A new approach to health coaching conversations
Pharmacists who understand patients’ behaviors can better influence them
- Many patients do not adhere to their treatment plans.
- Motivational interviewing has proven effective at guiding behavioral change.
- A new framework (the Four Tendencies) describes when and why people change behaviors.
- Understanding patients’ tendencies can help pharmacists be more effective health coaches.
Almost all pharmacies have patients who don’t take their medications as prescribed or don’t follow their treatment plan. The reasons patients don’t adhere are complex. However, research shows that motivational interviewing by healthcare providers can improve adherence to prescribed medications.1
Additional articles on coaching
Understanding patients’ tendencies
Writer Gretchen Rubin has looked at how and when people change and discovered patterns that explain when and why people act or don’t act.
In her book The Four Tendencies,2 Rubin presents a model of how people respond to external and internal expectations. Health providers should consider using Rubin’s model in their everyday work.3
|External (or outer)
|Expectations others place on us
|Internal (or inner)
|Expectations we place on ourselves
Rubin identifies four tendencies that may contribute to treatment adherence. These four tendencies are discussed below. They are Upholder, Obliger, Questioner and Rebel. By understanding these tendencies, pharmacists may provide health coaching that improves a patient’s adherence to their treatment plan.
Figure: Rubin’s Four Tendencies
Source: “Can Treatment Adherence Be Improved by Using Rubin’s Four Tendencies Framework to Understand a Patient’s Response to Expectations?” Kirk, J. et al: Biomed Hub 2017;2(suppl 1):484261 (DOI: 10.1159/000484261), used with permission from S. Karger AG, Basel.
- Upholders. These people respond to both outer and inner expectations. If a doctor tells them to take a pill twice daily, they’re likely to do it. However, upholders may be so rigid in following a routine or a doctor’s orders that they don’t recognize that discussing their health situation with a provider could lead to a better outcome.
- Obligers. This group responds well to outer expectations, as they hate to let others down. Techniques such as monitoring by calling weekly to check in may be effective. While emails, texts, apps and other types of technology may work, a human check-in is usually more effective.Watch out for “Obliger rebellion.” When an Obliger feels that demands have been too high for too long, they may then refuse to do what is expected. As a health coach, don’t try to address every issue at once.
- Questioners. These people crave information and won’t accept advice just because a person is an expert. They may reject a treatment plan because they think another solution will serve them better. They like to customize solutions themselves and may not say if they aren’t following a doctor’s orders.For questioners, do more than just explain something. Listen to their theories and address them. Rubin suggests that questioners may be open to “experiments.” Ask them to experiment by walking 30 minutes a day for a few weeks to see how they feel.
- Rebels. Rebels resist all expectations. They want to do what they want to do, in their own way, in their own time. Set a rule and they will break it. But that doesn’t mean they are impossible to coach. Provide information, explain the consequences and offer choices. For example, after explaining the danger of not losing weight, provide exercise options and say, “Here are activities that have worked for others. It’s up to you.” Let any action be the Rebel’s decision.
Tools from Gretchen Rubin
See Gretchen’s website for a free Four Tendencies quiz to determine your own tendency; a Flash Evaluation guide to determine someone’s tendency in a quick informal way; and Tips for Using the Four Tendencies in Health Care, a one-pager that gives a quick guide to using the Four Tendencies when dealing with a patient or a healthcare client.
Test your coaching skills
Now Health Mart® pharmacists and pharmacy staff can test their adherence coaching skills with Gail, a virtual diabetic patient.
In a 15-minute “Change the Conversation” training, pharmacists and technicians choose what to say to Gail to motivate her to fill her metformin, and then they receive personalized feedback.
Visit Health Mart UniversitySM to find “Change the Conversation: Interactive Adherence Coaching for Pharmacy.”