Special Advisers

#1 Ernesto Mola (GP since 1978)

Ernesto Mola
Why Patient Empowerment?
I have been involved in the Scientific Committee of the Leonardo Project since 2004. In 2006-2007 I had the opportunity to be the project leader of the complex feasibility study, based on the Chronic Care Model, where the motivational support to empower patient was a pillar of the research.

During the study I went into the topic thoroughly, and I developed the idea that General Practice is the most suitable setting to promote patient empowerment. In 2006 - and again in 2010 - I proposed to WONCA European Council to include in the European Definitions of General Practice an additional characteristic concerning patient empowerment.

Then I led a short commission for a minor revision of the definitions, and in 2011 in Warsaw the characteristic 'Promotes patient empowerment' has been included in the definitions.

In the meanwhile I collaborated in the Nardino Project and in the program Apulia Care, which is the widening of the experience of the Leonardo Project.


#2 John Litt (GP for more than 25 years)

John Litt
Why Patient Empowerment?
I was a young doctor doing a Masters in Clinical Epidemiology at McMaster University and getting further general practice training in Canada, when I came to the realisation that patient adherence was a big issue in getting better health outcomes.

Brian Haynes and David Sackett had recently published a book on compliance in health care and it was obvious to me that any good treatment frequently required the patient to be compliant. At the same time, the patient centred model was gaining traction as a framework for more effective doctor-patient relationships and communication, through the work of Ian McWhinney’s group and Joe Levenstein [1] [2]. 

Compliance meant that the patient 'obeyed the doctor' and was antithetical to being patient-centred. Despite the definition/terminology shifting (through concordance to adherence) there was a belated recognition that the quality of the clinician patient relationship was a key influence on patient behaviour [3, 4]. In acute illness it is often the clinician who has the power and the effective therapeutic interventions. In chronic illness the patient is the one who has the power. Telling the patient to do things didn’t work. Patient empowerment, on the other hand, has an intuitive logic. If the patient is more empowered to be involved in their care (self-care) then the doctor-patient relationship can more effectively achieve greater benefits for the patient. The key issue is how we go about it. Clinicians need to remain very wary of ‘victim blaming’ when greater patient involvement does not occur [5, 6].

At the same time, Motivational interviewing (MI) was evolving from managing patients with alcohol and substance abuse to other health related behaviours. MI has a strong commitment to being patient centred, respecting autonomy and collaboration and emphasising the expertise of the patient. I found that MI was a very useful strategy to work more collaboratively with patients and facilitate patient empowerment [7]. Developing skills in MI takes a weight off the shoulders of the clinician and facilitates a more effective partnership with the greater likelihood of achieving a better outcome for the patient. The evidence for the effectiveness of MI has been accumulating over the years [8-12] although many challenges remain, especially in training clinicians in the core elements of MI [13] and recognising that the MI spirit underpins its effectiveness [14, 15].

My PhD subsequently looked at providing clinicians with both MI skills and a supportive organisational infrastructure to help provide more effective preventive care.  The summarised version of the framework has been published as the RACGP Guide for Putting Prevention into practice, now it in second edition) (see http://www.racgp.org.au/your-practice/guidelines/greenbook/)

My involvement in patient empowerment has been to run MI workshops across Australia for more than 20 years to undergraduates, junior doctors, GPs and a range of other health care workers. The RACGP Putting Prevention into practice guide provides a complementary framework alongside MI skills to facilitate patient empowerment. Over the same time frame, I have promoted and advocated patient empowerment through teaching medical students about the value of continuity of care, especially in patients with complex health care needs and assisting in the development of educational and training packages for more effective chronic disease self-management. 

Professor Sharon Lawn, a friend and colleague with a long interest in patient centred care and patient empowerment,  commented that whatever treatment is given to the patient by the health professional, it should suit the patient’s needs and actually ameliorate or cure the health condition for which the patient has come to seek help, while minimizing other unwanted effects, as experienced and tolerated by the patient [16] I agree whole heartedly.

References
1. Levenstein, J., et al., The Patient-centred clinical method. 1 A model for the Doctor-patient interaction in Family Medicine. Fam Pract, 1986. 3(1): p. 24-30.

2. Weston, R., J. Brown, and M. Stewart, Patient-centred interviewing Part I: understanding patients' experiences. Can Fam Physician, 1989. 35: p. 147-151.

3. Ley, P., Satisfaction, compliance and communication. Br J Clin Psychol, 1982. 21 (Pt 4): p. 241-54.

4. Vermeire, E., et al., Patient adherence to treatment: three decades of research. A comprehensive review. J Clinical Pharmacy and Therapeutics, 2001. 26: p. 331-342.

5. Allegrante, J. and L. Green, Sounding board. When health policy becomes victim blaming. NEJM, 1981. 305: p. 1528-1529.

6. Becker, M.H., The tyranny of health promotion. Public Health Rev, 1986. 14(1): p. 15-23.

7. Anderson, R.M. and M.M. Funnell, Patient empowerment: myths and misconceptions. Patient Educ Couns, 2010. 79(3): p. 277-82.

8. Dunn, C., L. Deroo, and F. Rivara, The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review Addiction, 2001. 96(12): p. 1725-42.

9. Britt, E., S.M. Hudson, and N.M. Blampied, Motivational interviewing in health settings: a review. Patient Educ Couns, 2004. 53(2): p. 147-55.

10. Hettema, J., I. Steele, and W. Miller, Motivational Interviewing. Ann Rev Clin Psych, 2005. 1: p. 91-111.

11. Apodaca, T.R. and R. Longabaugh, Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence. Addiction, 2009. 104(5): p. 705-15.

12. VanBuskirk, K.A. and J.L. Wetherell, Motivational interviewing with primary care populations: a systematic review and meta-analysis. J Behav Med, 2014. 37(4): p. 768-80.

13. Hall, K., et al., After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing? Addiction, 2015.

14. Miller, W.R. and S. Rollnick, Ten things that motivational interviewing is not. Behav Cogn Psychother, 2009. 37(2): p. 129-40.

15. Miller, W.R. and G.S. Rose, Toward a theory of motivational interviewing. Am Psychol, 2009. 64(6): p. 527-37.

16. Lawn, S., Compliance, concordance, and patient-centered care. Patient Prefer Adherence, 2011. 5: p. 89-90.