinical rotations.
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Part I: When Patients Don’t Take Medications: Core Principles
Chapter 1. “Nonadherence”: The Extent of the Problem
Chapter 2. The Medication Interest Model: What Is It?
Chapter 3. The Crux of the Problem: The Nature of Medication Nonadherence
Chapter 4. Is It Really “Noncompliance”?
Chapter 5. The Choice Triad: How Do Patients Choose to Take a Medication?
Part II: Interviewing Techniques and Strategies: The Real World of Clinical Application
Chapter 6. The First Script
Chapter 7. First Step of the Choice Triad: Is There Something Really Wrong?
Chapter 8. Second Step of the Choice Triad: Can a Medication Help Me?
Chapter 9. Third Step of the Choice Triad: Do the Pros Outweigh the Cons?
Chapter 10. Choice Triad Redux: Caring for the Patient
Part III: Specialized Topics and Advanced Techniques for Enhancing Medication Interest
Chapter 11. Starting, Switching, and Adding Medications: Finding Collaborative Solutions
Chapter 12. Why Patients Hide the Truth About Their Medication Practice and How to Help Them Share It
Chapter 13. Pills and People: Assessing Cultural Beliefs About Medications
Chapter 14. Medication Interest: The Impact of Family, Friends, and the Digital World
Appendix A. The Next Step: A Concise Guide to Enhancing Medication Follow-through
Appendix B. Tip Archive
Appendix C. Reprinted Article: Shea, S.C. The "Medication Interest Model," an Integrative Clinical Interviewing Approach for Improving Medication Adherence - Part 2: Implications for Training and Research. Professional Case Management 2009; 14(1); 6-15.
The purpose of life is to serve and to show compassion
and the will to help others. Only then have we
ourselves become true human beings.
- Albert Schweitzer, MD
It has been nearly 12 years since former Surgeon General C. Everett Koop, MD, ScD, penned the words that you just read in his most gracious foreword to the first edition of this book. With his passing, we lost one of the greatest, if not the greatest, Surgeon Generals we have been blessed to have. He is not present to write the foreword to the second edition of this book on the Medication Interest Model (MIM) of which he was a great believer. As a point of gratefulness and respect, it seemed only fitting to let his first foreword herald this second edition as well. If he were alive today, I can only hope that Dr. Koop would be thrilled with this new edition and its presentation of the exciting recent developments in the MIM.
Let me begin by saying that, first, and foremost, this is a book about the therapeutic alliance. It highlights the pivotal role that skilled medical interviewing plays in shaping this alliance, indeed, gives it birth. A major component of that skill set lies with the ability to use shared decision making and collaborative exploration to help patients approach the daunting task of deciding whether it is a good idea to put a medication inside their bodies, and if they do so, should they continue to do so? The answer to this question is unique to each patient. Sometimes it is a good idea. Sometimes it is not.
Moreover, this conversation regarding the use of medications is a surprisingly complex process. It is determined by an extensive array of factors including illness beliefs, wellness beliefs, family opinions, cultural biases, personal experiences with taking medications, financial limitations, the benefits of the medications, the side effects of the medications, and the enormous variations in how patients weigh the pros and cons of taking medications. Decades of clinical experience have taught me that to expect medical, nursing, and other allied health care students to somehow magically know how to navigate these waters without intensive training is naïve at best and unfair at worst to both the students and their future patients.
The overarching goal of this book is to help medical, nursing, physician assistant, and clinical pharmacy students to learn about this process, become adept at its navigation, and be able to effectively, and compassionately, engage in this conversation in the extremely hectic environments of outpatient clinics, hospital units, and emergency rooms. Research has clearly indicated that the number one reason for treatment failure across most diseases is that patients do not take their medications as prescribed. The amount of human suffering resulting from this dilemma is truly unsettling.
Consequently, I think it is fair to say that it is of immense importance to address – in the training of medical, nursing, and other allied health care students – the complex issues that will arise for them on a daily basis as they talk with their future patients about the use of medications. In the following pages, we will give this critical topic the attention it so richly deserves.
I don’t believe that it is an overstatement to say that from the very first days in courses devoted to pharmacology to the numerous days spent in introductory courses on communication skills and the creation of the clinician/patient therapeutic alliance, students from all allied health care fields should be thinking about how they intend to talk with patients about their medications in a collaborative and compassionate fashion.
Traditional approaches such as motivational interviewing and cognitive therapy have significantly advanced our abilities to enhance medication motivation, but empirical research indicates that there is much more to be learned about enhancing medication motivation and use. Moreover, as any experienced clinician knows there is more to talking with patients about their medications than addressing their motivation for use.
A plethora of hidden traps and roadblocks regarding the discussion of medications await students once they step into their clinical rotations and, ultimately, step into their first jobs and residencies following graduation. In my opinion, these traps and roadblocks warrant careful discussion and ongoing training from more experienced clinicians.
