Dean Schillinger, M.D. is UCSF Professor of Medicine in Residence, and a primary care physician at San Francisco General Hospital (SFGH). He serves as Chief of the UCSF Division of General Internal Medicine at SFGH, and directs the Health Communications Research Program in the UCSF Center for Vulnerable Populations.
The 4 Rs to Success
Recently, Dr. Steven Schroeder, national leader on smoking cessation from UCSF, and I had the privilege of performing in a short video encouraging clinicians to ask, advise and refer their patients to the California’s Smoker’s Helpline.
As is true for most instructional and motivational videos, a certain degree of oversimplification was required, or, as in this case, a decision was made to present a clinical interaction that compressed the time course of smoking cessation conversations into a shorter period of time than is often required.
In reality, seasoned clinicians know that successful smoking cessation conversations—ones that not only motivate patients but also lead to cessation---often (but not always) require “the long view”. That is, success sometimes requires what I call the 4 R’s to success:
Putting Theory into Practice
This point came home to me this week during one of my morning clinic sessions. On my schedule was a middle aged African-American man with severe diabetes, a disease we had been struggling with together for many years. Management of his diabetes was made worse by the fact that his work as a security guard often involved night or “graveyard” shifts, making the timing of insulin administration challenging and even potentially unsafe. However, because of the strong synergies between tobacco use and diabetes with respect to early mortality (some studies suggest that the combination can reduce lifespan by as much as 18 years!), I always was mindful of the need to spend at least half of my visit focused on smoking cessation.
Because of my long-standing and trusting relationship with him, he was able to listen to my repeated advice without feeling judged and to respond in truthful ways that revealed the numerous barriers he felt to quitting, and the several issues that could be motivators to quit. One of his barriers had always been the fact that his wife also smoked. My gentle invitations to have her join him in his next visit with me were always rebuffed; I always made an effort to suggest that he share the 1-800-NO-BUTTS phone number with her.
For 8 years, our counseling sessions, while appearing to be authentically engaging, felt like they fell on deaf ears. He had never called the Helpline, had never filled the prescriptions I provided to him to aid with cessation, and had never set a quit date. Nevertheless, I remained resilient, mindful that nicotine addiction is a powerful foe, yet hopeful that this patient would be able to conquer this addiction under the right circumstances. So I did not give up, and I refused to get discouraged. Eighteen years is a lot of life to be saved. And this week, it happened -- albeit in a surprising way.
As we were closing our visit----one in which I did not bring up smoking cessation, as we were focused on his hypoglycemic episodes at night---he let me know that he had something to tell me. I already had my hand on the doorknob, and I had 3 patients waiting for me, so I was ambivalent about the idea of diving into another discussion. But I knew I needed to be responsive to him, a man usually of few words. He proudly told me he had finally called the Helpline. I was shocked, but delighted, and I took my hand off the doorknob, signaling to him that I was all ears. Then he also told me he just filled the prescription of the Nicotine Patch and pulled his collar down to show me that he was wearing a 21 mg patch right now. I practically swallowed my tears with my smile, and he smiled back.
“So what finally made you turn that corner?”, I asked him. A long pause. His face changed, and his smile collapsed into a look of anguish. “My wife. She was just told that she has…cancer…..lung cancer, actually. She’s been a smoker too y’know. Now I know I need to quit for her, because my smoking would be bad for her cancer. Plus, I need to quit so that I can be there for her when she needs me.”
I put my arm around his shoulder, feeling the patch under his T-shirt, and told him how sorry I was, but let him know that I was sure his making this effort meant a lot to her. He nodded and nodded, and I could see tears forming in the corners of his eyes.
Keep Up the Good Fight
Sometimes it takes a dramatic health event such as this one to shift patients’ motivation to quit to the next level. Other times it takes careful listening on the part of a clinician so as to identify inroads into motivation. But nearly always it requires the 4 R’s: Relationships (even brief ones can be meaningful), Repetition (do it again and again), Resilience (don’t get discouraged) and Responsiveness (listen to your patient and truly hear what they are saying).
Good luck out there. Keep up the fight. It is worth it.
For more practical tips on how to motivate your patients and clients to quit smoking, please join Dr. Schillinger and Gary Tedeschi, PhD, Clinical Director for the California Smoker's Helpline for a free webinar on Friday, June 19th from noon to 1 pm to hear Top Tips for Motivating Patients to Quit: