Improving Diabetes Care: Queries Versus Commands

“How much potassium is in a normal adult?” he asked casually.

My pause could have been because I was stunned, tired, or embarrassed. It was early July, and I was rounding with my attending at the Veterans Affairs hospital nearly two decades ago. I had had maybe an hour or two of sleep. I had just finished presenting an Intensive Care Unit patient who came in with a sepsis-like presentation, and my inclusion of the potassium repletion was, I thought, just for the purpose of completeness. My preparation for his interrogation did not include a review of potassium homeostasis.

When I finally responded that I didn't know, he followed with “Where did you go to medical school?” He never told me the answer on rounds. Two nights post-call, I spent an hour reading about potassium homeostasis and learned that there were ∼ 3,500 mEq of potassium in the body.

In this issue of Clinical Diabetes, Michele Heisler, MD, MPA, and Kenneth Resnicow, PhD, discuss the technique of Motivational Interviewing (MI) as a methodology for physicians and other health care providers to support patients in initiating and sustaining self-care practices. The technique includes several components during the interview process to motivate patients to engage in a desired self-care behavior. Although there are several variations on implementing this approach with emphasis on different components of the technique, asking open-ended questions is a core feature of MI. The questioning offers an opportunity for structured reflection that leads to awareness and, if executed properly, an internal desire to change.

Although MI is built on insights consistent with several behavioral change theories, its methodology is similar, though far less caustic (see above), to the modified Socratic approach that every law student or medical student/house officer has experienced. The basic premise is that the questions beget an invitation to self-discovery, which leads to a clarification of feelings, attitudes, and hopefully a pursuit of a change in behavior. When one asks a patient how important a particular diabetes self-care behavior is or how confident they feel to engage in that behavior, many potentially fruitful paths are opened. If the patient perceives the behavior as important and expresses confidence about doing it, but it is still not being done, follow-up questions attempt to resolve this dissonance, if the dissonance itself is not sufficient to promote change. If the behavior is not perceived as important, follow-up questions unpack this possible cognitive distortion. If the patient is not confident about carrying out the behavior, questions can assist in the discovery of specific obstacles to action. Although this approach is dissimilar from the classic Socratic method because it omits the dialectic component, it is similar in the goal of asking questions for the purpose of illuminating thoughts and promoting a rationale action plan.

A mentor of mine, who was once a law student and later a litigator, reminded me that the questions we ask determine the direction we take. Motivation, from the latin movere, means to move. As a young intern, I was asked questions that brought an awareness of a lack of knowledge, not to mention an uncomfortable emotional effect, and that moved me to learn—the intended effect. MI attempts to influence self-care behaviors, in part, through guided questions that move people to reflection and, hopefully, on to action. It may turn out that positively influencing diabetes self-care practices may be better realized through queries rather than commands.

While attending on the wards of my institution last June, I, predictably, asked an intern how much potassium was in the body. She came back the next day with the answer and, more importantly, understood why the 30 mEq she gave the previous call night was inadequate for the low potassium that she was treating. I didn't even have to ask where she went to medical school.