Questions that require such discussion and mentoring are numerous and include examples such as: What is my own personal philosophy about the use of medications? Do I need to share that philosophy with my patients? If so, when should I do so? What are some of the ways that experienced clinicians have found to effectively share their prescribing philosophies? What are some of the most effective ways to present patients information about side effects? How do you sensitively and effectively talk with a patient about a medication whose side effect might be death? How do you spot a patient who is hesitant to share their concerns about their medications? What questions help such patients to share their real concerns and fears? What types of questions are most effective in uncovering – in a sensitive fashion – whether doses are being missed or a medication has been unilaterally stopped? What are the cross-cultural issues that arise regarding medication use (such as the use of medications during Ramadan with Muslim patients or when is it necessary to share information about binding ingredients that may be problematic to a patient’s religious beliefs such as porcine products with Jewish patients)? How does one approach a patient’s interest in alternative and complementary interventions? What are the best interviewing techniques for providing education about medication dosing and scheduling? What are the typical concerns of family members? What are some of the best questions for sensitively uncovering these concerns?
The list goes on and on.
Even more disturbing is the realization that a breakdown in the therapeutic alliance along any one of these questions might result in a patient losing interest in using a medication or effectively following through with it.
And here is where I must share some personal excitement about the book you are about to read. Since its introduction in the first edition of this book 12 years ago, the Medication Interest Model (MIM) has expanded, become better conceptualized, and has grown to include over twice as many interviewing techniques as in the first edition. The MIM currently uses a well-defined and popular motivational model – the Choice Triad – specifically designed to reflect motivational gains regarding medication interest and use. Within the framework of the MIM, over 100 specific interviewing techniques have been described and named all of which are easily understood, demonstrated, learned, and tested for competence if so desired.
Readers of the first edition will be glad to know that I have tried to keep intact whatever elements of the first edition reader feedback has suggested were most effective, while approaching the topics of each chapter with the same informal writing style that readers seemed to enjoy so much in the first edition. As they say, don’t fix what isn’t broken.
Over six chapters have been added on topics not addressed thoroughly in the first edition. I am particularly excited about new chapters such as “The First Script,” “Pills and People: Assessing Cultural Beliefs About Medication,” and “Medication Interest: The Impact of Family, Friends, and the Digital World,” which address the types of questions listed above with the thoroughness I think they deserve. Indeed, the MIM has evolved into an easily taught and distinctive model, hence the change in the title of the book itself.
Further enhancements from the first edition await the reader in the three appendices. A “bonus chapter” – The Next Step: A Concise Guide to Enhancing Medication Follow-through has been added as Appendix A. Such a chapter was not present in the first edition for, technically, the topic is not part of the MIM per se for it does not directly relate to interviewing techniques regarding patient choice, motivation, and conversation related to medication management.Complementing the interviewing tips of the MIM described in the previous fourteen chapters, this new bonus chapter provides the student with knowledge regarding a variety of answers (pillboxes, cell phone apps, digital reminders, behavioral tailoring, Medication Therapy Management provided by pharmacists, ongoing medication support via case managers, etc.) to the following question: “Once a patient has chosen to take a medication – and is motivated to do so – how does one help a patient to navigate the external factors that often lead to medication problems and discontinuance such as forgetting to take the medication, being confused about the medication’s dosing schedule, not being able to cut pills in half if required to do so, lacking transportation to the pharmacy, and not having enough money for the medications?”
The second appendix – “The Tip Archives: Quick Reference” – has been moved in this second edition to the state-of-the-art, free e-book, which automatically accompanies the paperback, appearing as Appendix B. This movement to a digital version greatly improves a student’s ability – as he or she first steps onto inpatient units during clinical rotations – to quickly access a concise listing of all the interviewing tips previously described in the text.
When accessing Appendix B, the exact wording of each tip immediately appears on-screen for quick reference. In addition, cross-referencing to the text pages – where the original discussion of each tip appeared – is provided if a more detailed immediate review is desired by the student. Thus, a concise summary of the over 100 interviewing tips of the MIM is only as far away as a click or two on the student’s tablet, cell phone, or other mobile device.
The third appendix was added specifically for faculty interested in learning innovative ways of teaching the MIM as well as researchers interested in designing research to quantitatively and qualitatively study the impact of MIM techniques on clinical outcomes as well as the efficacy of various training approaches both didactic and experiential (one of my hopes is that the publication of this book will lead to the type of research which I believe the MIM warrants). Toward this end, a popular article from the journal Professional Case Management has been reprinted exactly as it appeared in the journal. This digitized reprint – The “Medication Interest Model” An Integrative Clinical Interviewing Approach for Improving Medication Adherence—Part 2: Implications for Teaching and Research – appears as Appendix C in the e-book.
A few comments are in order regarding the text itself and the unique method in which large parts of the MIM were created. Although clearly designed as a textbook for medical, nursing, and other allied health provider students, it is my hope that the book will also be of value to residents and other more experienced clinicians. If I’ve done my job well, as an experienced clinician reads on, he or she will find interviewing techniques and strategies that validate his or her current practice, provide a handful of immediately useful ideas for his or her future practice, and, most importantly, stimulate him or her to find new answers born from their own clinical wisdom.
Moreover, the techniques in this book are not provided as the “right way” to increase our patients’ interest in their medications but merely as suggestions of various ways of tackling these difficult and sometimes vexing problems. The reader is invited to check out the following techniques, adopt the ones that he or she likes, discard the ones that he or she doesn’t, and create ever more powerful solutions that resonate with his or her own interviewing styles and the unique needs of his or her patients.
Before I turn the reader loose to follow up on my invitation, I should mention where many of the interviewing tips, that fill the pages of this book, have originated.
Over the past 20 years, as the Founder and Director of the Training Institute for Suicide Assessment and Clinical Interviewing (TISA) – information available at http://www.suicideassessment.com – it has been my privilege to present over 200 workshops on the MIM to primary care physicians, specialists (such as cardiologists, endocrinologists, neurologists, and psychiatrists), staff nurses and advance practice nurses, clinical pharmacists, and case managers (on teams managing diseases as diverse as CHF and diabetes to schizophrenia) from around the United States and Canada. At each workshop, I ask my workshop participants to stop me if any of the ideas that I suggest to them appear to be impractical in the setting of a hectic primary care clinic or hospital unit. In the following pages, I share only those ideas that have passed the “acid test” of their discerning judgment.
More importantly, I always invite the participants of my workshops to share the tips that they have found to be most useful in their daily practices – their private cache of practical interviewing gems. Thus, the MIM is an ever-growing model of which a large part is the direct result of these ongoing workshops and input from the participants who attend them or who visit our website.
In this sense, the MIM holds the distinction of being a motivational model for improving medication adherence that was created by directly observing and learning from the physicians, nurses, physician assistants, clinical pharmacists, and case managers who prescribe, discuss, and monitor medications on a daily basis. It is a compilation of the practical tips – suggested at my workshops – coupled with the lessons that I’ve learned in my own clinical practice over the years.
Finally, I should add that for over 30 years, it has been my great pleasure to study and write about the art of interviewing. I have specialized in developing methods for training both inexperienced and experienced clinicians.
Over these years, I have become convinced of the necessity of providing the clinician, not only with sound principles, but also with direct examples of how to implement these principles. The clinician needs to see the exact phrases and questions that can transform a sound principle into a sound practice. In the last analysis, mastering medical interviewing is probably not as dependent on knowing what to say than on knowing how, and when, to say it. Thus, as was the case with my previous books, I have tried to pack this text with sample questions, concrete interviewing strategies, and illustrative bits of clinical dialogue that will bring the interviewing techniques alive for the reader.
In closing, it’s my wish that the reader thoroughly enjoys the following pages. I certainly enjoyed writing them. I truly believe that, in the last analysis, it is a privilege to be a healer.
As healers, our journey is a rich one. In our efforts to provide relief to our patients, we succeed at times, and, at other times, we fail. No matter what the outcome, we always learn. As we move more deeply into our patient’s pains and fears, we encounter the reflections of those pains and fears – their hopes and expectations. Our medications often become symbols of potential cure, and their expectations are that our medications will be the lifelines that lead to that cure. Sometimes they do, sometimes they don’t.
It is here, within the chaotic world where suffering and compassion meet and sometimes collide that we move ever more deeply into the souls of our patients. Once there, we have the great privilege, as Albert Schweitzer observed, to suddenly know what it is “to become true human beings.” These moments are the moments that define our livelihoods as physicians, nurses, physician assistants, clinical pharmacists, and case managers. This book is about such moments.
Shawn Christopher Shea, M.D. is an internationally acclaimed workshop leader, author, and innovator in the fields of improving medication adherence, clinical interviewing, enhancing the therapeutic alliance and suicide prevention, having given over 850 presentations worldwide. In addition to the MIM, his clinical interviewing innovations including facilic supervision, macrotraining, and the Chronological Assessment of Suicide Events (CASE Approach) have been adopted around the world with his writings being translated into a variety of languages as diverse as French, Spanish, Greek, Japanese, and Chinese.
The British Medical Association chose his text, Psychiatric Interviewing: The Art of Understanding, 3rd Edition as the 2017 Book of the Year in the field of Psychiatry. He has authored a total of seven books as well as numerous articles including one of the classic texts in the field of suicide prevention, The Practical Art of Suicide Assessment.
Dr. Shea has been a recipient of an Outstanding Course Award presented by the American Psychiatric Association for his presentations at their annual meetings. He is a frequent presenter at the annual meeting of the American Association of Suicidology and at the Psychiatric Congress. He has been a guest lecturer at numerous academic centers including the Harvard School of Medicine, McGill University, and the Mayo Clinic.
Dr. Shea is the Director of the Training Institute for Suicide Assessment and Clinical Interviewing (www.suicideassessment.com), a training and consultation service providing workshops, consultations, and quality assurance design in mental health assessments. He is also in private practice.
To see Dr. Shea’s workshops and keynotes that are available to be brought to your organization or center, click here.