Mark Latowsky applies the concept of informed and shared decision-making to physicians' work with a challenging group of patients, injection drug users, and suggests that we have a moral obligation to treat them with respect, as people with a disease rather than as bad people deserving punishment. Finding common ground1 with these patients is often difficult because we want them to change too much, too fast and we become frustrated and judgmental when they do not follow our advice. Finding common ground does not mean coercing, cajoling or even coaxing our patients to agree with our treatment guidelines. Rather, it means seeking to understand the patient's world and their illness experience well enough that we can empathize with their plight and appreciate the difficult and sometimes unhealthy choices they feel compelled to make. We need to stick with them so that they know we care and they learn to trust us. Then, together we can tackle their problems.2
Two concepts help physicians to be more helpful and less pessimistic. Motivational interviewing methods are based on the theory of stages of change3,4: people first ignore the issue, then they think about it and make plans to change, and finally they undertake the hard work of changing and preventing relapse. Success is measured in moving from one stage to the next, not jumping from denial of the problem to lifelong cure in a single leap. The second, and related, concept is harm reduction.5 It is not realistic to expect every patient to be cured of their drug addiction. It is important to encourage any move in the direction of less risk, such as drinking 6 beers a day instead of 12 or using clean needles instead of shared needles. Whether this is the first step in the long road to controlling their substance abuse or the only step, it is a step in the right direction. We need to be there to support our patients in this struggle, not to judge their failings.
Signature
W. Wayne Weston
Department of Family Medicine University of Western Ontario London, Ont.
References
- 1.Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centered medicine: transforming the clinical method. Thousand Oaks (CA): Sage Publications; 1995.
- 2.Suchman AL, Botelho RJ, Hinton-Walker P, editors. Partnerships in healthcare: transforming relational process. Rochester (NY): University of Rochester Press; 1998.
- 3.Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behaviour. New York: The Guilford Press;, 1991.
- 4.Rollnick S, Mason P, Butler C. Health behavior change: a guide for practitioners. Edinburgh: Churchill Livingstone; 1999.
- 5.Skinner W, Drake J. Helping cocaine and heroin users. In: Harrison S, Carver V, editors. Alcohol and drug problems: a practical guide for counsellors. 2nd ed. Toronto: Addiction Research Foundation; 1997. p. 541-6.