The human factor is the determining factor when you choose collaboration over coercion.

From Doctors, Is It O.K. if We Talk About Why Finger-Wagging Isn’t Working? by Perri Klass, M.D.

Lots of subtle things going on in this article. The first thing that leaps out is that it is an advocacy article apparently presented as reporting. Klass is arguing that directive advice (telling people what to do) doesn't work and that instead doctors should be trained in motivational interviewing (training "doctors to discuss the changes that might help people be healthier, while emphasizing respect for the patient’s volition and autonomy.")

At a fundamental level, I do not disagree. But this is an advocacy piece and not straight reporting and therefore it belongs in the opinion section.

“There’s excellent data directive advice doesn’t work, when you use what we call the language of control: you must, you should, you have to,” he said. And usually, “when a doctor uses any of those approaches, both parents and children respond aversely.”

This sets up the second subtlety, and it is an ironic one. The substance of the recommendation is doctors should collaborate with patients to facilitate the patients own recognition of what they should do rather than the doctor telling them what they should do. Fair enough. But this article is a doctor telling us that we should conduct these discussions differently. I imagine that there is a special word for this sort of construct where the form of the statement contradicts the nature of the statement. Ironic is all I can come up with.

That quoted paragraph is another stumbling block. If there's excellent data that direct instruction does not work, why won't you (the reporter) show it to us? With a long career in management consulting I am perfectly aware that bringing the proverbial horse to the factual water is never the same as that proverbial horse drinking the factual water.

It is a gross professional dereliction to assume that any complex trade-off decision can be easily resolved by putting more facts on the table. Collaborative decision-making is reliant on trust, respect, and mutual persuasion. The human factor is the determining factor when you choose collaboration over coercion.

Even though I accept Klass's argument for my own reasons, I recognize that his advocacy argument is unpersuasive. He declares direct advice does not work but offers no evidence that that is the case. And since he is dealing, through the selected quotes, in absolutes ("Directive advice doesn't work") you know that the statement is false. Directive advice doesn't work all the time but it certainly works in some circumstances. If you make an improbable absolute claim such as "Directive advice doesn't work" and then fail to provide any sort of evidence supporting that improbable claim, you are not practicing the very collaborative approach (gentle persuasion) which you are advocating.

Later in the article Klass offers multiple examples of evidence for how motivational interviewing does work. He has the information but he is only presenting one side of the argument and not treating us as equals in the discussion, showing us both sides of the evidence ledger.

This problem of selective evidence presentation is exacerbated by how anemic the evidence appears to be for motivational interviewing. The two questions are 1) Is there a real effect for motivational interviewing? and 2) How big is the effect size? I am happy to stipulate that motivational interviewing works but I am very interested in just how effective it might be.

If directive advice leads to improved results 20% of the time and motivational interviewing leads to improved results 30% of the time, that is useful information and tells me that I need to know both techniques and need to be good at figuring out when to use which technique. But if motivational interviewing achieves improved results 90% of the time, then perhaps I replace the one technique with the other. But we aren't given that information that would allow a comparison between the approaches.

And in terms of effect size, what is provided is pretty negligible.

There is particularly strong evidence that this approach works for helping overweight children, Dr. Resnicow said. In one randomized trial funded by the National Institutes of Health, overweight children from 42 different pediatric practices whose parents received motivational interviewing counseling from their primary care provider as well as a registered dietitian reduced their body mass index by 4.9 percentile points over two years compared to children receiving usual care, who dropped by 1.8 percentile points.

This seems to suggest that both directive advice and motivational interviewing work, but that motivational interviewing works nearly three times as well as directive advice (4.9/1.8 = 2.7). That is impressive. But those effect sizes, if I am understanding them correctly, are tiny. A ~5% reduction in BMI in two years? And really, it is a 3% reduction in BMI (compared to what would have happened anyway). That doesn't seem especially effective. Is this much ado about nothing?

And how do we reconcile two contradictory statements? At the beginning of the article, it was claimed that there is plenty of evidence that directive advice does not work. And here we have evidence that it does work, just not as well as motivational interviewing.

Since he never makes the case that both techniques work and therefore each should be used when pertinent, Klass seems to be recommending a replacement of directive advice with motivational interviewing. It feels like one more expert recommending one more silver bullet. And if there is one thing we know at a practical level, it is that there are no silver bullets.

This is beginning to feel like a subtle sales job rather than factual reporting.

That sense of one sided spinning is further enforced by the fact that Klass presents no cost information. Directive advice has the advantage that it is expeditious. You come in, I check you over, diagnose, tell you what to do. Done! 10 minutes. Easy peasy. Motivated interviewing? How long does that take? There is no data presented on the comparative time taken. 20 minutes? 30 minutes? 45 minutes? An hour? The longer it takes the greater the loss of medical productivity. If it is ten minutes versus an hour you are talking about seeing 48 patients a day versus 8 patients. And for a 3% improvement in outcome? I don't think so.

What read as a marginally interesting topic feels more and more sullied the more you think about what is actually going on here.

Then you get to this paragraph.

This isn’t an easy skill to learn, Dr. Faith said, and it can take an organizational shift to support the training and get providers on board. Online modules are not as effective, she said. “You need individual feedback from an instructor.” But having mastered the skill, clinicians who start using it may experience less burnout. “The providers tend to feel they are making a difference in patients’ lives,” she said.

OK. This is a business proposition. You are going to have to reorganize the business. Train the doctors and PAs. Conduct practice sessions face to face. Conveniently, cheap online courses don't work. I am a consultant. I hear this sales pitch. X hundreds of training hours, some organizational consulting, lots of facilitated meetings, etc. This is a lucrative gig.

And for what? So that "providers tend to feel they are making a difference in patients’ lives?" That's a pretty weak value proposition. Sorry. Feelings don't pay the bills. Nor does a possible 3% improvement.

Well, maybe Klass will finish with the compelling evidence why this would be worthwhile.

With motivational interviewing, patients tend to rate their providers as more empathic and as better listeners, she said, and are less likely to miss appointments and, most important, more likely to make changes. Even if individual conversations take a little longer, the ultimate effect on the clinic is beneficial. “You actually improve clinic flow, people are not crowding the schedule with things they could have made changes at home to prevent,” she said.

There's the value proposition. Weasel words and obfuscation. Not a single quantified benefit.

Outcomes. I want beneficial outcomes. Patients tending to rate providers as more empathetic? Nah. Not a beneficial outcome. Nice, yes, but not valuable. I want patients getting better, faster and cheaper. This is patients liking something that is more expensive but not necessarily getting any better.

Give me numbers, not loose generic claims. And don't just dismiss the extra cost with that "conversations take a little longer." Be honest. How much longer? The fact that you acknowledge that there is a cost without quantifying that cost makes me more and more suspicious.

It used to be that newspapers would run full page infomercials where the content read like a news report but at the top of the page they had a banner with something like "Paid Advertising". If you paid attention, you knew that this was just advertising passing as news reporting. Nowadays it seems like they have dispensed with the warning "Paid Advertising" and are just running sales pitches as if they were actually news.

Read with even a modicum of skepticism, I am left with the feeling that all this is is a sales pitch to hospitals to buy a new service of motivational interviewing so that everyone feels happier. The argument is one-sided, provides little data, ignores costs, fails to measure the value of benefits and fails to treat the reader as a sentient consumer of news. All we are is the target of masked advertising.

I used to buy half a dozen newspapers - the AJC, the NYT, the Washington Post, the WSJ, etc. I bought them to learn things about what was going on in the world. The papers have collapsed. I am down to just two of them. And more and more I am not learning things from them. All I am learning is what is the narrative that the Mandarin Class want to feed us.

News reporting has always been an advertising based business. You looked at advertising in order to get the factual news. That model is gone. Factual news is now too expensive to produce so what we get is press release journalism, opinions and advertising which is made to look like advertising.

No wonder trust in the press keeps falling.